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Binois Y, Renaudier M, Dumas F, Youssfi Y, Beganton F, Jost D, Lamhaut L, Marijon E, Jouven X, Cariou A, Bougouin W. Factors associated with circulatory death after out-of-hospital cardiac arrest: a population-based cluster analysis. Ann Intensive Care 2023; 13:49. [PMID: 37294400 DOI: 10.1186/s13613-023-01143-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 05/25/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Out-of-hospital cardiac arrest (OHCA) is a common cause of death. Early circulatory failure is the most common reason for death within the first 48 h. This study in intensive care unit (ICU) patients with OHCA was designed to identify and characterize clusters based on clinical features and to determine the frequency of death from refractory postresuscitation shock (RPRS) in each cluster. METHODS We retrospectively identified adults admitted alive to ICUs after OHCA in 2011-2018 and recorded in a prospective registry for the Paris region (France). We identified patient clusters by performing an unsupervised hierarchical cluster analysis (without mode of death among the variables) based on Utstein clinical and laboratory variables. For each cluster, we estimated the hazard ratio (HRs) for RPRS. RESULTS Of the 4445 included patients, 1468 (33%) were discharged alive from the ICU and 2977 (67%) died in the ICU. We identified four clusters: initial shockable rhythm with short low-flow time (cluster 1), initial non-shockable rhythm with usual absence of ST-segment elevation (cluster 2), initial non-shockable rhythm with long no-flow time (cluster 3), and long low-flow time with high epinephrine dose (cluster 4). RPRS was significantly associated with this last cluster (HR, 5.51; 95% confidence interval 4.51-6.74). CONCLUSIONS We identified patient clusters based on Utstein criteria, and one cluster was strongly associated with RPRS. This result may help to make decisions about using specific treatments after OHCA.
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Affiliation(s)
- Yannick Binois
- Université de Paris, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Paris Sudden Death Expertise Center, 75015, Paris, France
| | - Marie Renaudier
- Université de Paris, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Paris Sudden Death Expertise Center, 75015, Paris, France
| | - Florence Dumas
- Université de Paris, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Emergency Department, AP-HP, Cochin-Hotel-Dieu Hospital, 75014, Paris, France
| | - Younès Youssfi
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Center for Research in Economics and Statistics, 91120, Palaiseau, France
| | - Frankie Beganton
- Université de Paris, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Paris Sudden Death Expertise Center, 75015, Paris, France
| | - Daniel Jost
- Université de Paris, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Paris Sudden Death Expertise Center, 75015, Paris, France
- BSPP (Paris Fire-Brigade Emergency-Medicine Department), 1 Place Jules Renard, 75017, Paris, France
| | - Lionel Lamhaut
- Université de Paris, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Intensive Care Unit and SAMU 75, Necker Enfants-Malades Hospital, 75014, Paris, France
| | - Eloi Marijon
- Université de Paris, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Cardiology Department, AP-HP, European Georges Pompidou Hospital, 75015, Paris, France
| | - Xavier Jouven
- Université de Paris, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Cardiology Department, AP-HP, European Georges Pompidou Hospital, 75015, Paris, France
| | - Alain Cariou
- Université de Paris, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Medical Intensive Care Unit, AP-HP, Cochin Hospital, 75014, Paris, France
- Paris Sudden Death Expertise Center, 75015, Paris, France
- AfterROSC network, Paris, France
| | - Wulfran Bougouin
- Université de Paris, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France.
- Paris Sudden Death Expertise Center, 75015, Paris, France.
- Medical Intensive Care Unit, Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300, Massy, France.
- AfterROSC network, Paris, France.
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2
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Lazzarin T, Tonon CR, Martins D, Fávero EL, Baumgratz TD, Pereira FWL, Pinheiro VR, Ballarin RS, Queiroz DAR, Azevedo PS, Polegato BF, Okoshi MP, Zornoff L, Rupp de Paiva SA, Minicucci MF. Post-Cardiac Arrest: Mechanisms, Management, and Future Perspectives. J Clin Med 2022; 12:jcm12010259. [PMID: 36615059 PMCID: PMC9820907 DOI: 10.3390/jcm12010259] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 12/22/2022] [Accepted: 12/23/2022] [Indexed: 12/31/2022] Open
Abstract
Cardiac arrest is an important public health issue, with a survival rate of approximately 15 to 22%. A great proportion of these deaths occur after resuscitation due to post-cardiac arrest syndrome, which is characterized by the ischemia-reperfusion injury that affects the role body. Understanding physiopathology is mandatory to discover new treatment strategies and obtain better results. Besides improvements in cardiopulmonary resuscitation maneuvers, the great increase in survival rates observed in recent decades is due to new approaches to post-cardiac arrest care. In this review, we will discuss physiopathology, etiologies, and post-resuscitation care, emphasizing targeted temperature management, early coronary angiography, and rehabilitation.
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3
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Narvaez Linares N, Munelith-Souksanh K, Tanguay A, Plamondon H. The impact of myocardial infarction on basal and stress-induced heart rate variability and cortisol secretion in women: A pilot study. COMPREHENSIVE PSYCHONEUROENDOCRINOLOGY 2022; 9:100113. [PMID: 35755922 PMCID: PMC9216611 DOI: 10.1016/j.cpnec.2022.100113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/07/2022] [Accepted: 01/07/2022] [Indexed: 10/24/2022] Open
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4
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Nso N, Nassar M, Baraka B, Mbome Y, Alfishawy M. Adrenal Insufficiency in patients with cardiogenic shock: A meta-analysis. Diabetes Metab Syndr 2021; 15:102274. [PMID: 34628137 DOI: 10.1016/j.dsx.2021.102274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 08/30/2021] [Accepted: 09/01/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Adrenal Insufficiency (AI) is rarely observed in patients with cardiogenic shock (CS). We aimed to identify the prevalence of AI in patients with CS and its effect on their clinical outcomes. AIMS Our study aimed to determine the prevalence of AI in CS patients who underwent treatments for CS. METHODS The articles concerning AI in CS were extracted for review from PubMed/Medline, Science Direct, World Wide Science.org, and Pro-Quest. The research articles included patients with CS, post-cardiac-arrest shock, out-of-hospital cardiac arrest, and CS after acute myocardial infarction. RStudio (version 1.0.136) was used for analyzing AI in CS patients. RESULTS The search revealed 1463 unique publications, including 256 studies identified after screening the titles and the abstracts. Five observational cohort studies met the eligibility criteria for meta-analysis after the preliminary screening. The included studies reported a corticotropin stimulation test for AI diagnosis. The studies reportedly exhibited a low-to-fair quality. The random-effects pooled estimates indicated a 32% AI prevalence in the setting of CS [95% CI; 21%-45%; I2 = 81%]. The outcomes from the included studies were statistically significant for high heterogeneity (P = 0.001). The pooled results confirmed an 11%-51% AI prevalence in CS patients. CONCLUSIONS This meta-analysis revealed a moderate level prevalence of AI in CS patients.
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Affiliation(s)
- Nso Nso
- Internal Medicine Department, Icahn School of Medicine at Mount Sinai / NYC Health+Hospitals / Queens, New York, NY, USA.
| | - Mahmoud Nassar
- Internal Medicine Department, Icahn School of Medicine at Mount Sinai / NYC Health+Hospitals / Queens, New York, NY, USA.
| | - Bahaaeldin Baraka
- Clinical Oncology Department, Nottingham University Hospital, Nottingham, UK.
| | - Yolanda Mbome
- Internal Medicine Department, Richmond University Medical Center, New York, USA.
| | - Mostafa Alfishawy
- Infectious Diseases, Infectious Diseases Consultants and Academic Researchers of Egypt (IDCARE), Cairo, Egypt.
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5
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Sahebnasagh A, Nejad PS, Salehi-Abargouei A, Dehghani MH, Saghafi F. A characterization of cortisol level and adrenal reservation in human cardiopulmonary arrest: systematic review and meta-analysis. Syst Rev 2021; 10:266. [PMID: 34625103 PMCID: PMC8499554 DOI: 10.1186/s13643-021-01820-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 09/25/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Cardiopulmonary arrest (CPA) is an urgency, which is associated with high mortality. This systematic review evaluated the relationship between baseline cortisol level and the outcome of resuscitated CPA patients. METHODS We searched the following databases: PubMed, Scopus, ISI Web of Science, and Google Scholar. Relevant observational and controlled trials were explored from inception by April 2020. The quality of the articles was assessed using the Newcastle-Ottawa Scale (NOS). RESULTS Finally, five cohort studies (n = 201 participants in total) were eligible for including in the meta-analysis. The results of this meta-analysis showed that although the baseline serum cortisol levels were higher in survivors of cardiac arrest compared with non-survivors, the differences between groups do not reach a significance level (Hedges' g = 0.371, 95% CI, -0.727, 1.469, P value = 0.508). Between-study heterogeneity was statistically significant (Cochrane Q test: P value < 0.001, I2 = 89.323). CONCLUSIONS The result of the present meta-analysis was suggestive of a higher baseline serum cortisol levels in survivors of CPA. Future randomized controlled studies with a large sample size will determine the exact relationship between adrenal reservation and the eventual outcome of patients with CPA. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018085468.
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Affiliation(s)
- Adeleh Sahebnasagh
- Clinical Research Center, Department of Internal Medicine, School of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Paria Soltani Nejad
- Pharmaceutical Sciences Research Center, School of Pharmacy, Student Research Committee, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Amin Salehi-Abargouei
- Nutrition and Food Security Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
- Department of Nutrition, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mohammad Hossein Dehghani
- Department of Anesthesiology and Critical Care, Shahid Rahnemoun Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Fatemeh Saghafi
- Department of Clinical Pharmacy, Faculty of Pharmacy and Pharmaceutical Sciences Research Center, Shahid Sadoughi University of Medical Sciences, Professor Hesabi Blvd, Yazd, Iran.
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6
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Sahebnasagh A, Najmeddin F, Najafi A, Saghafi F, Salehi-Abargouei A, Ahmadi A, Amini S, Mojtahedzadeh M, Sharifnia H. Efficacy of Glucocorticoid Administration in Patients with Cardiac Arrest: A Systematic Review of Clinical Studies. Curr Med Chem 2021; 29:136-151. [PMID: 34060997 DOI: 10.2174/0929867328666210531145617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/31/2021] [Accepted: 04/05/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND The pathophysiology of cardiac arrest (CA) involves over-activation of systemic inflammatory responses, relative adrenal insufficiency, and glycocalyx damage. Corticosteroids have beneficial effects in preventing the perturbation of the endothelial glycocalyx. OBJECTIVES The aim of this systematic review was to determine the efficacy of glucocorticoids in patients with cardiac arrest. METHODS We searched PubMed, Scopus, ISI Web of Science, Google Scholar and Cochrane central register for relevant clinical trials and cohort studies until September 2019. RESULTS We retrieved 7 peer-reviewed published studies for the systematic review. Two studies were clinical trials evaluating 147 patients, while five illustrated cohort design, evaluating 196,192 patients. In total, 196,339 patients were assessed. There was limited evidence and conflicting results to establish a correlation between glucocorticoids and the survival of patients suffering from cardiac arrest. However, the link between these medications and survival-to-admission, survival-to discharge, and 1-year survival rates was strong and consistent in observational studies. CONCLUSION The clinical evidence regarding the efficacy and safety of glucocorticoids in CA is limited to observational studies with inconsistent methodology and few clinical trials with small sample size. Nevertheless, it seems that glucocorticoid supplementation during and after cardiopulmonary resuscitation (CPR) may have significant effects in terms of survival-to-admission, survival to discharge, 1-year survival rates and an improved return of spontaneous circulation (ROSC) rate, especially in patients with hemodynamic instability and cardiovascular diseases (i.e., refractory hemodynamic shock). Future studies with high-quality, large-scale, long-term intervention and precise baseline characteristics are needed to evaluate the exact effective dose, duration, and efficacy of glucocorticoids in CA.
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Affiliation(s)
- Adeleh Sahebnasagh
- Clinical Research Center, Department of Internal Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Farhad Najmeddin
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Atabak Najafi
- Department of Anesthesiology and Critical Care Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Saghafi
- Department of Clinical Pharmacy, Faculty of Pharmacy and Pharmaceutical Sciences Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Amin Salehi-Abargouei
- Nutrition and Food Security Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Arezoo Ahmadi
- Department of Anesthesiology and Critical Care Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahideh Amini
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mojtaba Mojtahedzadeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Sharifnia
- Department of Anesthesiology and Critical Care Medicine, Sina Hospital, Tehran University of Medical Sciences, Iran
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7
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Tsai MS, Huang CH, Wang CH, Cheng HJ, Wu SN, Chang WT, Chen WJ. Post-Cardiac Arrest Hydrocortisone Use Ameliorates Cardiac Mitochondrial Injury in a Male Rat Model of Ventricular Fibrillation Cardiac Arrest. J Am Heart Assoc 2021; 10:e019837. [PMID: 33960200 PMCID: PMC8200688 DOI: 10.1161/jaha.120.019837] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background Steroid use after cardiac arrest has been reported to improve survival and neurological outcome in cardiac arrest survivors. The study aimed to evaluate the effect of post‐arrest hydrocortisone use on myocardial damage and cardiac mitochondrial injury in a rat model of ventricular fibrillation cardiac arrest. Methods and Results Ventricular fibrillation cardiac arrest was induced and left untreated for 5 minutes in adult male Wistar rats. Cardiopulmonary resuscitation and electric shocks were then applied to achieve return of spontaneous circulation (ROSC). Successfully resuscitated animals were randomized into 3 groups: control, low‐dose hydrocortisone (2 mg/kg), and high‐dose hydrocortisone (8 mg/kg). The low‐dose hydrocortisone and high‐dose hydrocortisone (treatment) groups received intravenous hydrocortisone immediately after ROSC and the control group received saline as placebo. Each group consisted of 15 animals. Within 4 hours of ROSC, both treatment groups showed a higher cardiac output than the control group. At the fourth hour following ROSC, histological examination and transmission electron microscopy demonstrated less myocardial damage and mitochondrial injury in the animals treated with hydrocortisone. In the treatment groups, hydrocortisone mitigated the acceleration of Ca2+‐induced mitochondrial swelling and suppression of complex activity observed in the control group. At the 72nd hour after ROSC, a significantly higher proportion of animals treated with hydrocortisone survived and had good neurological recovery compared with those given a placebo. Conclusions Hydrocortisone use after cardiac arrest may mitigate myocardial injury and cardiac mitochondrial damage and thus improve survival, neurological and histological outcomes in a rat model of ventricular fibrillation cardiac arrest.
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Affiliation(s)
- Min-Shan Tsai
- Department of Emergency Medicine National Taiwan University Medical College and Hospital Taipei Taiwan
| | - Chien-Hua Huang
- Department of Emergency Medicine National Taiwan University Medical College and Hospital Taipei Taiwan
| | - Chen-Hsu Wang
- Medical Intensive Care Unit Cathay General Hospital Taipei Taiwan
| | - Hsaio-Ju Cheng
- Department of Emergency Medicine National Taiwan University Medical College and Hospital Taipei Taiwan
| | - Shih-Ni Wu
- Department of Emergency Medicine National Taiwan University Medical College and Hospital Taipei Taiwan
| | - Wei-Tien Chang
- Department of Emergency Medicine National Taiwan University Medical College and Hospital Taipei Taiwan
| | - Wen-Jone Chen
- Department of Emergency Medicine National Taiwan University Medical College and Hospital Taipei Taiwan.,Department of Internal Medicine (Cardiology Division) National Taiwan University Medical College and Hospital Taipei Taiwan
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8
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Liu B, Zhang Q, Li C. Steroid use after cardiac arrest is associated with favourable outcomes: a systematic review and meta-analysis. J Int Med Res 2021; 48:300060520921670. [PMID: 32400236 PMCID: PMC7223213 DOI: 10.1177/0300060520921670] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background The effect of steroid use on outcomes in patients with cardiac arrest (CA) remains controversial. We systematically reviewed the literature to investigate whether steroid use after CA increased the return of spontaneous circulation (ROSC) rate and survival to discharge in patients with CA. Methods PubMed, Embase, CNKI, and the Cochrane Central Register of Controlled Trials were searched for randomized controlled trials (RCTs) and observational studies on the effect of steroid use on outcomes in adults with CA. The outcomes were ROSC and survival to discharge. Results Seven studies (four RCTs and three observational studies) were included. Pooled analysis suggested that steroid use was associated with increased ROSC in patients with CA. Steroid use was significantly associated with survival to discharge, which was a consistent finding in RCTs and observational studies. Subgroup analysis based on the time of drug administration (during cardiopulmonary resuscitation [CPR] vs. after CA) showed that steroid use during CPR and after CA were significantly associated with an increased rate of ROSC and survival to discharge. Conclusion Current evidence indicates that steroid use after CA could increase ROSC and survival to discharge in patients with CA. However, high-quality and adequately powered RCTs are warranted.
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Affiliation(s)
- Bo Liu
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Qiang Zhang
- Department of Critical Care Medicine, Peking University Third Hospital, Beijing, China
| | - Chunsheng Li
- Department of Emergency Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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9
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Dezfulian C, Orkin AM, Maron BA, Elmer J, Girotra S, Gladwin MT, Merchant RM, Panchal AR, Perman SM, Starks MA, van Diepen S, Lavonas EJ. Opioid-Associated Out-of-Hospital Cardiac Arrest: Distinctive Clinical Features and Implications for Health Care and Public Responses: A Scientific Statement From the American Heart Association. Circulation 2021; 143:e836-e870. [PMID: 33682423 DOI: 10.1161/cir.0000000000000958] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Opioid overdose is the leading cause of death for Americans 25 to 64 years of age, and opioid use disorder affects >2 million Americans. The epidemiology of opioid-associated out-of-hospital cardiac arrest in the United States is changing rapidly, with exponential increases in death resulting from synthetic opioids and linear increases in heroin deaths more than offsetting modest reductions in deaths from prescription opioids. The pathophysiology of polysubstance toxidromes involving opioids, asphyxial death, and prolonged hypoxemia leading to global ischemia (cardiac arrest) differs from that of sudden cardiac arrest. People who use opioids may also develop bacteremia, central nervous system vasculitis and leukoencephalopathy, torsades de pointes, pulmonary vasculopathy, and pulmonary edema. Emergency management of opioid poisoning requires recognition by the lay public or emergency dispatchers, prompt emergency response, and effective ventilation coupled to compressions in the setting of opioid-associated out-of-hospital cardiac arrest. Effective ventilation is challenging to teach, whereas naloxone, an opioid antagonist, can be administered by emergency medical personnel, trained laypeople, and the general public with dispatcher instruction to prevent cardiac arrest. Opioid education and naloxone distributions programs have been developed to teach people who are likely to encounter a person with opioid poisoning how to administer naloxone, deliver high-quality compressions, and perform rescue breathing. Current American Heart Association recommendations call for laypeople and others who cannot reliably establish the presence of a pulse to initiate cardiopulmonary resuscitation in any individual who is unconscious and not breathing normally; if opioid overdose is suspected, naloxone should also be administered. Secondary prevention, including counseling, opioid overdose education with take-home naloxone, and medication for opioid use disorder, is important to prevent recurrent opioid overdose.
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10
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Jozwiak M, Bougouin W, Geri G, Grimaldi D, Cariou A. Post-resuscitation shock: recent advances in pathophysiology and treatment. Ann Intensive Care 2020; 10:170. [PMID: 33315152 PMCID: PMC7734609 DOI: 10.1186/s13613-020-00788-z] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 12/02/2020] [Indexed: 12/28/2022] Open
Abstract
A post-resuscitation shock occurs in 50–70% of patients who had a cardiac arrest. It is an early and transient complication of the post-resuscitation phase, which frequently leads to multiple-organ failure and high mortality. The pathophysiology of post-resuscitation shock is complex and results from the whole-body ischemia–reperfusion process provoked by the sequence of circulatory arrest, resuscitation manoeuvers and return of spontaneous circulation, combining a myocardial dysfunction and sepsis features, such as vasoplegia, hypovolemia and endothelial dysfunction. Similarly to septic shock, the hemodynamic management of post-resuscitation shock is based on an early and aggressive hemodynamic management, including fluid administration, vasopressors and/or inotropes. Norepinephrine should be considered as the first-line vasopressor in order to avoid arrhythmogenic effects of other catecholamines and dobutamine is the most established inotrope in this situation. Importantly, the optimal mean arterial pressure target during the post-resuscitation shock still remains unknown and may probably vary according to patients. Mechanical circulatory support by extracorporeal membrane oxygenation can be necessary in the most severe patients, when the neurological prognosis is assumed to be favourable. Other symptomatic treatments include protective lung ventilation with a target of normoxia and normocapnia and targeted temperature management by avoiding the lowest temperature targets. Early coronary angiogram and coronary reperfusion must be considered in ST-elevation myocardial infarction (STEMI) patients with preserved neurological prognosis although the timing of coronary angiogram in non-STEMI patients is still a matter of debate. Further clinical research is needed in order to explore new therapeutic opportunities regarding inflammatory, hormonal and vascular dysfunction.
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Affiliation(s)
- Mathieu Jozwiak
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Paris-Centre, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 27, rue du faubourg Saint Jacques, 75014, Paris, France. .,Université de Paris, Paris, France.
| | - Wulfran Bougouin
- Service de Médecine Intensive Réanimation, Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France.,INSERM U970, Paris-Cardiovascular-Research-Center, Paris, France.,Paris Sudden-Death-Expertise-Centre, Paris, France.,AfterROSC Network Group, Paris, France
| | - Guillaume Geri
- Service de Médecine Intensive Réanimation, Hôpital Universitaire Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Boulogne-Billancourt, France.,Université Paris-Saclay, Paris, France.,INSERM UMR1018, Centre de Recherche en Epidémiologie Et Santé Des Populations, Villejuif, France.,AfterROSC Network Group, Paris, France
| | - David Grimaldi
- Service de Soins Intensifs CUB-Erasme, Université Libre de Bruxelles (ULB), Bruxelles, Belgium.,AfterROSC Network Group, Paris, France
| | - Alain Cariou
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Paris-Centre, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 27, rue du faubourg Saint Jacques, 75014, Paris, France.,Université de Paris, Paris, France.,INSERM U970, Paris-Cardiovascular-Research-Center, Paris, France.,Paris Sudden-Death-Expertise-Centre, Paris, France.,AfterROSC Network Group, Paris, France
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11
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Wang CH, Chang WT, Huang CH, Tsai MS, Chou E, Yu PH, Wu YW, Chen WJ. Associations between intra-arrest blood glucose level and outcomes of adult in-hospital cardiac arrest: A 10-year retrospective cohort study. Resuscitation 2019; 146:103-110. [PMID: 31786236 DOI: 10.1016/j.resuscitation.2019.11.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 10/14/2019] [Accepted: 11/16/2019] [Indexed: 11/16/2022]
Abstract
AIM We attempted to examine the association between intra-arrest blood glucose (BG) level and outcomes of in-hospital cardiac arrest (IHCA). The interaction between diabetes mellitus (DM) and BG level as well as between dextrose administration and BG level were investigated. METHODS This single-centred retrospective study reviewed IHCA patients between 2006 and 2015. Patients with measured intra-arrest BG levels were included. Multivariable logistic regression analyses were conducted. Generalised additive models were used to identify appropriate cut-off points for continuous variables. Interactions between independent variables were assessed during the model-fitting process. RESULTS Among the 580 included patients, 34 (5.9%) achieved neurologically intact survival. There were 197 DM patients (34.0%). The mean intra-arrest BG level was 191.5 mg/dl, with 57 patients (9.8%) experiencing hypoglycaemia (BG level ≤ 70 mg/dl). A total of 165 patients (28.4%) received a dextrose injection. An intra-arrest BG level ≤ 150 mg/dl was inversely associated with favourable neurological outcomes at hospital discharge (odds ratio [OR]: 0.28, 95% confidence interval [CI]: 0.11-0.73; p-value = 0.01). In analyses of interactions, non-DM × BG level ≤ 168 mg/dl was inversely associated with favourable neurological outcomes (OR: 0.30, 95% CI: 0.11-0.80; p-value = 0.02). There were no significant interactions between BG level and dextrose administration. CONCLUSION IHCA patients with intra-arrest BG level ≤ 150 mg/dl had worse neurological recovery. Intra-arrest hypoglycaemia might be a marker of critical illness. Dextrose administration was not shown to improve outcomes of IHCA patients with intra-arrest BG level ≤ 150 mg/dl, indicating the need to develop new therapeutics other than dextrose administration for these patients.
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Affiliation(s)
- Chih-Hung Wang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Wei-Tien Chang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Min-Shan Tsai
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Eric Chou
- Department of Emergency Medicine, Baylor Scott&White All Saints Medical Center, Fort Worth, TX, USA
| | - Ping-Hsun Yu
- Department of Emergency Medicine, Taipei Hospital, Ministry of Health and Welfare, New Taipei City, Taiwan
| | - Yen-Wen Wu
- Departments of Internal Medicine and Nuclear Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Department of Nuclear Medicine and Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan; National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Wen-Jone Chen
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
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Abstract
OBJECTIVES To evaluate the ramifications of steroid use during postarrest care. DESIGN Retrospective observational population-based study enrolled patients during years 2004-2011 with 1-year follow-up. SETTING Taiwan National Health Insurance Research Database. PATIENTS Adult nontraumatic cardiac arrest patients in the emergency department, who survived to admission. INTERVENTIONS These patients were classified into the steroid and nonsteroid groups based on whether steroid was used or not during hospitalization. A propensity score was used to match patient underlying characteristics, steroid use prior to cardiac arrest, the vasopressors, and shockable rhythm during cardiopulmonary resuscitation, hospital level, and socioeconomic status. MEASUREMENTS AND MAIN RESULTS There were 5,445 patients in each group after propensity score matching. A total of 4,119 patients (75.65%) in the steroid group died during hospitalization, as compared with 4,403 patients (80.86%) in the nonsteroid group (adjusted hazard ratio, 0.74; 95% CI, 0.70-0.77; p < 0.0001). The mortality rate at 1 year was significantly lower in the steroid group than in the nonsteroid group (83.54% vs 87.77%; adjusted hazard ratio, 0.73; 95% CI, 0.70-0.76; p < 0.0001). Steroid use during hospitalization was associated with survival to discharge, regardless of age, gender, underlying diseases (diabetes mellitus, chronic obstructive pulmonary disease, asthma), shockable rhythm, and steroid use prior to cardiac arrest. CONCLUSIONS In this retrospective observational study, postarrest steroid use was associated with better survival to hospital discharge and 1-year survival.
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Critical Illness-Related Corticosteroid Insufficiency in Cardiogenic Shock Patients: Prevalence and Prognostic Role. Shock 2019; 50:408-413. [PMID: 29280926 DOI: 10.1097/shk.0000000000001090] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Cardiogenic shock shares with septic shock common hemodynamic features, inflammatory patterns, and most likely similar complications such as critical illness-related corticosteroid insufficiency. The aim of this study was to evaluate the prevalence of critical illness-related corticosteroid insufficiency in cardiogenic shock patients and to secondarily assess its prognostic value on 90-day mortality. METHODS A single-center prospective observational study conducted over a 3-year period and including all patients with cardiogenic shock. Main exclusion criteria were patients with prior cardiac arrest, sepsis, ongoing corticosteroid therapy, and etomidate administration. A short corticotropin test was performed in the first 24 h following admission. Serum cortisol levels were measured before (T0) and 60 min (T60) after administration of 250 μg of cosyntropin. Critical illness-related corticosteroid insufficiency was defined according to the 2017 consensus definition (basal total cortisol<10 μg·dL or a delta cortisol T60-T0<9 μg·dL) as well as the thresholds published in 2016 in cardiogenic shock patients associated with worst prognosis (basal total cortisol>29 μg·dL and delta cortisol T60-T0<17 μg·dL). RESULTS Seventy-nine consecutive patients hospitalized in intensive care for cardiogenic shock met the inclusion criteria. Overall mortality was 43% at day 90. Forty-two percent had critical illness-related corticosteroid insufficiency using the 2017 consensus definition and 32% using the 2016 cardiogenic shock thresholds. Presence of critical illness-related corticosteroid insufficiency was not an independent factor associated with 90-day mortality irrespective of the thresholds used. CONCLUSION Critical illness-related corticosteroid insufficiency is a frequent occurrence in medical cardiogenic shock. However, in this study, such insufficiency was not associated with prognosis.
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Vasopressors During Cardiopulmonary Resuscitation. A Network Meta-Analysis of Randomized Trials. Crit Care Med 2019; 46:e443-e451. [PMID: 29652719 DOI: 10.1097/ccm.0000000000003049] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Several randomized controlled trials have compared adrenaline (epinephrine) with alternative therapies in patients with cardiac arrest with conflicting results. Recent observational studies suggest that adrenaline might increase return of spontaneous circulation but worsen neurologic outcome. We systematically compared all the vasopressors tested in randomized controlled trials in adult cardiac arrest patients in order to identify the treatment associated with the highest rate of return of spontaneous circulation, survival, and good neurologic outcome. DESIGN Network meta-analysis. PATIENTS Adult patients undergoing cardiopulmonary resuscitation. INTERVENTIONS PubMed, Embase, BioMed Central, and the Cochrane Central register were searched (up to April 1, 2017). We included all the randomized controlled trials comparing a vasopressor with any other therapy. A network meta-analysis with a frequentist approach was performed to identify the treatment associated with the highest likelihood of survival. MEASUREMENTS AND MAIN RESULTS Twenty-eight studies randomizing 14,848 patients in 12 treatment groups were included. Only a combined treatment with adrenaline, vasopressin, and methylprednisolone was associated with increased likelihood of return of spontaneous circulation and survival with a good neurologic outcome compared with several other comparators, including adrenaline. Adrenaline alone was not associated with any significant difference in mortality and good neurologic outcome compared with any other comparator. CONCLUSIONS In randomized controlled trials assessing vasopressors in adults with cardiac arrest, only a combination of adrenaline, vasopressin, and methylprednisolone was associated with improved survival with a good neurologic outcome compared with any other drug or placebo, particularly in in-hospital cardiac arrest. There was no significant randomized evidence to support neither discourage the use of adrenaline during cardiac arrest.
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Topjian AA, de Caen A, Wainwright MS, Abella BS, Abend NS, Atkins DL, Bembea MM, Fink EL, Guerguerian AM, Haskell SE, Kilgannon JH, Lasa JJ, Hazinski MF. Pediatric Post–Cardiac Arrest Care: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e194-e233. [DOI: 10.1161/cir.0000000000000697] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Successful resuscitation from cardiac arrest results in a post–cardiac arrest syndrome, which can evolve in the days to weeks after return of sustained circulation. The components of post–cardiac arrest syndrome are brain injury, myocardial dysfunction, systemic ischemia/reperfusion response, and persistent precipitating pathophysiology. Pediatric post–cardiac arrest care focuses on anticipating, identifying, and treating this complex physiology to improve survival and neurological outcomes. This scientific statement on post–cardiac arrest care is the result of a consensus process that included pediatric and adult emergency medicine, critical care, cardiac critical care, cardiology, neurology, and nursing specialists who analyzed the past 20 years of pediatric cardiac arrest, adult cardiac arrest, and pediatric critical illness peer-reviewed published literature. The statement summarizes the epidemiology, pathophysiology, management, and prognostication after return of sustained circulation after cardiac arrest, and it provides consensus on the current evidence supporting elements of pediatric post–cardiac arrest care.
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16
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Is Inappropriate Response to Cosyntropin Stimulation Test an Indication of Corticosteroid Resistance in Septic Shock? Shock 2019; 49:543-550. [PMID: 28991048 DOI: 10.1097/shk.0000000000001014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We recently published a comparison of two hydrocortisone dosage regimens in patients with septic shock. We compare the results conferred by the two regimens as a function of the response to cosyntropin stimulation test (CST). Patients with septic shock were treated by one of two hydrocortisone regimens: either a 50-mg intravenous bolus every 6 h during 7 days (200 mg group; n = 49), or a 100-mg initial bolus followed by a continuous infusion of 300 mg daily for 5 days (300 mg group; n = 50). Nonresponders was defined as a CST response of 9 μg/dL or less. Nonresponders had more severe septic shock, greater fluid resuscitation needs, and greater vasopressor dependence than responders. When analyzed only as a function of CST results, there was no difference in survival between responders and nonresponders. However, analyses crossing CST results and the treatment regimens showed that patients who were responders and in the 300 mg group had significantly less intensive care unit mortality compared with responders in the 200 mg group (respective mortality of 24% vs. 55% [relative risk 0.43, 95% confidence interval, 0.20 to 0.94, P = 0.018]). Multivariate analysis identified baseline blood cortisol as an independent prognostic factor for 28-day mortality in all groups (hazard ratio 1.002, 95% confidence interval, 1.001 to 1.002, P ≤ 0.0001). The results suggest that in patients who respond to CST, hydrocortisone can provide a dose-dependent benefit. In contrast, nonresponse may indicate corticosteroid resistance. This heterogeneity of response to hydrocortisone may explain the difficulties encountered when trying to demonstrate its benefit in septic shock.
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Storm C, Behringer W, Wolfrum S, Michels G, Fink K, Kill C, Arrich J, Leithner C, Ploner C, Busch HJ. [Postcardiac arrest treatment guide]. Med Klin Intensivmed Notfmed 2019; 115:573-584. [PMID: 31197420 DOI: 10.1007/s00063-019-0591-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/28/2019] [Accepted: 05/06/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Treatment after cardiac arrest has become more complex and interdisciplinary over the last few years. Thus, the clinically active intensive and emergency care physician not only has to carry out the immediate care and acute diagnostics, but also has to prognosticate the neurological outcome. AIM The different, most important steps are presented by leading experts in the area, taking into account the interdisciplinarity and the currently valid guidelines. MATERIALS AND METHODS Attention was paid to a concise, practice-oriented presentation. RESULTS AND DISCUSSION The practical guide contains all important steps from the acute care to the neurological prognosis generation that are relevant for the clinically active intensive care physician.
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Affiliation(s)
- C Storm
- Medizinische Klinik mit Schwerpunkt Nephrologie und Internistische Intensivmedizin, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland.
| | - W Behringer
- Zentrum für Notfallmedizin, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland.
| | - S Wolfrum
- Interdisziplinäre Notaufnahme, Universitätsklinikum Lübeck, Lübeck, Deutschland
| | - G Michels
- Klinik III für Innere Medizin, Herzzentrum, Universität zu Köln, Köln, Deutschland
| | - K Fink
- Universitäts-Notfallzentrum, Universitätsklinikum Freiburg, Sir-Hans-A.-Krebs-Straße, 79106, Freiburg Breisgau, Deutschland
| | - C Kill
- Zentrum für Notfallmedizin, Universitätsklinikum Essen, Essen, Deutschland
| | - J Arrich
- Zentrum für Notfallmedizin, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland
| | - C Leithner
- Klinik für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - C Ploner
- Klinik für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - H-J Busch
- Universitäts-Notfallzentrum, Universitätsklinikum Freiburg, Sir-Hans-A.-Krebs-Straße, 79106, Freiburg Breisgau, Deutschland.
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Mongardon N, Savary G, Geri G, El Bejjani MR, Silvera S, Dumas F, Charpentier J, Pène F, Mira JP, Cariou A. Prognostic value of adrenal gland volume after cardiac arrest: Association of CT-scan evaluation with shock and mortality. Resuscitation 2018; 129:135-140. [PMID: 29852197 DOI: 10.1016/j.resuscitation.2018.05.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 05/18/2018] [Accepted: 05/26/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Adrenal gland volume is associated with survival in septic shock. As sepsis and post-cardiac arrest syndrome share many pathophysiological features, we assessed the association between adrenal gland volume measured by computerized tomography (CT)-scan and post-cardiac arrest shock and intensive care unit (ICU) mortality, in a large cohort of out-of-hospital cardiac arrest (OHCA) patients. We also investigated the association between adrenal hormonal function and both adrenal gland volume and outcomes. PATIENTS AND METHODS Prospective analysis of CT-scan performed at hospital admission in patients admitted after OHCA (2007-2012). A pair of blinded radiologist calculated manually adrenal gland volume. In a subgroup of patients, plasma cortisol was measured at admission and 60 min after a cosyntropin test. Factors associated with post-cardiac arrest shock and ICU mortality were identified using multivariate logistic regression. RESULTS Among 775 patients admitted during this period after OHCA, 138 patients were included: 72 patients (52.2%) developed a post-cardiac arrest shock, and 98 patients (71.1%) died. In univariate analysis, adrenal gland volume was not different between patients with and without post-cardiac arrest shock: 10.6 and 11.3 cm3, respectively (p = 0.9) and between patients discharged alive or dead: 10.2 and 11.8 cm3, respectively (p = 0.4). Multivariate analysis confirmed that total adrenal gland volume was associated neither with post-cardiac arrest shock nor mortality. Neither baseline cortisol level nor delta between baseline and after cosyntropin test cortisol levels were associated with adrenal volume, post-cardiac arrest shock onset or mortality. CONCLUSION After OHCA, adrenal gland volume is not associated with post-cardiac arrest shock onset or ICU mortality. Adrenal gland volume does not predict adrenal gland hormonal response.
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Affiliation(s)
- Nicolas Mongardon
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France
| | - Guillaume Savary
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France
| | - Guillaume Geri
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France; INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 56 rue Leblanc, 75015 Paris, France
| | - Marie-Rose El Bejjani
- Radiology Department, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Stéphane Silvera
- Radiology Department, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Florence Dumas
- Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France; INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 56 rue Leblanc, 75015 Paris, France; Emergency Department, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Julien Charpentier
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France
| | - Frédéric Pène
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France
| | - Jean-Paul Mira
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France
| | - Alain Cariou
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France; INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 56 rue Leblanc, 75015 Paris, France.
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Marino BS, Tabbutt S, MacLaren G, Hazinski MF, Adatia I, Atkins DL, Checchia PA, DeCaen A, Fink EL, Hoffman GM, Jefferies JL, Kleinman M, Krawczeski CD, Licht DJ, Macrae D, Ravishankar C, Samson RA, Thiagarajan RR, Toms R, Tweddell J, Laussen PC. Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association. Circulation 2018; 137:e691-e782. [PMID: 29685887 DOI: 10.1161/cir.0000000000000524] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Cardiac arrest occurs at a higher rate in children with heart disease than in healthy children. Pediatric basic life support and advanced life support guidelines focus on delivering high-quality resuscitation in children with normal hearts. The complexity and variability in pediatric heart disease pose unique challenges during resuscitation. A writing group appointed by the American Heart Association reviewed the literature addressing resuscitation in children with heart disease. MEDLINE and Google Scholar databases were searched from 1966 to 2015, cross-referencing pediatric heart disease with pertinent resuscitation search terms. The American College of Cardiology/American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. The recommendations in this statement concur with the critical components of the 2015 American Heart Association pediatric basic life support and pediatric advanced life support guidelines and are meant to serve as a resuscitation supplement. This statement is meant for caregivers of children with heart disease in the prehospital and in-hospital settings. Understanding the anatomy and physiology of the high-risk pediatric cardiac population will promote early recognition and treatment of decompensation to prevent cardiac arrest, increase survival from cardiac arrest by providing high-quality resuscitations, and improve outcomes with postresuscitation care.
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Prognostic Value of Relative Adrenal Insufficiency During Cardiogenic Shock: A Prospective Cohort Study With Long-Term Follow-Up. Shock 2018; 47:86-92. [PMID: 27984534 DOI: 10.1097/shk.0000000000000710] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Relative adrenal insufficiency (RAI) is common in intensive care unit patients, particularly during septic shock (SS). Cardiogenic shock (CS) may share some pathophysiological features with SS. The aim of this study was to evaluate the prevalence and long-term prognosis of RAI during CS. PATIENTS AND METHODS Prospective observational study conducted in the intensive care and cardiology units in one university hospital in France. Patients meeting the criteria for CS without prior corticosteroid therapy were included. Total blood cortisol levels were assessed immediately before (T0) a short corticotropin stimulation test (0.25 mg i.v. of tetracosactrin) and 30 and 60 min afterward. Δmax was defined as the difference between the maximal value after the test and T0. RESULTS Of the 92 patients enrolled, 42 (46%) (95% confidence interval [CI] [36%-56%]) died in hospital and 7 more died during a median follow-up of 616 [57-2,498] days, for an overall mortality rate of 53% (95% CI [43%-63%]). Three groups were identified based on the corticotropin test: group 1 (T0 ≤798 nmol/L and Δmax >473 nmol/L), group 2 ([T0 >798 nmol/L and Δmax >473 nmol/L] or [T0 ≤798 nmol/L and Δmax ≤473 nmol/L]), and group 3 (T0 >798 nmol/L and Δmax ≤473 nmol/L) with an overall survival of 76%, 43%, and 15%, respectively (log rank P = 0.003). In the multivariable analysis, adrenal nonresponse (group 3) was an independent predictor of mortality (P = 0.04), along with left ventricular ejection fraction, Simplified Acute Physiology Score II, and cardiac arrest. CONCLUSIONS These data suggest that a short corticotropin test has a good prognostic value in CS and allows identifying patients at higher risk of death.
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Guidelines for the Diagnosis and Management of Critical Illness-Related Corticosteroid Insufficiency (CIRCI) in Critically Ill Patients (Part II). Crit Care Med 2018; 46:146-148. [DOI: 10.1097/ccm.0000000000002840] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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22
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Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (Part II): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017. Intensive Care Med 2017; 44:474-477. [DOI: 10.1007/s00134-017-4951-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 09/25/2017] [Indexed: 01/14/2023]
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23
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Postreanimationsbehandlung. Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0331-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Effects of Erythropoietin Administration on Adrenal Glands of Landrace/Large White Pigs after Ventricular Fibrillation. BIOMED RESEARCH INTERNATIONAL 2016; 2016:7261960. [PMID: 27504455 PMCID: PMC4967690 DOI: 10.1155/2016/7261960] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 06/13/2016] [Accepted: 06/21/2016] [Indexed: 11/17/2022]
Abstract
Aim. To evaluate the effects of erythropoietin administration on the adrenal glands in a swine model of ventricular fibrillation and resuscitation. Methods. Ventricular fibrillation was induced via pacing wire forwarded into the right ventricle in 20 female Landrace/Large White pigs, allocated into 2 groups: experimental group treated with bolus dose of erythropoietin (EPO) and control group which received normal saline. Cardiopulmonary resuscitation (CPR) was performed immediately after drug administration as per the 2010 European Resuscitation Council (ERC) guidelines for Advanced Life Support (ALS) until return of spontaneous circulation (ROSC) or death. Animals who achieved ROSC were monitored, mechanically ventilated, extubated, observed, and euthanized. At necroscopy, adrenal glands samples were formalin-fixed, paraffin-embedded, and routinely processed. Sections were stained with hematoxylin-eosin. Results. Oedema and apoptosis were the most frequent histological changes and were detected in all animals in the adrenal cortex and in the medulla. Mild and focal endothelial lesions were also detected. A marked interindividual variability in the degree of the intensity of apoptosis and oedema at cortical and medullary level was observed within groups. Comparing the two groups, higher levels of pathological changes were detected in the control group. No significant difference between the two groups was observed regarding the endothelial changes. Conclusions. In animals exposed to ventricular fibrillation, EPO treatment has protective effects on the adrenal gland.
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Nolan JP, Soar J, Cariou A, Cronberg T, Moulaert VRM, Deakin CD, Bottiger BW, Friberg H, Sunde K, Sandroni C. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines for Post-resuscitation Care 2015: Section 5 of the European Resuscitation Council Guidelines for Resuscitation 2015. Resuscitation 2016; 95:202-22. [PMID: 26477702 DOI: 10.1016/j.resuscitation.2015.07.018] [Citation(s) in RCA: 734] [Impact Index Per Article: 91.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jerry P Nolan
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, UK.
| | - Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK
| | - Alain Cariou
- Cochin University Hospital (APHP) and Paris Descartes University, Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Division of Neurology, Lund University, Lund, Sweden
| | - Véronique R M Moulaert
- Adelante, Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands
| | - Charles D Deakin
- Cardiac Anaesthesia and Cardiac Intensive Care and NIHR Southampton Respiratory Biomedical Research Unit, University Hospital, Southampton, UK
| | - Bernd W Bottiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Hans Friberg
- Department of Clinical Sciences, Division of Anesthesia and Intensive Care Medicine, Lund University, Lund, Sweden
| | - Kjetil Sunde
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
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Tsai MS, Chuang PY, Yu PH, Huang CH, Tang CH, Chang WT, Chen WJ. Glucocorticoid use during cardiopulmonary resuscitation may be beneficial for cardiac arrest. Int J Cardiol 2016; 222:629-635. [PMID: 27517652 DOI: 10.1016/j.ijcard.2016.08.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 08/01/2016] [Accepted: 08/02/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Various studies have indicated that glucocorticoid supplementation during cardiopulmonary resuscitation (CPR), in conjunction with vasopressors, may improve outcomes in instances of cardiac arrest. However, further population-based analysis is warranted with respect to resuscitative and long-term survival benefits conferred by administering glucocorticoids in this setting. METHODS A total of 145,644 adult patients who experienced non-traumatic, cardiac arrest occurred at emergency room during years 2004-2011 were selected for study from the Taiwan National Health Insurance Research database. These patients were grouped as steroid and non-steroid recipients during CPR, and group members were matched in terms of patient characteristics, including presenting complaint, prior steroid use, resuscitative drugs and shocks delivered, treatment setting (medical center or not), socioeconomic status, and year that cardiac arrest occurred, through propensity scoring. Logistic regression analysis was performed to determine the impact of steroid usage on survival to admission, survival to discharge, and 1-year survival. RESULTS Compared with matched non-steroid group members (n=8628), patients given steroid (n=2876) displayed significantly higher rates of survival to admission (38.32% vs 18.67%; adjusted OR=2.97, 95% CI 2.69-3.29; p<0.0001), survival to discharge (14.50% vs 5.61%; adjusted OR=1.71, 95% CI 1.42-2.05; p<0.0001), and 1-year overall survival (10.81% vs 4.74%; adjusted OR=1.48, 95% CI 1.22-1.79; p<0.0001). Steroid use proved more beneficial in patients with COPD or asthma and in the absence of shockable rhythm during CPR. CONCLUSION Glucocorticoid use during CPR is associated with improved survival-to-admission, survival-to-discharge, and 1-year survival rates.
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Affiliation(s)
- Min-Shan Tsai
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan.
| | - Po-Ya Chuang
- School of Health Care Administration, Taipei Medical University, Taipei, Taiwan.
| | - Ping-Hsun Yu
- Department of Emergency Medicine, Taipei Hospital, Ministry of Health and Welfare, Taipei, Taiwan.
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan.
| | - Chao-Hsiun Tang
- School of Health Care Administration, Taipei Medical University, Taipei, Taiwan.
| | - Wei-Tien Chang
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan.
| | - Wen-Jone Chen
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan; Department of Emergency Medicine, Lotung Poh-Ai Hospital, Yilan County, Taiwan.
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Mosaddegh R, Kianmehr N, Mahshidfar B, Rahmani Z, Aghdam H, Mofidi M. Serum cortisol level and adrenal reserve as a predictor of patients' outcome after successful cardiopulmonary resuscitation. J Cardiovasc Thorac Res 2016; 8:61-4. [PMID: 27489598 PMCID: PMC4970572 DOI: 10.15171/jcvtr.2016.12] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 06/03/2016] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION It is thought that pituitary-adrenal axis has a fundamental role in outcome of cardiopulmonary arrest (CPA). This study designed to evaluate the correlation between adrenal reserve and post-resuscitation outcome. METHODS In this clinical trial study, 52 consecutive patients with CPA were enrolled in two emergency departments (EDs) over a 3-month period. Plasma cortisol level was measured at the beginning of CPR. Intravenous adrenocorticotropic hormone (ACTH) stimulation test was carried out after successful CPR, and blood samples were taken at 30 and 60 minutes, and 24 hours thereafter. Patients were divided into two groups: in-hospital death or hospital discharge. RESULTS In patients who died, baseline and post-ACTH serum cortisol after 30 and 60 minutes and 24 hours were higher than patients who discharged from the hospital, but it was not statistically significant except to that of minute 60 (P=0.49). A model of multivariate logistic regression analysis showed that age and need for vasopressor infusion correlated with mortality. CONCLUSION Current study could not show the statistically significant difference in initial and post-ACTH serum cortisol levels between survivor and non-survivor patients with cardiac arrest who had initial successful CPR, except to that of minute 60.
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Affiliation(s)
- Reza Mosaddegh
- Firoozgar Hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Nahid Kianmehr
- Rasoul Akram Hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Babak Mahshidfar
- Emergency Management Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Zahra Rahmani
- Rasoul Akram Hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Hamed Aghdam
- Rasoul Akram Hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Mani Mofidi
- Emergency Management Research Center, Iran University of Medical Sciences, Tehran, Iran
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Geri G, Cariou A. Syndrome post-arrêt cardiaque. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-016-1191-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Corticosteroid therapy in refractory shock following cardiac arrest: a randomized, double-blind, placebo-controlled, trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:82. [PMID: 27038920 PMCID: PMC4818959 DOI: 10.1186/s13054-016-1257-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 02/26/2016] [Indexed: 12/17/2022]
Abstract
Background The purpose of this study was to determine whether the provision of corticosteroids improves time to shock reversal and outcomes in patients with post-cardiac arrest shock. Methods We conducted a randomized, double-blind trial of post-cardiac arrest patients in shock, defined as vasopressor support for a minimum of 1 hour. Patients were randomized to intravenous hydrocortisone 100 mg or placebo every 8 hours for 7 days or until shock reversal. The primary endpoint was time to shock reversal. Results Fifty patients were included with 25 in each group. There was no difference in time to shock reversal between groups (hazard ratio: 0.83 [95 % CI: 0.40–1.75], p = 0.63). We found no difference in secondary outcomes including shock reversal (52 % vs. 60 %, p = 0.57), good neurological outcome (24 % vs. 32 %, p = 0.53) or survival to discharge (28 % vs. 36 %, p = 0.54) between the hydrocortisone and placebo groups. Of the patients with a baseline cortisol < 15 ug/dL, 100 % (6/6) in the hydrocortisone group achieved shock reversal compared to 33 % (1/3) in the placebo group (p = 0.08). All patients in the placebo group died (100 %; 3/3) whereas 50 % (3/6) died in the hydrocortisone group (p = 0.43). Conclusions In a population of cardiac arrest patients with vasopressor-dependent shock, treatment with hydrocortisone did not improve time to shock reversal, rate of shock reversal, or clinical outcomes when compared to placebo. Clinical trial registration Clinicaltrials.gov: NCT00676585, registration date: May 9, 2008.
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Pellis T, Sanfilippo F, Ristagno G. The optimal hemodynamics management of post-cardiac arrest shock. Best Pract Res Clin Anaesthesiol 2015; 29:485-95. [DOI: 10.1016/j.bpa.2015.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 09/29/2015] [Accepted: 10/01/2015] [Indexed: 01/14/2023]
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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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Myocardial Dysfunction and Shock after Cardiac Arrest. BIOMED RESEARCH INTERNATIONAL 2015; 2015:314796. [PMID: 26421284 PMCID: PMC4572400 DOI: 10.1155/2015/314796] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 06/28/2015] [Indexed: 01/12/2023]
Abstract
Postarrest myocardial dysfunction includes the development of low cardiac output or ventricular systolic or diastolic dysfunction after cardiac arrest. Impaired left ventricular systolic function is reported in nearly two-thirds of patients resuscitated after cardiac arrest. Hypotension and shock requiring vasopressor support are similarly common after cardiac arrest. Whereas shock requiring vasopressor support is consistently associated with an adverse outcome after cardiac arrest, the association between myocardial dysfunction and outcomes is less clear. Myocardial dysfunction and shock after cardiac arrest develop as the result of preexisting cardiac pathology with multiple superimposed insults from resuscitation. The pathophysiology involves cardiovascular ischemia/reperfusion injury and cardiovascular toxicity from excessive levels of inflammatory cytokine activation and catecholamines, among other contributing factors. Similar mechanisms occur in myocardial dysfunction after cardiopulmonary bypass, in sepsis, and in stress-induced cardiomyopathy. Hemodynamic stabilization after resuscitation from cardiac arrest involves restoration of preload, vasopressors to support arterial pressure, and inotropic support if needed to reverse the effects of myocardial dysfunction and improve systemic perfusion. Further research is needed to define the role of postarrest myocardial dysfunction on cardiac arrest outcomes and identify therapeutic strategies.
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Taccone FS, Crippa IA, Dell'Anna AM, Scolletta S. Neuroprotective strategies and neuroprognostication after cardiac arrest. Best Pract Res Clin Anaesthesiol 2015; 29:451-64. [PMID: 26670816 DOI: 10.1016/j.bpa.2015.08.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 08/20/2015] [Indexed: 12/23/2022]
Abstract
Neurocognitive disturbances are common among survivors of cardiac arrest (CA). Although initial management of CA, including bystander cardiopulmonary resuscitation, optimal chest compression, and early defibrillation, has been implemented continuously over the last years, few therapeutic interventions are available to minimize or attenuate the extent of brain injury occurring after the return of spontaneous circulation. In this review, we discuss several promising drugs that could provide some potential benefits for neurological recovery after CA. Most of these drugs have been investigated exclusively in experimental CA models and only limited clinical data are available. Further research, which also considers combined neuroprotective strategies that target multiple pathways involved in the pathophysiology of postanoxic brain injury, is certainly needed to demonstrate the effectiveness of these interventions in this setting. Moreover, the evaluation of neurological prognosis of comatose patients after CA remains an important challenge that requires the accurate use of several tools. As most patients with CA are currently treated with targeted temperature management (TTM), combined with sedative drug therapy, especially during the hypothermic phase, the reliability of neurological examination in evaluating these patients is delayed to 72-96 h after admission. Thus, additional tests, including electrophysiological examinations, brain imaging and biomarkers, have been largely implemented to evaluate earlier the extent of brain damage in these patients.
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Affiliation(s)
- Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070 Brussels, Belgium.
| | - Ilaria Alice Crippa
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070 Brussels, Belgium
| | - Antonio Maria Dell'Anna
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070 Brussels, Belgium
| | - Sabino Scolletta
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070 Brussels, Belgium
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Varvarousi G, Stefaniotou A, Varvaroussis D, Xanthos T. Glucocorticoids as an emerging pharmacologic agent for cardiopulmonary resuscitation. Cardiovasc Drugs Ther 2015; 28:477-88. [PMID: 25163464 PMCID: PMC4163188 DOI: 10.1007/s10557-014-6547-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Although cardiac arrest (CA) constitutes a major health problem with dismal prognosis, no specific drug therapy has been shown to improve survival to hospital discharge. CA causes adrenal insufficiency which is associated with poor outcome and increased mortality. Adrenal insufficiency may manifest as an inability to increase cortisol secretion during and after cardiopulmonary resuscitation (CPR). Several studies suggest that glucocorticoids during and after CPR seem to confer benefits with respect to return of spontaneous circulation (ROSC) rates and long term survival. They have beneficial hemodynamic effects that may favor their use during CPR and in the early post-resuscitation period. Moreover, they have anti-inflammatory and anti-apoptotic properties that improve organ function by reducing ischemia/reperfusion (I/R) injury. However, glucocorticoid supplementation has shown conflicting results with regard to survival to hospital discharge and neurological outcome. The purpose of this article is to review the pathophysiology of hypothalamic-pituitary-adrenal (HPA) axis during CPR. Furthermore, this article reviews the effects of glucocorticoids use during CRP and the post-resuscitation phase.
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Affiliation(s)
- Giolanda Varvarousi
- National and Kapodistrian University of Athens, Medical School, MSc "Cardiopulmonary Resuscitation", Athens, Greece,
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Hypothermie thérapeutique après arrêt cardiaque et infections acquises en réanimation. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1045-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Ristagno G, Latini R, Plebani M, Zaninotto M, Vaahersalo J, Masson S, Tiainen M, Kurola J, Gaspari F, Milani V, Pettilä V, Skrifvars MB. Copeptin levels are associated with organ dysfunction and death in the intensive care unit after out-of-hospital cardiac arrest. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:132. [PMID: 25886856 PMCID: PMC4415235 DOI: 10.1186/s13054-015-0831-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 02/20/2015] [Indexed: 01/20/2023]
Abstract
Introduction We studied associations of the stress hormones copeptin and cortisol with outcome and organ dysfunction after out-of-hospital cardiac arrest (OHCA). Methods Plasma was obtained after consent from next of kin in the FINNRESUSCI study conducted in 21 Finnish intensive care units (ICUs) between 2010 and 2011. We measured plasma copeptin (pmol/L) and free cortisol (nmol/L) on ICU admission (245 patients) and at 48 hours (additional 33 patients). Organ dysfunction was categorised with 24-hour Sequential Organ Failure Assessment (SOFA) scores. Twelve-month neurological outcome (available in 276 patients) was classified with cerebral performance categories (CPC) and dichotomised into good (CPC 1 or 2) or poor (CPC 3 to 5). Data are presented as medians and interquartile ranges (IQRs). A Mann–Whitney U test, multiple linear and logistic regression tests with odds ratios (ORs) 95% confidence intervals (CIs) and beta (B) values, repeated measure analysis of variance, and receiver operating characteristic curves with area under the curve (AUC) were performed. Results Patients with a poor 12-month outcome had higher levels of admission copeptin (89, IQR 41 to 193 versus 51, IQR 29 to 111 pmol/L, P = 0.0014) and cortisol (728, IQR 522 to 1,017 versus 576, IQR 355 to 850 nmol/L, P = 0.0013). Copeptin levels fell between admission and 48 hours (P <0.001), independently of outcome (P = 0.847). Cortisol levels did not change between admission and 48 hours (P = 0.313), independently of outcome (P = 0.221). The AUC for predicting long-term outcome was weak for copeptin (0.62, 95% CI 0.55 to 0.69) and cortisol (0.62, 95% CI 0.54 to 0.69). With logistic regression, admission copeptin (standard deviation (SD) increase OR 1.4, 95% CI 1.03 to 1.98) and cortisol (SD increase OR 1.5, 95% CI 1.1 to 2.0) predicted ICU mortality but not 12-month outcome. Admission factors correlating with SOFA were shockable rhythm (B −1.3, 95% CI −2.2 to −0.5), adrenaline use (B 1.1, 95% CI 0.2 to 2.0), therapeutic hypothermia (B 1.3 95% CI 0.4-2.2), and copeptin (B 0.04, 95% CI 0.02 to 0.07). Conclusions Admission copeptin and free cortisol were not of prognostic value regarding 12-month neurological outcome after OHCA. Higher admission copeptin and cortisol were associated with ICU death, and copeptin predicted subsequent organ dysfunction. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-0831-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Giuseppe Ristagno
- Department of Cardiovascular Research, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Via La Masa, 19 - 20156 Milano, Milan, Italy.
| | - Roberto Latini
- Department of Cardiovascular Research, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Via La Masa, 19 - 20156 Milano, Milan, Italy.
| | - Mario Plebani
- Department of Laboratory Medicine, University-Hospital of Padova, Via Giustiniani 2, 35128, Padova, Italy.
| | - Martina Zaninotto
- Department of Laboratory Medicine, University-Hospital of Padova, Via Giustiniani 2, 35128, Padova, Italy.
| | - Jukka Vaahersalo
- Division of Intensive Care Medicine, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, 00290, Helsinki, Finland.
| | - Serge Masson
- Department of Cardiovascular Research, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Via La Masa, 19 - 20156 Milano, Milan, Italy.
| | - Marjaana Tiainen
- Department of Neurology, Helsinki University Hospital, Haartmaninkatu 4, 00290, Helsinki, Finland.
| | - Jouni Kurola
- Centre for Prehospital Emergency Care, Kuopio University Hospital, P.O. Box 100, FI 70029, Kuopio, Finland.
| | - Flavio Gaspari
- Laboratory of Pharmacokinetics and Clinical Chemistry, IRCCS-Istituto di Ricerche Farmacologiche 'Mario Negri', Villa Camozzi, 24020, Ranica, Italy.
| | - Valentina Milani
- Department of Cardiovascular Research, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Via La Masa, 19 - 20156 Milano, Milan, Italy.
| | - Ville Pettilä
- Division of Intensive Care Medicine, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, 00290, Helsinki, Finland.
| | - Markus Benedikt Skrifvars
- Division of Intensive Care Medicine, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, 00290, Helsinki, Finland.
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Buddineni JP, Callaway C, Huang DT. Epinephrine, vasopressin and steroids for in-hospital cardiac arrest: the right cocktail therapy? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:308. [PMID: 25043404 PMCID: PMC4075112 DOI: 10.1186/cc13903] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Tavakoli N, Bidari A, Shams Vahdati S. Serum Cortisol Levels as a Predictor of Neurologic Survival inSuccessfully Resuscitated Victims of Cardiopulmonary Arrest. J Cardiovasc Thorac Res 2012; 4:107-11. [PMID: 24250997 DOI: 10.5681/jcvtr.2012.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2012] [Accepted: 10/08/2012] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Out-of-hospital cardiac arrest (OHCA) is the most stressful lifetime event for the victims and an important issue for the emergency physicians. The status of the hypothalamic pituitary- adrenal axis (HPA) function in successfully resuscitated victims of cardiopulmonary arrest has been recently of an interest for the researchers. METHODS In a prospective cohort study, 50 successfully resuscitated OHCA victims' serum cortisol levels were measured 5 minutes and 1 hour after return of spontaneous circulation (ROSC). The data were analyzed comparing the one-week neurologic survival. RESULTS Fifty blood samples were obtained for serum cortisol levels after 5 minutes of ROSC. Fourteen patients (28%) pronounced death during one hour after CPR. Blood sample from living 36 patients after one hour post-CPR were obtained for second cortisol assay. Eleven patients (22%) were neurologically survived after one week. Seven patients (14%) were discharged finally from hospital with good neurologic recovery. The serum cortisol levels in both the neurologically surviving and the non-surviving after 5 minutes of ROSC patients were 63.4 ±13.6 and 43.2±25.5(microg/ml), (mean±S.D., respectively) and after 1 hour of ROSC patients' serum cortisol levels were 64.9±13.1 and 47.3±27.1(microg/ml), (mean±S.D., respectively). The difference was significantly higher in neurologically survived group in both 5 minutes and 1 hour after ROSC (P= 0.015 and 0.013 respectively). CONCLUSION serum cortisol levels after 5 minutes and one hour of ROSC in victims of cardiopulmonary arrest are significantly higher in neurologically survived than non-survived patients.
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Affiliation(s)
- Nader Tavakoli
- Department of Emergency Medicine, Hazrate-Rasul Hospital ,Tehran University of Medical Science, Tehran, Iran
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Schneider A, Albertsmeier M, Böttiger BW, Teschendorf P. [Post-resuscitation syndrome. Role of inflammation after cardiac arrest]. Anaesthesist 2012; 61:424-36. [PMID: 22576987 DOI: 10.1007/s00101-012-2002-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Cardiac arrest with subsequent cardiopulmonary resuscitation causes an ischemic reperfusion syndrome of the whole body resulting in localized damage of particularly sensitive organs, such as the brain and heart, together with systemic sequelae. The main factor is a generalized activation of inflammatory reactions resulting in symptoms similar in many aspects to those of sepsis. Systemic inflammation strengthens organ damage due to disorders in the macrocirculation and microcirculation due to metabolic imbalance as well as the effects of direct leukocyte transmitted tissue destruction. The current article gives an overview on the role of inflammation following cardiac arrest and presents in detail the underlying mechanisms, the clinical symptoms and possible therapeutic approaches.
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Affiliation(s)
- A Schneider
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Köln, Kerpener Str. 62, 50937 Köln, Deutschland.
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Smarick SD, Haskins SC, Boller M, Fletcher DJ. RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 6: Post-cardiac arrest care. J Vet Emerg Crit Care (San Antonio) 2012; 22 Suppl 1:S85-101. [DOI: 10.1111/j.1476-4431.2012.00754.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | | | - Manuel Boller
- Department of Emergency Medicine, Center for Resuscitation Science, School of Medicine, and the Department of Clinical Studies; School of Veterinary Medicine, University of Pennsylvania; Philadelphia; PA
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Chalkias A, Xanthos T. Post-cardiac arrest syndrome: Mechanisms and evaluation of adrenal insufficiency. World J Crit Care Med 2012; 1:4-9. [PMID: 24701395 PMCID: PMC3956066 DOI: 10.5492/wjccm.v1.i1.4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Revised: 10/18/2011] [Accepted: 12/21/2011] [Indexed: 02/06/2023] Open
Abstract
Cardiac arrest is one of the leading causes of death and represents maximal stress in humans. After restoration of spontaneous circulation, post-cardiac arrest syndrome is the predominant disorder in survivors. Besides the post-arrest brain injury, the post-resuscitation myocardial stunning, and the systemic ischemia/reperfusion response, this syndrome is characterized by adrenal insufficiency, a disorder that often remains undiagnosed. The pathophysiology of adrenal insufficiency has not been elucidated. We performed a comprehensive search of three medical databases in order to describe the major pathophysiological disturbances which are responsible for the occurrence of the disorder. Based on the available evidence, this article will help physicians to better evaluate and understand the hidden yet deadly post-cardiac arrest adrenal insufficiency.
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Affiliation(s)
- Athanasios Chalkias
- Athanasios Chalkias, Theodoros Xanthos, Department of Anatomy, Medical School, University of Athens, 11527 Athens, Greece
| | - Theodoros Xanthos
- Athanasios Chalkias, Theodoros Xanthos, Department of Anatomy, Medical School, University of Athens, 11527 Athens, Greece
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Reynolds JC, Lawner BJ. Management of the post-cardiac arrest syndrome. J Emerg Med 2012; 42:440-9. [PMID: 22281034 DOI: 10.1016/j.jemermed.2011.09.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 05/23/2011] [Accepted: 09/27/2011] [Indexed: 11/18/2022]
Abstract
BACKGROUND Recent advances in resuscitation science have revolutionized care of the cardiac arrest patient. Dramatic departures from time-honored advanced cardiac life support therapies, such as cardiocerebral resuscitation and bundled post-arrest care, have given rise to a new paradigm of resuscitation practices, which has boosted the rate of neurologically intact survival. OBJECTIVES This article reviews the pathophysiology of the post-cardiac arrest syndrome, the collective pathophysiology after return of spontaneous circulation, and presents management pearls specifically for the emergency physician. This growing area of scientific inquiry must be managed appropriately to sustain improved outcomes. DISCUSSION The emergency physician must understand this pathophysiology, manage resuscitated patients according to the latest evidence, and coordinate with appropriate inpatient resources. CONCLUSION The new approach to cardiac arrest care is predicated on a chain of survival that spans the spectrum of care from the prehospital arena through the emergency, intensive, and inpatient settings. The emergency physician is a crucial link in this chain.
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Affiliation(s)
- Joshua C Reynolds
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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Mongardon N, Dumas F, Ricome S, Grimaldi D, Hissem T, Pène F, Cariou A. Postcardiac arrest syndrome: from immediate resuscitation to long-term outcome. Ann Intensive Care 2011; 1:45. [PMID: 22053891 PMCID: PMC3223497 DOI: 10.1186/2110-5820-1-45] [Citation(s) in RCA: 151] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Accepted: 11/03/2011] [Indexed: 11/15/2022] Open
Abstract
The prognosis for postcardiac arrest patients remains very bleak, not only because of anoxic-ischemic neurological damage, but also because of the "postcardiac arrest syndrome," a phenomenon often severe enough to cause death before any neurological evaluation. This syndrome includes all clinical and biological manifestations related to the phenomenon of global ischemia-reperfusion triggered by cardiac arrest and return of spontaneous circulation. The main component of the postcardiac arrest syndrome is an early but severe cardiocirculatory dysfunction that may lead to multiple organ failure and death. Cardiovascular support relies on conventional medical and mechanical treatment of circulatory failure. Hemodynamic stabilization is a major objective to limit secondary brain insult. When the cause of cardiac arrest is related to myocardial infarction, percutaneous coronary revascularization is associated with improved prognosis; early angiographic exploration should then be discussed when there is no obvious extracardiac cause. Therapeutic hypothermia is now the cornerstone of postanoxic cerebral protection. Its widespread use is clearly recommended, with a favorable risk-benefit ratio in selected population. Neuroprotection also is based on the prevention of secondary cerebral damages, pending the results of ongoing therapeutic evaluations regarding the potential efficiency of new therapeutic drugs.
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Affiliation(s)
- Nicolas Mongardon
- Medical Intensive Care Unit, Cochin Hospital, Groupe Hospitalier Universtitaire Cochin Broca Hôtel-Dieu, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France.
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Kaji AH, Hanif AM, Thomas JL, Niemann JT. Out-of-hospital cardiac arrest: early in-hospital hypotension versus out-of-hospital factors in predicting in-hospital mortality among those surviving to hospital admission. Resuscitation 2011; 82:1314-7. [PMID: 21723027 DOI: 10.1016/j.resuscitation.2011.05.030] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Accepted: 05/18/2011] [Indexed: 01/21/2023]
Abstract
OBJECTIVE The purpose of this study was to determine the prevalence of in-hospital hypotension in patients surviving to admission after resuscitation from out-of-hospital cardiac arrest and compare it to that of traditional Utstein factors in predicting in-hospital mortality. METHODS Single-center retrospective cohort of adult patients surviving to hospital admission after resuscitation from out-of-hospital sudden death between January 1, 2006 and October 31, 2009. Study variables included Utstein template data: age, sex, initial rhythm, witnessed or nonwitnessed arrest, presence or absence of bystander CPR, location of arrest, response time (time of 9-1-1 dispatch to first vehicle arrival), and hypotension (systolic pressure<90 or mean arterial pressure<60) within 24h of ROSC. Univariate comparisons of categorical variables were performed and the Wilcoxon rank-sum test was used to compare continuous variables. Multivariable logistic regression was then performed after inclusion of Utstein variables. RESULTS 73 patients met the inclusion criteria, and in-hospital mortality occurred in 54 (74%). On univariate analysis, in-hospital hypotension (OR=3.5, 95%CI 1.1-10.0, p=0.02), pre-hospital rhythm other than VF/VT (OR 4.3, 95%CI 1.4-13.3, p=0.008), and an unwitnessed arrest (OR=6.9, 95%CI 0.8-56.5, p=0.04), were significant predictors of in-hospital mortality. On multivariable analysis, in-hospital hypotension (OR=9.8, 95%CI 1.5, 63.0, p=0.02), pre-hospital rhythm other than VT/VF (OR=8.5, 95%CI 1.3-58.8, p=0.03), and lack of bystander CPR (OR=13.2, 95%CI 1.6-111, p=0.02) remained statistically significant predictors of in-hospital mortality. CONCLUSIONS In-hospital hypotension was predictive of mortality, as was a pre-hospital nonshockable rhythm and lack of bystander CPR. In contrast, traditional pre-hospital risk factors: age, gender, public location of arrest, response time, and witnessed arrest, were not predictive.
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Affiliation(s)
- Amy H Kaji
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA
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Kim JJ, Hyun SY, Hwang SY, Jung YB, Shin JH, Lim YS, Cho JS, Yang HJ, Lee G. Hormonal responses upon return of spontaneous circulation after cardiac arrest: a retrospective cohort study. Crit Care 2011; 15:R53. [PMID: 21299901 PMCID: PMC3221984 DOI: 10.1186/cc10019] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Revised: 12/29/2010] [Accepted: 02/07/2011] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Cardiac arrest is often fatal and can be extremely stressful to patients, even if spontaneous rhythm is returned. The purpose of this study was to analyze the hormonal response after return of spontaneous circulation (ROSC). METHODS This is a retrospective review of the chart and laboratory findings in a single medical facility. The patients admitted to the intensive care unit after successful resuscitation after out-of-hospital cardiac arrest were retrospectively identified and evaluated. Patients with hormonal diseases, patients who received cortisol treatment, those experiencing trauma, and pregnant women were excluded. Serum cortisol, adrenocorticotropic hormone (ACTH), and anti-diuretic hormone (ADH (vasopressin)) were analyzed and a corticotropin-stimulation test was performed. Mortality at one week and one month after admission, and neurologic outcome (cerebral performance category (CPC)) one month after admission were evaluated. RESULTS A total of 117 patients, including 84 males (71.8%), were evaluated in this study. One week and one month after admission, 87 (74.4%) and 65 patients (55.6%) survived, respectively. Relative adrenal insufficiency, and higher plasma ACTH and ADH levels were associated with shock-related mortality (P = 0.046, 0.005, and 0.037, respectively), and ACTH and ADH levels were also associated with late mortality (P = 0.002 and 0.004, respectively). Patients with relative adrenal insufficiency, ACTH ≧5 pg/mL, and ADH ≧30 pg/mL, had a two-fold increased risk of a poor outcome (shock-related mortality): (odds ratio (OR), 2.601 and 95% confidence interval (CI), 1.015 to 6.664; OR, 2.759 and 95% CI, 1.060 to 7.185; OR, 2.576 and 95% CI, 1.051 to 6.313, respectively). Thirty-five patients (29.9%) had a good CPC (1 to 2), and 82 patients (70.1%) had a bad CPC (3 to 5). Age ≧50 years and an ADH ≧30 pg/mL were associated with a bad CPC (OR, 4.564 and 95% CI, 1.794 to 11.612; OR, 6.568 and 95% CI, 1.918 to 22.483, respectively). CONCLUSIONS The patients with relative adrenal insufficiency and higher blood levels of ACTH and ADH upon ROSC after cardiac arrest had a poor outcome. The effectiveness of administration of cortisol and ADH to patients upon ROSC after cardiac arrest is uncertain and additional studies are needed.
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Affiliation(s)
- Jin Joo Kim
- 1Department of Emergency Medicine, Gachon University Gil Hospital, 1198Guwoldong Namdonggu Incheon 405-760, South Korea
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L’arrêt cardiaque — Protection cérébrale post-arrêt cardiaque. MEDECINE INTENSIVE REANIMATION 2011. [DOI: 10.1007/s13546-010-0038-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Elbuken G, Karaca Z, Tanriverdi F, Unluhizarci K, Kelestimur F. Assessment of the hypothalamic-pituitary-adrenal axis in critical illness. Expert Rev Endocrinol Metab 2011; 6:35-48. [PMID: 30764034 DOI: 10.1586/eem.10.80] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Cortisol is the main corticosteroid secreted from the human adrenal cortex, and it has a crucial role for survival in stressful conditions. An adequate increase in levels of cortisol helps patients to cope with the severity of the disease in the acute phase of critical illness. Either higher or lower than expected cortisol levels were found to be related to increased mortality. Prolonged activation of the hypothalamic-pituitary-adrenal (HPA) axis can result in hypercortisolemia or hypocortisolemia; both can be detrimental to recovery from critical illness. Primary and secondary adrenal insufficiency, relative adrenal insufficiency, tissue resistance to glucocorticoids, adrenocorticotrophic hormone deficiency and immune-mediated inhibition of the HPA axis can be the cause of the impairment of the secretion or action of cortisol in critically ill patients. Recently, some authors offered the term 'critical illness-related corticosteroid insufficiency' to better point out the relative adrenal insufficiency that is seen during critical illness. Patients with critical illness-related corticosteroid insufficiency not only have insufficient circulating cortisol but also have impaired cellular utilization of cortisol. In this article, how adrenal dysfunction presents in critical illness and how appropriate diagnosis and management can be achieved in the critical care setting will be discussed.
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Affiliation(s)
- Gulsah Elbuken
- a Department of Endocrinology and Metabolism, Erciyes University Medical School, 38039, Kayseri, Turkey
| | - Zuleyha Karaca
- a Department of Endocrinology and Metabolism, Erciyes University Medical School, 38039, Kayseri, Turkey
| | - Fatih Tanriverdi
- a Department of Endocrinology and Metabolism, Erciyes University Medical School, 38039, Kayseri, Turkey
| | - Kursad Unluhizarci
- a Department of Endocrinology and Metabolism, Erciyes University Medical School, 38039, Kayseri, Turkey
| | - Fahrettin Kelestimur
- a Department of Endocrinology and Metabolism, Erciyes University Medical School, 38039, Kayseri, Turkey
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