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Yao Z, Zhao Y, Lu L, Li Y, Yu Z. Extracerebral multiple organ dysfunction and interactions with brain injury after cardiac arrest. Resusc Plus 2024; 19:100719. [PMID: 39149223 PMCID: PMC11325081 DOI: 10.1016/j.resplu.2024.100719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 07/02/2024] [Accepted: 07/03/2024] [Indexed: 08/17/2024] Open
Abstract
Cardiac arrest and successful resuscitation cause whole-body ischemia and reperfusion, leading to brain injury and extracerebral multiple organ dysfunction. Brain injury is the leading cause of death and long-term disability in resuscitated survivors, and was conceptualized and treated as an isolated injury, which has neglected the brain-visceral organ crosstalk. Extracerebral organ dysfunction is common and is significantly associated with mortality and poor neurological prognosis after resuscitation. However, detailed description of the characteristics of post-resuscitation multiple organ dysfunction is lacking, and the bidirectional interactions between brain and visceral organs need to be elucidated to explore new treatment for neuroprotection. This review aims to describe current concepts of post-cardiac arrest brain injury and specific characteristics of post-resuscitation dysfunction in cardiovascular, respiratory, renal, hepatic, adrenal, gastrointestinal, and neurohumoral systems. Additionally, we discuss the crosstalk between brain and extracerebral organs, especially focusing on how visceral organ dysfunction and other factors affect brain injury progression. We think that clarifying these interactions is of profound significance on how we treat patients for neural/systemic protection to improve outcome.
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Affiliation(s)
- Zhun Yao
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Yuanrui Zhao
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Liping Lu
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Yinping Li
- Department of Pathophysiology, Hubei Province Key Laboratory of Allergy and Immunology, Taikang Medical School (School of Basic Medical Sciences), Wuhan University, Wuhan 430060, China
| | - Zhui Yu
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan 430060, China
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Marchese G, Bungaro E, Magliocca A, Fumagalli F, Merigo G, Semeraro F, Mereto E, Babini G, Roman-Pognuz E, Stirparo G, Cucino A, Ristagno G. Acute Lung Injury after Cardiopulmonary Resuscitation: A Narrative Review. J Clin Med 2024; 13:2498. [PMID: 38731027 PMCID: PMC11084269 DOI: 10.3390/jcm13092498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 04/15/2024] [Accepted: 04/21/2024] [Indexed: 05/13/2024] Open
Abstract
Although cardiopulmonary resuscitation (CPR) includes lifesaving maneuvers, it might be associated with a wide spectrum of iatrogenic injuries. Among these, acute lung injury (ALI) is frequent and yields significant challenges to post-cardiac arrest recovery. Understanding the relationship between CPR and ALI is determinant for refining resuscitation techniques and improving patient outcomes. This review aims to analyze the existing literature on ALI following CPR, emphasizing prevalence, clinical implications, and contributing factors. The review seeks to elucidate the pathogenesis of ALI in the context of CPR, assess the efficacy of CPR techniques and ventilation strategies, and explore their impact on post-cardiac arrest outcomes. CPR-related injuries, ranging from skeletal fractures to severe internal organ damage, underscore the complexity of managing post-cardiac arrest patients. Chest compression, particularly when prolonged and vigorous, i.e., mechanical compression, appears to be a crucial factor contributing to ALI, with the concept of cardiopulmonary resuscitation-associated lung edema (CRALE) gaining prominence. Ventilation strategies during CPR and post-cardiac arrest syndrome also play pivotal roles in ALI development. The recognition of CPR-related lung injuries, especially CRALE and ALI, highlights the need for research on optimizing CPR techniques and tailoring ventilation strategies during and after resuscitation.
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Affiliation(s)
- Giuseppe Marchese
- UOC Anestesia e Rianimazione, Ospedale Nuovo di Legnano, ASST Ovest Milanese, 20025 Legnano, Italy
| | - Elisabetta Bungaro
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy (A.M.); (E.M.)
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.M.)
| | - Aurora Magliocca
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy (A.M.); (E.M.)
| | - Francesca Fumagalli
- Department of Acute Brain and Cardiovascular Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20122 Milan, Italy
| | - Giulia Merigo
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.M.)
- Department of Biomedical Sciences for Health, University of Milan, 20122 Milan, Italy
| | - Federico Semeraro
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, 40133 Bologna, Italy
| | - Elisa Mereto
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy (A.M.); (E.M.)
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.M.)
| | - Giovanni Babini
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.M.)
| | - Erik Roman-Pognuz
- Department of Anesthesia and Intensive Care, University of Trieste, 34127 Trieste, Italy
| | | | - Alberto Cucino
- Department of Anaesthesia and Intensive Care Medicine, APSS, Provincia Autonoma di Trento, 38121 Trento, Italy;
| | - Giuseppe Ristagno
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy (A.M.); (E.M.)
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.M.)
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Katsandres SC, Hall J, Danielson K, Sakr S, Dean SG, Carlbom DJ, Wurfel MM, Bhatraju PK, Hippensteel JA, Schmidt EP, Oshima K, Counts CR, Sayre MR, Henning DJ, Johnson NJ. Inflammation, endothelial injury, and the acute respiratory distress syndrome after out-of-hospital cardiac arrest. Resusc Plus 2024; 17:100590. [PMID: 38463638 PMCID: PMC10924201 DOI: 10.1016/j.resplu.2024.100590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/07/2024] [Accepted: 02/13/2024] [Indexed: 03/12/2024] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) is often seen in patients resuscitated from out-of-hospital cardiac arrest (OHCA). We aim to test whether inflammatory or endothelial injury markers are associated with the development of ARDS in patients hospitalized after OHCA. Methods We conducted a prospective, cohort, pilot study at an urban academic medical center in 2019 that included a convenience sample of adults with non-traumatic OHCA. Blood and pulmonary edema fluid (PEF) were collected within 12 hours of hospital arrival. Samples were assayed for cytokines (interleukin [IL]-1, tumor necrosis factor-α [TNF-α], tumor necrosis factor receptor1 [TNFR1], IL-6), epithelial injury markers (pulmonary surfactant-associated protein D), endothelial injury markers (Angiopoietin-2 [Ang-2] and glycocalyx degradation products), and other proteins (matrix metallopeptidase-9 and myeloperoxidase). Patients were followed for 7 days for development of ARDS, as adjudicated by 3 blinded reviewers, and through hospital discharge for mortality and neurological outcome. We examined associations between biomarker concentrations and ARDS, hospital mortality, and neurological outcome using multivariable logistic regression. Latent phase analysis was used to identify distinct biological classes associated with outcomes. Results 41 patients were enrolled. Mean age was 58 years, 29% were female, and 22% had a respiratory etiology for cardiac arrest. Seven patients (17%) developed ARDS within 7 days. There were no significant associations between individual biomarkers and development of ARDS in adjusted analyses, nor survival or neurologic status after adjusting for use of targeted temperature management (TTM) and initial cardiac arrest rhythm. Elevated Ang-2 and TNFR-1 were associated with decreased survival (RR = 0.6, 95% CI = 0.3-1.0; RR = 0.5, 95% CI = 0.3-0.9; respectively), and poor neurologic status at discharge (RR = 0.4, 95% CI = 0.2-0.8; RR = 0.4, 95% CI = 0.2-0.9) in unadjusted associations. Conclusion OHCA patients have markedly elevated plasma and pulmonary edema fluid biomarker concentrations, indicating widespread inflammation, epithelial injury, and endothelial activation. Biomarker concentrations were not associated with ARDS development, though several distinct biological phenotypes warrant further exploration. Latent phase analysis demonstrated that patients with low biomarker levels aside from TNF-α and TNFR-1 (Class 2) fared worse than other patients. Future research may benefit from considering other tools to predict and prevent development of ARDS in this population.
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Affiliation(s)
- Sarah C. Katsandres
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, United States
| | - Jane Hall
- Department of Emergency Medicine, University of Washington, Seattle, WA, United States
| | - Kyle Danielson
- Airlift Northwest, University of Washington, Seattle, WA, United States
| | - Sana Sakr
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA, United States
| | - Sarah G. Dean
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA, United States
| | - David J. Carlbom
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA, United States
| | - Mark M. Wurfel
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA, United States
| | - Pavan K. Bhatraju
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA, United States
| | - Joseph A. Hippensteel
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Denver, CO, United States
| | - Eric P. Schmidt
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Kaori Oshima
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Catherine R. Counts
- Department of Emergency Medicine, University of Washington, Seattle, WA, United States
- Seattle Fire Department, Seattle, WA, United States
| | - Michael R. Sayre
- Department of Emergency Medicine, University of Washington, Seattle, WA, United States
- Seattle Fire Department, Seattle, WA, United States
| | | | - Nicholas J. Johnson
- Department of Emergency Medicine, University of Washington, Seattle, WA, United States
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA, United States
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Battaglini D, Bogossian EG, Anania P, Premraj L, Cho SM, Taccone FS, Sekhon M, Robba C. Monitoring of Brain Tissue Oxygen Tension in Cardiac Arrest: a Translational Systematic Review from Experimental to Clinical Evidence. Neurocrit Care 2024; 40:349-363. [PMID: 37081276 DOI: 10.1007/s12028-023-01721-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 03/24/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Cardiac arrest (CA) is a sudden event that is often characterized by hypoxic-ischemic brain injury (HIBI), leading to significant mortality and long-term disability. Brain tissue oxygenation (PbtO2) is an invasive tool for monitoring brain oxygen tension, but it is not routinely used in patients with CA because of the invasiveness and the absence of high-quality data on its effect on outcome. We conducted a systematic review of experimental and clinical evidence to understand the role of PbtO2 in monitoring brain oxygenation in HIBI after CA and the effect of targeted PbtO2 therapy on outcomes. METHODS The search was conducted using four search engines (PubMed, Scopus, Embase, and Cochrane), using the Boolean operator to combine mesh terms such as PbtO2, CA, and HIBI. RESULTS Among 1,077 records, 22 studies were included (16 experimental studies and six clinical studies). In experimental studies, PbtO2 was mainly adopted to assess the impact of gas exchanges, drugs, or systemic maneuvers on brain oxygenation. In human studies, PbtO2 was rarely used to monitor the brain oxygen tension in patients with CA and HIBI. PbtO2 values had no clear association with patients' outcomes, but in the experimental studies, brain tissue hypoxia was associated with increased inflammation and neuronal damage. CONCLUSIONS Further studies are needed to validate the effect and the threshold of PbtO2 associated with outcome in patients with CA, as well as to understand the physiological mechanisms influencing PbtO2 induced by gas exchanges, drug administration, and changes in body positioning after CA.
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Affiliation(s)
- Denise Battaglini
- Anesthesiology and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Elisa Gouvea Bogossian
- Department of Intensive Care, Hospital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Pasquale Anania
- Department of Neurosurgery, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.
| | - Lavienraj Premraj
- Griffith University School of Medicine, Gold Coast, QLD, Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Sung-Min Cho
- Departments of Neurology, Surgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hospital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Mypinder Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Chiara Robba
- Anesthesiology and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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van Veelen NM, Babst R, Link BC, van de Wall BJM, Beeres FJP. [Distal radius fracture-tactic and approach]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2023; 35:352-369. [PMID: 37395767 DOI: 10.1007/s00064-023-00818-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/21/2022] [Accepted: 12/25/2022] [Indexed: 07/04/2023]
Abstract
OBJECTIVE The aim of surgical treatment is fracture healing with restored alignment, rotation, and joint surface. Stable fixation allows for functional postoperative aftercare. INDICATIONS Displaced intra- and extra-articular fractures which either could not be adequately reduced or in which a secondary displacement is to expected due to instability criteria. The following factors are considered instability criteria: age > 60 years, female, initial dorsal displacement > 20°, dorsal comminution, radial shortening > 5 mm, palmar displacement. CONTRAINDICATIONS The only absolute contraindication is if the patient is deemed unfit for surgery due to concerns regarding anesthesia. Old age is a relative contraindication, as it is currently debated whether older patients benefit from the operation. SURGICAL TECHNIQUE The surgical technique is guided by the fracture pattern. Palmar plating is most commonly performed. If the joint surface needs to be visualized, a dorsal approach (in combination with another approach or alone) or arthroscopically assisted fixation should be chosen. POSTOPERATIVE MANAGEMENT In general, a functional postoperative regime can be carried out after plate fixation with mobilization without weightbearing. Short-term splinting can provide pain relief. Concomitant ligamentous injuries and fixations, which are not stable enough for functional aftercare (such as k‑wires) require a longer period of immobilization. RESULTS Provided the fracture is reduced correctly, osteosynthesis improves functional outcome. The complication rate ranges between 9 and 15% with the most common complication being tendon irritation/rupture and plate removal. Whether surgical treatment holds the same benefits for patients > 65 years as for younger patients is currently under debate.
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Affiliation(s)
- Nicole M van Veelen
- Klinik für Orthopädie und Unfallchirurgie, Luzerner Kantonsspital, Spitalstrasse, 6000, Luzern, Schweiz.
| | - Reto Babst
- Klinik für Orthopädie und Unfallchirurgie, Luzerner Kantonsspital, Spitalstrasse, 6000, Luzern, Schweiz
- Fakultät für Gesundheitswissenschaften und Medizin, Universität Luzern, Frohburgstrasse 3, 6002, Luzern, Schweiz
| | - Björn-Christian Link
- Klinik für Orthopädie und Unfallchirurgie, Luzerner Kantonsspital, Spitalstrasse, 6000, Luzern, Schweiz
| | - Bryan J M van de Wall
- Klinik für Orthopädie und Unfallchirurgie, Luzerner Kantonsspital, Spitalstrasse, 6000, Luzern, Schweiz
| | - Frank J P Beeres
- Klinik für Orthopädie und Unfallchirurgie, Luzerner Kantonsspital, Spitalstrasse, 6000, Luzern, Schweiz
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Nakayama R, Bunya N, Uemura S, Sawamoto K, Narimatsu E. Prehospital Advanced Airway Management and Ventilation for Out-of-Hospital Cardiac Arrest with Prehospital Return of Spontaneous Circulation: A Prospective Observational Cohort Study in Japan. PREHOSP EMERG CARE 2023; 28:470-477. [PMID: 37748189 DOI: 10.1080/10903127.2023.2260479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 09/12/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND The relationship among advanced airway management (AAM), ventilation, and oxygenation in patients with out-of-hospital cardiac arrest (OHCA) who achieve prehospital return of spontaneous circulation (ROSC) has not been validated. This study was designed to evaluate ventilation and oxygenation for each AAM technique (supraglottic devices [SGA] or endotracheal intubation [ETI]) using arterial blood gas (ABG) results immediately after hospital arrival. METHODS This observational cohort study, using data from the Japanese Association for Acute Medicine OHCA Registry, included patients with OHCA with prehospital and hospital arrival ROSC between July 1, 2014, and December 31, 2019. The primary outcomes were the partial pressure of carbon dioxide in the arterial blood (PaCO2) and partial pressure of oxygen in the arterial blood (PaO2) in the initial ABG at the hospital for each AAM technique (SGA or ETI) performed by paramedics. The secondary outcome was favorable neurological outcome (cerebral performance category [CPC] 1 or 2) for specific PaCO2 levels, which were defined as good ventilation (PaCO2 ≤45 mmHg) and insufficient ventilation (PaCO2 >45 mmHg). RESULTS This study included 1,527 patients. Regarding AAM, 1,114 and 413 patients were ventilated using SGA and ETI, respectively. The median PaCO2 and PaO2 levels were 74.50 mmHg and 151.35 mmHg in the SGA group, while 66.30 mmHg and 173.50 mmHg in the ETI group. PaCO2 was significantly lower in the ETI group than in the SGA group (12.55 mmHg; 95% CI 15.27 to 8.20, P-value < 0.001), while no significant difference was found in PaO2 by multivariate linear regression analysis. After stabilizing inverse probability of weighting (IPW), the adjusted odds ratio for favorable neurological outcome at 1 month was significant in the good ventilation group compared to the insufficient ventilation cohort (adjusted odds ratio = 2.12, 95%CI: 1.40 to 3.19, P value < 0.001). CONCLUSION The study showed that in OHCA patients with prehospital ROSC, the PaCO2 levels in the initial ABG were lower in the group with AAM by ETI than in the SGA group. Furthermore, patients with prehospital ROSC and PaCO2 ≤45 mmHg on arrival had an increased odds of favorable neurological outcome after stabilized IPW adjustment.
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Affiliation(s)
- Ryuichi Nakayama
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Naofumi Bunya
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Shuji Uemura
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Keigo Sawamoto
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Eichi Narimatsu
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
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Cotter EKH, Jacobs M, Jain N, Chow J, Estimé SR. Post-cardiac arrest care in the intensive care unit. Int Anesthesiol Clin 2023; 61:71-78. [PMID: 37678200 DOI: 10.1097/aia.0000000000000418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Affiliation(s)
- Elizabeth K H Cotter
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas
| | - Matthew Jacobs
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, Illinois
| | - Nisha Jain
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, Illinois
| | - Jarva Chow
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, Illinois
| | - Stephen R Estimé
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, Illinois
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Li Y, Yang M, Xie L, Zhang G, Xu J, Xu S. SULFORAPHANE ALLEVIATES POSTRESUSCITATION LUNG PYROPTOSIS POSSIBLY VIA ACTIVATING THE NRF2/HO-1 PATHWAY. Shock 2023; 60:427-433. [PMID: 37548635 DOI: 10.1097/shk.0000000000002180] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
ABSTRACT Introduction: Sulforaphane (SFN), known as the activator of the nuclear factor E2-related factor 2 (Nrf2)/heme oxygenase 1 (HO-1) pathway, has been proven to protect the lung against various pathological stimuli. The present study aimed to investigate the effect of SFN on lung injury induced by systemic ischemia reperfusion after cardiac arrest and resuscitation. Methods: After animal preparation, 24 pigs were randomly divided into sham group (n = 6), cardiopulmonary resuscitation group (CPR, n = 9), or CPR + SFN group (n = 9). The experimental model was then established by 10 min of cardiac arrest followed by 6 min of CPR. Once spontaneous circulation was achieved, a dose of 2 mg/kg of SFN diluted in 20 mL of saline was intravenously infused with a duration of 5 min. During 4 h of observation after resuscitation, extravascular lung water index (ELWI), pulmonary vascular permeability index (PVPI), and oxygenation index were regularly evaluated. At 24 h after resuscitation, lung tissues were harvested to evaluate the score of lung histopathological injury, the activity of superoxide dismutase, the contents of malondialdehyde, IL-1β, and IL-18, and the expression levels of NOD-like receptor pyrin domain 3, cleaved caspase 1, gasdermin D (GSDMD), GSDMD N-terminal, Nrf2, and HO-1. Results: During CPR, spontaneous circulation was achieved in six and seven pigs in the CPR and CPR + SFN groups, respectively. After resuscitation, the indicators of lung injury (ELWI, PVPI, and oxygenation index) were all better in the CPR + SFN group than in the CPR group, in which the differences in ELWI and PVPI at 2, and 4 h after resuscitation were significant between the two groups. In addition, SFN significantly reduced lung injury score, improved oxidative imbalance (superoxide dismutase, malondialdehyde), decreased pyroptosis-related proinflammatory cytokines (IL-1β, IL-18), downregulated pyroptosis-related proteins (NOD-like receptor pyrin domain 3, cleaved caspase 1, GSDMD, GSDMD N-terminal), and activated the Nrf2/HO-1 pathway when compared with the CPR group. Conclusion: SFN produced effective postresuscitation lung protection through alleviating lung pyroptosis possibly via activating the Nrf2/HO-1 pathway in pigs.
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Frisvold S, Coppola S, Ehrmann S, Chiumello D, Guérin C. Respiratory challenges and ventilatory management in different types of acute brain-injured patients. Crit Care 2023; 27:247. [PMID: 37353832 PMCID: PMC10290317 DOI: 10.1186/s13054-023-04532-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 06/15/2023] [Indexed: 06/25/2023] Open
Abstract
Acute brain injury (ABI) covers various clinical entities that may require invasive mechanical ventilation (MV) in the intensive care unit (ICU). The goal of MV, which is to protect the lung and the brain from further injury, may be difficult to achieve in the most severe forms of lung or brain injury. This narrative review aims to address the respiratory issues and ventilator management, specific to ABI patients in the ICU.
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Affiliation(s)
- S Frisvold
- Department of Anesthesia and Intensive Care, University Hospital of North Norway, Tromso, Norway
- Department of Clinical Medicine, UiT the Arctic University of Norway, Tromso, Norway
| | - S Coppola
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy
- Department of Health Sciences, University of Milan, Milan, Italy
- Coordinated Research Center On Respiratory Failure, University of Milan, Milan, Italy
| | - S Ehrmann
- CHRU Tours, Médecine Intensive Réanimation, CIC INSERM 1415, CRICS-TriggerSep F-CRIN Research Network, Tours, France
- INSERM, Centre d'étude Des Pathologies Respiratoires, U1100, Université de Tours, Tours, France
| | - D Chiumello
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy
- Department of Health Sciences, University of Milan, Milan, Italy
- Coordinated Research Center On Respiratory Failure, University of Milan, Milan, Italy
| | - Claude Guérin
- Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 8 Avenue Rockefeller, 69008, Lyon, France.
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van Veelen NM, Buenter L, Kremo V, Peek J, Leiser A, Kestenholz P, Babst R, Paulus Beeres FJ, Minervini F. Outcomes after fixation of rib fractures sustained during cardiopulmonary resuscitation: A retrospective single center analysis. Front Surg 2023; 10:1120399. [PMID: 36755767 PMCID: PMC9899886 DOI: 10.3389/fsurg.2023.1120399] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 01/04/2023] [Indexed: 01/24/2023] Open
Abstract
Background Historically rib fractures have been typically treated non-operatively. Recent studies showed promising results after osteosynthesis of rib fractures in trauma patients with flail segments or multiple rib fractures. However, there is a paucity of data on rib fixation after cardiopulmonary resuscitation (CPR). This study evaluated the outcomes of patients who received rib fixation after CPR. Methods Adult patients who received surgical fixation of rib fractures sustained during CPR between 2010 and 2020 were eligible for inclusion in this retrospective study. Outcome measures included complications, quality of life (EQ 5D 5L) and level of dyspnea. Results Nineteen patients were included with a mean age of 66.8 years. The mean number of fractured ribs was ten, seven patients additionally had a sternum fracture. Pneumonia occurred in 15 patients (74%), of which 13 were diagnosed preoperatively and 2 post-operatively. Six patients developed a postoperative pneumothorax, none of which required revision surgery. One patient showed persistent flail chest after rib fixation and required additional fixation of a concomitant sternum fracture. One infection of the surgical site of sternal plate occurred, while no further surgery related complications were reported. Mean EQ-5D-5L was 0.908 and the average EQ VAS was 80. One patient reported persisting dyspnea. Conclusion To date, this is the largest reported cohort of patients who received rib fixation for fractures sustained during CPR. No complications associated with rib fixation were reported whereas one infection after sternal fixation did occur. Current follow-up demonstrated a good long-term quality of life after fixation, warranting further studies on this topic. Deeper knowledge on this subject would be beneficial for a wide spectrum of physicians.
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Affiliation(s)
- Nicole Maria van Veelen
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Lea Buenter
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Valérie Kremo
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Jesse Peek
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Alfred Leiser
- Department of Thoracic Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Peter Kestenholz
- Department of Thoracic Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Reto Babst
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland,Department of Health Science and Medicine, University of Lucerne, Lucerne, Switzerland
| | | | - Fabrizio Minervini
- Department of Thoracic Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland,Correspondence: Fabrizio Minervini
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11
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Gutierrez A, Kalra R, Elliott AM, Marquez A, Yannopoulos D, Bartos JA. Acute lung injury and recovery in patients with refractory VT/VF cardiac arrest treated with prolonged CPR and veno-arterial extracorporeal membrane oxygenation. Resuscitation 2023; 182:109651. [PMID: 36442595 DOI: 10.1016/j.resuscitation.2022.11.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 11/19/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022]
Abstract
AIM Describe the lung injury patterns among patients presenting with refractory ventricular tachycardia/ventricular fibrillation out-of-hospital cardiac arrest (VT/VF OHCA) supported with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) facilitated resuscitation. METHODS In this retrospective single-center cohort study including VT/VF OHCA patients supported with VA ECMO, we compared OHCA characteristics, post-arrest computed tomography (CT) scans, ventilator parameters, and other lung-related pathology between survivors, patients who developed brain death, and those with other causes of death. RESULTS Among 138 patients, 48/138 (34.8%) survived, 31/138 (22.4%) developed brain death, and 59/138 (42.7%) died of other causes. Successful extubation was achieved in 39/138 (28%) with a median time to extubation of 8.0 days (6.0, 11.0) in those who survived. Tracheostomy was required in 15/48 (31.3%) survivors. Chest CT obtained on all patients showed lung injury in at least one lung area in 124/135 (91.8%) patients, predominantly in the dependent posterior areas. There was no association between the number of affected areas and survival. Lung compliance was low on admission [26 (19,33) ml/cmH20], improved throughout hospitalization (p = 0.03), and recovered faster in survivors compared to those who died (p < 0.001). VA-ECMO allowed the use of lung-protective ventilation while maintaining normalized PaO2 and PaCO2. Patients treated with V-A ECMO and either IABP or Impella had lower pulmonary compliance and more affected areas on their CT compared to those treated with V-A ECMO alone. CONCLUSIONS Lung injury is common among patients with refractory VT/VF OHCA requiring V-A ECMO, but imaging severity is not associated with survival. Reductions in lung compliance accompany post-arrest lung injury while compliance recovery is associated with survival.
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Affiliation(s)
- Alejandra Gutierrez
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States; Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States.
| | - Rajat Kalra
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States; Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Andrea M Elliott
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States; Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Alexandra Marquez
- Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States; Pediatric Cardiology Critical Care, Children's Hospital, University of Minnesota, United States
| | - Demetris Yannopoulos
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States; Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Jason A Bartos
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States; Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
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12
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Abrahamowicz AA, Counts CR, Danielson KR, Bulger NE, Maynard C, Carlbom DJ, Swenson ER, Latimer AJ, Yang B, Sayre MR, Johnson NJ. The association between arterial-end-tidal carbon dioxide difference and outcomes after out-of-hospital cardiac arrest. Resuscitation 2022; 181:3-9. [PMID: 36183813 DOI: 10.1016/j.resuscitation.2022.09.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 09/14/2022] [Accepted: 09/23/2022] [Indexed: 02/01/2023]
Abstract
AIM We sought to determine if the difference between PaCO2 and ETCO2 is associated with hospital mortality and neurologic outcome following out-of-hospital cardiac arrest (OHCA). METHODS This was a retrospective cohort study of adult patients who achieved return of spontaneous circulation (ROSC) after OHCA over 3 years. The primary exposure was the PaCO2-ETCO2 difference on hospital arrival. The primary outcome was survival to hospital discharge. The secondary outcome was favorable neurologic status at discharge. We used receiver operating characteristic (ROC) curves to determine discrimination threshold and multivariate logistic regression to examine the association between the PaCO2-ETCO2 difference and outcome. RESULTS Of 698 OHCA patients transported to the hospitals, 381 had sustained ROSC and qualifying ETCO2 and PaCO2 values. Of these, 160 (42%) survived to hospital discharge. Mean ETCO2 was 39 mmHg among survivors and 43 mmHg among non-survivors. Mean PaCO2-ETCO2 was 6.8 mmHg and 9.0 mmHg (p < 0.05) for survivors and non-survivors. After adjustment for Utstein characteristics, a higher PaCO2-ETCO2 difference on hospital arrival was not associated with hospital mortality (OR 0.99, 95% CI: 0.97-1.0) or neurological outcome. Area under the ROC curve or PaCO2-ETCO2 difference was 0.56 (95% CI 0.51-0.62) compared with 0.58 (95% CI 0.52-0.64) for ETCO2. CONCLUSION Neither PaCO2-ETCO2 nor ETCO2 were strong predictors of survival or neurologic status at hospital discharge. While they may be useful to guide ventilation and resuscitation, these measures should not be used for prognostication after OHCA.
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Affiliation(s)
| | - Catherine R Counts
- Seattle Fire Department, Seattle, WA, United States; Department of Emergency Medicine, University of Washington, Seattle, WA, United States
| | | | | | - Charles Maynard
- Seattle Fire Department, Seattle, WA, United States; University of Washington School of Public Health, Seattle, WA, United States
| | - David J Carlbom
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States
| | - Erik R Swenson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States
| | - Andrew J Latimer
- Airlift Northwest, Seattle, WA, United States; Department of Emergency Medicine, University of Washington, Seattle, WA, United States
| | - Betty Yang
- Department of Emergency Medicine, University of Washington, Seattle, WA, United States
| | - Michael R Sayre
- Seattle Fire Department, Seattle, WA, United States; Department of Emergency Medicine, University of Washington, Seattle, WA, United States
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington, Seattle, WA, United States; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States.
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13
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Wu H, Xu S, Diao M, Wang J, Zhang G, Xu J. ALDA-1 TREATMENT ALLEVIATES LUNG INJURY AFTER CARDIAC ARREST AND RESUSCITATION IN SWINE. Shock 2022; 58:464-469. [PMID: 36156537 DOI: 10.1097/shk.0000000000002003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
ABSTRACT Introduction: Alda-1, an aldehyde dehydrogenase 2 (ALDH2) activator, has been shown to protect the lung against a variety of diseases including regional ischemia-reperfusion injury, severe hemorrhagic shock, hyperoxia, and so on. The present study was designed to investigate the effectiveness of Alda-1 treatment in alleviating lung injury after cardiac arrest (CA) and cardiopulmonary resuscitation (CPR) in swine. Methods: A total of 24 swine were randomized into three groups: sham (n = 6), CA/CPR (n = 10), and CA/CPR + Alda-1 (n = 8). The swine model was established by 8 min of electrically induced and untreated CA, and then 8 min of manual CPR. A dose of 0.88 mg/kg of Alda-1 was intravenously injected at 5 min after CA/CPR. After CA/CPR, extravascular lung water index (ELWI), pulmonary vascular permeability index (PVPI), and oxygenation index (OI) were regularly evaluated for 4 h. At 24 h after resuscitation, lung ALDH2 activity was detected, and its injury score, apoptosis, and ferroptosis were measured. Results: After experiencing the same procedure of CA and CPR, five swine in the CA/CPR group and six swine in the CA/CPR + Alda-1 group restored spontaneous circulation. Subsequently, significantly increased ELWI and PVPI, and markedly decreased OI were observed in these two groups compared with the sham group. However, all of them were gradually improved and significantly better in the swine treated with the Alda-1 compared with the CA/CPR group. Tissue analysis indicated that lung ALDH2 activity was significantly decreased in those swine experiencing the CA/CPR procedure compared with the sham group; nevertheless, its activity was significantly greater in the CA/CPR + Alda-1 group than in the CA/CPR group. In addition, lung injury score, and its apoptosis and ferroptosis were significantly increased in the CA/CPR and CA/CPR + Alda-1 groups compared with the sham group. Likewise, Alda-1 treatment significantly decreased these pathological damages in lung tissue when compared with the CA/CPR group. Conclusions: Alda-1 treatment was effective to alleviate lung injury after CA/CPR in a swine model, in which the protective role was possibly related to the inhibition of cell apoptosis and ferroptosis. It might provide a novel therapeutic target and a feasible therapeutic drug for lung protection after CA/CPR.
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Affiliation(s)
| | | | - Mengyuan Diao
- Department of Intensive Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | | | - Gongping Zhang
- Department of Emergency Medicine, Lishui Muncipal Central Hospital, Lishui, China
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14
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Robba C, Badenes R, Battaglini D, Ball L, Sanfilippo F, Brunetti I, Jakobsen JC, Lilja G, Friberg H, Wendel-Garcia PD, Young PJ, Eastwood G, Chew MS, Unden J, Thomas M, Joannidis M, Nichol A, Lundin A, Hollenberg J, Hammond N, Saxena M, Martin A, Solar M, Taccone FS, Dankiewicz J, Nielsen N, Grejs AM, Ebner F, Pelosi P. Oxygen targets and 6-month outcome after out of hospital cardiac arrest: a pre-planned sub-analysis of the targeted hypothermia versus targeted normothermia after Out-of-Hospital Cardiac Arrest (TTM2) trial. Crit Care 2022; 26:323. [PMID: 36271410 PMCID: PMC9585831 DOI: 10.1186/s13054-022-04186-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 10/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Optimal oxygen targets in patients resuscitated after cardiac arrest are uncertain. The primary aim of this study was to describe the values of partial pressure of oxygen values (PaO2) and the episodes of hypoxemia and hyperoxemia occurring within the first 72 h of mechanical ventilation in out of hospital cardiac arrest (OHCA) patients. The secondary aim was to evaluate the association of PaO2 with patients' outcome. METHODS Preplanned secondary analysis of the targeted hypothermia versus targeted normothermia after OHCA (TTM2) trial. Arterial blood gases values were collected from randomization every 4 h for the first 32 h, and then, every 8 h until day 3. Hypoxemia was defined as PaO2 < 60 mmHg and severe hyperoxemia as PaO2 > 300 mmHg. Mortality and poor neurological outcome (defined according to modified Rankin scale) were collected at 6 months. RESULTS 1418 patients were included in the analysis. The mean age was 64 ± 14 years, and 292 patients (20.6%) were female. 24.9% of patients had at least one episode of hypoxemia, and 7.6% of patients had at least one episode of severe hyperoxemia. Both hypoxemia and hyperoxemia were independently associated with 6-month mortality, but not with poor neurological outcome. The best cutoff point associated with 6-month mortality for hypoxemia was 69 mmHg (Risk Ratio, RR = 1.009, 95% CI 0.93-1.09), and for hyperoxemia was 195 mmHg (RR = 1.006, 95% CI 0.95-1.06). The time exposure, i.e., the area under the curve (PaO2-AUC), for hyperoxemia was significantly associated with mortality (p = 0.003). CONCLUSIONS In OHCA patients, both hypoxemia and hyperoxemia are associated with 6-months mortality, with an effect mediated by the timing exposure to high values of oxygen. Precise titration of oxygen levels should be considered in this group of patients. TRIAL REGISTRATION clinicaltrials.gov NCT02908308 , Registered September 20, 2016.
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Affiliation(s)
- Chiara Robba
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy ,grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Viale Benedetto XV 16, Genoa, Italy
| | - Rafael Badenes
- grid.106023.60000 0004 1770 977XDepartment of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clínic Universitari de Valencia, Valencia, Spain ,grid.5338.d0000 0001 2173 938XDepartment of Surgery, University of Valencia, Valencia, Spain
| | - Denise Battaglini
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy ,grid.5841.80000 0004 1937 0247Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Lorenzo Ball
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy ,grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Viale Benedetto XV 16, Genoa, Italy
| | - Filippo Sanfilippo
- Department of Anaesthesia and Intensive Care, A.O.U. “Policlinico-San Marco”, Catania, Italy
| | - Iole Brunetti
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Janus Christian Jakobsen
- grid.475435.4Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark ,grid.10825.3e0000 0001 0728 0170Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Gisela Lilja
- grid.4514.40000 0001 0930 2361Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Getingevägen 4, 222 41 Lund, Malmö, Sweden
| | - Hans Friberg
- grid.4514.40000 0001 0930 2361Department of Clinical Sciences Lund, Anesthesia and Intensive Care, Lund University, Lund, Sweden
| | - Pedro David Wendel-Garcia
- grid.412004.30000 0004 0478 9977Institute of Intensive Care Medicine, University Hospital of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Paul J. Young
- grid.415117.70000 0004 0445 6830Medical Research Institute of New Zealand, Private Bag 7902, Wellington, 6242 New Zealand ,grid.416979.40000 0000 8862 6892Intensive Care Unit, Wellington Regional Hospital, Wellington, New Zealand ,grid.1002.30000 0004 1936 7857Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC Australia ,grid.1008.90000 0001 2179 088XDepartment of Critical Care, University of Melbourne, Parkville, VIC Australia
| | - Glenn Eastwood
- grid.1002.30000 0004 1936 7857Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC Australia ,grid.414094.c0000 0001 0162 7225Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Michelle S. Chew
- grid.5640.70000 0001 2162 9922Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Johan Unden
- grid.4514.40000 0001 0930 2361Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden ,grid.4514.40000 0001 0930 2361Department of Operation and Intensive Care, Hallands Hospital Halmstad, Lund University, Halland, Sweden
| | - Matthew Thomas
- grid.410421.20000 0004 0380 7336University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Michael Joannidis
- grid.5361.10000 0000 8853 2677Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Alistair Nichol
- grid.1002.30000 0004 1936 7857Monash University, Melbourne, VIC Australia
| | - Andreas Lundin
- grid.8761.80000 0000 9919 9582Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 423 45 Gothenburg, Sweden
| | - Jacob Hollenberg
- grid.465198.7Department of Clinical Science and Education, Södersjukhuset, Centre for Resuscitation Science, Karolinska Institutet, Solna, Sweden
| | - Naomi Hammond
- grid.1005.40000 0004 4902 0432Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Critical Care Division, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, Australia
| | - Manoj Saxena
- grid.416398.10000 0004 0417 5393Intensive Care Unit, St George Hospital, Sydney, Australia
| | - Annborn Martin
- grid.4514.40000 0001 0930 2361Department of Clinical Medicine, Anaesthesiology and Intensive Care, Lund University, Lund, Sweden
| | - Miroslav Solar
- grid.4491.80000 0004 1937 116XDepartment of Internal Medicine, Faculty of Medicine in Hradec Králové, Charles University, Hradec Králové, Czech Republic ,grid.412539.80000 0004 0609 2284Department of Internal Medicine - Cardioangiology, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Fabio Silvio Taccone
- grid.412157.40000 0000 8571 829XDepartment of Intensive Care Medicine, Université Libre de Bruxelles, Hopital Erasme, Brussels, Belgium
| | - Josef Dankiewicz
- grid.4514.40000 0001 0930 2361Department of Clinical Sciences Lund, Cardiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Niklas Nielsen
- grid.4514.40000 0001 0930 2361Department of Clinical Sciences Lund, Anaesthesia and Intensive Care and Clinical Sciences Helsingborg, Helsingborg Hospital, Lund University, Lund, Sweden
| | - Anders Morten Grejs
- grid.154185.c0000 0004 0512 597XDepartment of Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark ,grid.7048.b0000 0001 1956 2722Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Florian Ebner
- grid.4514.40000 0001 0930 2361Department of Clinical Sciences Lund, Anesthesia and Intensive Care, Helsingborg Hospital, Lund University, 251 87 Helsingborg, Sweden
| | - Paolo Pelosi
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy ,grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Viale Benedetto XV 16, Genoa, Italy
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15
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Kawai Y, Takano K, Miyazaki K, Yamamoto K, Tada Y, Asai H, Maegawa N, Urisono Y, Saeki K, Fukushima H. Association of multiple rib fractures with the frequency of pneumonia in the post-resuscitation period. Resusc Plus 2022; 11:100267. [PMID: 35812719 PMCID: PMC9256829 DOI: 10.1016/j.resplu.2022.100267] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 06/11/2022] [Accepted: 06/20/2022] [Indexed: 11/18/2022] Open
Abstract
Purpose Successful cardiopulmonary resuscitation is associated with a high incidence of chest wall injuries. However, few studies have examined chest wall injury as a risk factor for respiratory complications after cardiopulmonary resuscitation. Therefore, herein, we investigated the association of multiple rib fractures on the incidence of post-resuscitation pneumonia. Methods This single-centre retrospective cohort study enrolled adult, nontraumatic, out-of-hospital cardiac arrest patients who maintained circulation for more than 48 h between June 2015 and May 2019. Rib fractures were evaluated by computed tomography on the day of hospital admission. The association with newly developed pneumonia within 7 days of hospitalisation was analysed using a Fine-Gray proportional hazards regression model adjusted for the propensity score of multiple rib fractures estimated from age, sex, presence of witnessed status, bystander CPR, initial rhythm, and total CPR time and for previously reported risk factors for pneumonia (therapeutic hypothermia and prophylactic antibiotics). Results Overall, 683 patients with out-of-hospital cardiac arrest were treated; 87 eligible cases were enrolled for analysis. Thirty-two (36.8%) patients had multiple rib fractures identified on computed tomography, and 35 (40.2%) patients developed pneumonia. The presence of multiple rib fractures was significantly associated with a higher incidence of pneumonia, consistently both with and without adjustment for background factors (unadjusted hazard ratio 4.63, 95% confidence interval: 2.35–9.13, p < 0.001; adjusted hazard ratio 4.03, 95% confidence interval: 2.08–7.82, p < 0.001). Conclusions Multiple rib fractures are independently associated with the development of pneumonia after successful resuscitation.
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16
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Shih JA, Robertson HK, Issa MS, Grossestreuer AV, Donnino MW, Berg KM, Moskowitz A. Acute respiratory distress syndrome after in-hospital cardiac arrest. Resuscitation 2022; 177:78-84. [PMID: 35580706 PMCID: PMC9320405 DOI: 10.1016/j.resuscitation.2022.05.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Acute respiratory distress syndrome (ARDS) after out-of-hospital cardiac arrest is common and associated with worse outcomes. In the hospital setting, there are many potential risk factors for post-arrest ARDS, such as aspiration, sepsis, and shock. ARDS after in-hospital cardiac arrest (IHCA) has not been characterized. METHODS We performed a single-center retrospective study of adult patients admitted to the hospital between 2014-2018 who suffered an IHCA, achieved return of spontaneous circulation (ROSC), and were either already intubated at the time of arrest or within 2 hours of ROSC. Post-IHCA ARDS was defined as meeting the Berlin criteria in the first 3 days following ROSC. Outcomes included alive-and-ventilator free days across 28 days, hospital length-of-stay, hospital mortality, and hospital disposition. RESULTS Of 203 patients included, 146 (71.9%) developed ARDS. In unadjusted analysis, patients with ARDS had fewer alive-and-ventilator-free days over 28 days with a median of 1 (IQR: 0, 21) day, compared to 18 (IQR: 0, 25) days in patients without ARDS (p = 0.03). However, this association was not significant after multivariate adjustment. There was also a non-significant longer hospital length-of-stay (15 [IQR: 7, 26] vs 10 [IQR: 7, 22] days, p = 0.25; median adjusted increase in ARDS patients: 3 [95% CI: -2 to 8] days, p = 0.27) and higher hospital mortality (53% vs 44%, p = 0.26; aOR 1.6 [95% CI: 0.8-2.9], p = 0.17) in the ARDS group. CONCLUSION Among IHCA patients, almost three-quarters developed ARDS within 3 days of ROSC. As in out of hospital cardiac arrest, post-IHCA ARDS is common.
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Affiliation(s)
- Jenny A. Shih
- Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, United States,Corresponding author. (J.A. Shih)
| | - Hannah K. Robertson
- Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, United States
| | - Mahmoud S. Issa
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, United States
| | - Anne V. Grossestreuer
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, United States
| | - Michael W. Donnino
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, United States,Department of Pulmonology and Critical Care, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, United States,Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, United States
| | - Katherine M. Berg
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, United States,Department of Pulmonology and Critical Care, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, United States
| | - Ari Moskowitz
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, United States,Department of Pulmonology and Critical Care, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467-2401, United States
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17
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Bhandari S, Coult J, Counts CR, Bulger NE, Kwok H, Latimer AJ, Sayre MR, Rea TD, Johnson NJ. Investigating the Airway Opening Index during Cardiopulmonary Resuscitation. Resuscitation 2022; 178:96-101. [PMID: 35850376 DOI: 10.1016/j.resuscitation.2022.07.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 06/27/2022] [Accepted: 07/11/2022] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Chest compressions during CPR induce oscillations in capnography (ETCO2) waveforms. Studies suggest ETCO2 oscillation characteristics are associated with intrathoracic airflow dependent on airway patency. Oscillations can be quantified by the Airway Opening Index (AOI). We sought to evaluate multiple methods of computing AOI and their association with return of spontaneous circulation (ROSC). METHODS We conducted a retrospective study of 307 out-of-hospital cardiac arrest (OHCA) cases in Seattle, WA during 2019. ETCO2 and chest impedance waveforms were annotated for the presence of intubation and CPR. We developed four methods for computing AOI based on peak ETCO2 and the oscillations in ETCO2 during CCs (ΔETCO2). We examined the feasibility of automating ΔETCO2 and AOI calculation and evaluated differences in AOI across the methods using nonparametric testing (p=0.05). RESULTS Median [interquartile range] AOI across all cases using Methods 1-4 was 28.0% [17.9-45.5%], 20.6% [13.0-36.6%], 18.3% [11.4-30.4%], and 22.4% [12.8-38.5%], respectively (p<0.001). Cases with ROSC had a higher median AOI than those without ROSC across all methods, though not statistically significant. Cases with ROSC had a significantly higher median [interquartile range] ΔETCO2 of 7.3 mmHg [4.5-13.6 mmHg] compared to those without ROSC (4.8 mmHg [2.6-9.1 mmHg], p<0.001). CONCLUSION We calculated AOI using four proposed methods resulting in significantly different AOI. Additionally, AOI and ΔETCO2 were larger in cases achieving ROSC. Further investigation is required to characterize AOI's ability to predict OHCA outcomes, and whether this information can improve resuscitation care.
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Affiliation(s)
- Shiv Bhandari
- Department of Medicine, University of Washington, Seattle, WA.
| | - Jason Coult
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Natalie E Bulger
- Department of Emergency Medicine, University of Washington, Seattle, WA
| | - Heemun Kwok
- Department of Emergency Medicine, University of Washington, Seattle, WA
| | - Andrew J Latimer
- Department of Emergency Medicine, University of Washington, Seattle, WA; University of Washington Airlift Northwest, Seattle, WA
| | - Michael R Sayre
- Department of Emergency Medicine, University of Washington, Seattle, WA; Seattle Fire Department, Seattle, WA
| | - Thomas D Rea
- Department of Medicine, University of Washington, Seattle, WA; Division of Emergency Medical Services, Public Health - Seattle & King County
| | - Nicholas J Johnson
- Division of Emergency Medical Services, Public Health - Seattle & King County; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
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18
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Don't go breaking my…lungs? The acute respiratory distress syndrome is common, deadly, and probably underrecognized after cardiac arrest. Resuscitation 2022; 177:1-2. [PMID: 35697174 DOI: 10.1016/j.resuscitation.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/02/2022] [Indexed: 11/23/2022]
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Racial and Ethnic Disparities Plague the Chain of Survival Even After Return of Spontaneous Circulation. Resuscitation 2022; 176:21-23. [DOI: 10.1016/j.resuscitation.2022.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 04/29/2022] [Indexed: 11/19/2022]
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Davis DP, Bosson N, Guyette FX, Wolfe A, Bobrow BJ, Olvera D, Walker RG, Levy M. Optimizing Physiology During Prehospital Airway Management: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:72-79. [PMID: 35001819 DOI: 10.1080/10903127.2021.1992056] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Airway management is a critical component of resuscitation but also carries the potential to disrupt perfusion, oxygenation, and ventilation as a consequence of airway insertion efforts, the use of medications, and the conversion to positive-pressure ventilation. NAEMSP recommends:Airway management should be approached as an organized system of care, incorporating principles of teamwork and operational awareness.EMS clinicians should prevent or correct hypoxemia and hypotension prior to advanced airway insertion attempts.Continuous physiological monitoring must be used during airway management to guide the timing of, limit the duration of, and inform decision making during advanced airway insertion attempts.Initial and ongoing confirmation of advanced airway placement must be performed using waveform capnography. Airway devices must be secured using a reliable method.Perfusion, oxygenation, and ventilation should be optimized before, during, and after advanced airway insertion.To mitigate aspiration after advanced airway insertion, EMS clinicians should consider placing a patient in a semi-upright position.When appropriate, patients undergoing advanced airway placement should receive suitable pharmacologic anxiolysis, amnesia, and analgesia. In select cases, the use of neuromuscular blocking agents may be appropriate.
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Bonnemain J, Rusca M, Ltaief Z, Roumy A, Tozzi P, Oddo M, Kirsch M, Liaudet L. Hyperoxia during extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest is associated with severe circulatory failure and increased mortality. BMC Cardiovasc Disord 2021; 21:542. [PMID: 34775951 PMCID: PMC8591834 DOI: 10.1186/s12872-021-02361-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 11/03/2021] [Indexed: 11/13/2022] Open
Abstract
Background High levels of arterial oxygen pressures (PaO2) have been associated with increased mortality in extracorporeal cardiopulmonary resuscitation (ECPR), but there is limited information regarding possible mechanisms linking hyperoxia and death in this setting, notably with respect to its hemodynamic consequences. We aimed therefore at evaluating a possible association between PaO2, circulatory failure and death during ECPR. Methods We retrospectively analyzed 44 consecutive cardiac arrest (CA) patients treated with ECPR to determine the association between the mean PaO2 over the first 24 h, arterial blood pressure, vasopressor and intravenous fluid therapies, mortality, and cause of deaths. Results Eleven patients (25%) survived to hospital discharge. The main causes of death were refractory circulatory shock (46%) and neurological damage (24%). Compared to survivors, non survivors had significantly higher mean 24 h PaO2 (306 ± 121 mmHg vs 164 ± 53 mmHg, p < 0.001), lower mean blood pressure and higher requirements in vasopressors and fluids, but displayed similar pulse pressure during the first 24 h (an index of native cardiac recovery). The mean 24 h PaO2 was significantly and positively correlated with the severity of hypotension and the intensity of vasoactive therapies. Patients dying from circulatory failure died after a median of 17 h, compared to a median of 58 h for patients dying from a neurological cause. Patients dying from neurological cause had better preserved blood pressure and lower vasopressor requirements. Conclusion In conclusion, hyperoxia is associated with increased mortality during ECPR, possibly by promoting circulatory collapse or delayed neurological damage. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-021-02361-3.
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Affiliation(s)
- Jean Bonnemain
- The Service of Adult Intensive Care Medicine, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
| | - Marco Rusca
- The Service of Adult Intensive Care Medicine, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Zied Ltaief
- The Service of Adult Intensive Care Medicine, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Aurélien Roumy
- The Service of Cardiac Surgery, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Piergiorgio Tozzi
- The Service of Cardiac Surgery, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Mauro Oddo
- The Service of Adult Intensive Care Medicine, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Matthias Kirsch
- The Service of Cardiac Surgery, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Lucas Liaudet
- The Service of Adult Intensive Care Medicine, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
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Shao R, Wang X, Xu T, Xia Y, Cui D. The balance between AIM2-associated inflammation and autophagy: the role of CHMP2A in brain injury after cardiac arrest. J Neuroinflammation 2021; 18:257. [PMID: 34740380 PMCID: PMC8571899 DOI: 10.1186/s12974-021-02307-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 10/27/2021] [Indexed: 12/30/2022] Open
Abstract
Background Activation of the absent in melanoma 2 (AIM2) inflammasome and impaired autophagosome clearance in neurons contribute significantly to cardiac arrest and return of spontaneous circulation (CA-ROSC) injury, while the mechanism by which the AIM2 inflammasome is regulated and relationship between the processes remain poorly understood. Recently, charged multivesicular body protein 2A (CHMP2A), a subunit of endosomal sorting complex required for transport (ESCRT), was shown to regulate phagophore closure, and its depletion led to the accumulation of autophagosomes and induced cell death. Here, we investigated whether CHMP2A-mediated autophagy was an underlying mechanism of AIM2-associated inflammation after CA-ROSC and explored the potential link between the AIM2 inflammasome and autophagy under ischemic conditions. Methods AIM2 inflammasome activation and autophagic flux in the cortex were assessed in the CA-ROSC rat model. We injected LV-Vector or LV-CHMP2A virus into the motor cortex with stereotaxic coordinates and divided the rats into four groups: Sham, CA, CA+LV-Vector, and CA+LV-CHMP2A. Neurologic deficit scores (NDSs), balance beam tests, histopathological injury of the brain, and expression of the AIM2 inflammasome and proinflammatory cytokines were analyzed. Results AIM2 inflammasome activation and increased interleukin 1 beta (IL-1β) and IL-18 release were concurrent with reduced levels of CHMP2A-induced autophagy in CA-ROSC rat neurons. In addition, silencing CHMP2A resulted in autophagosome accumulation and decreased autophagic degradation of the AIM2 inflammasome. In parallel, a reduction in AIM2 contributed to autophagy activation and mitigated oxygen–glucose deprivation and reperfusion (OGD-Rep)-induced inflammation. Notably, CHMP2A overexpression in the cortex hindered neuroinflammation, protected against ischemic brain damage, and improved neurologic outcomes after CA. Conclusions Our results support a potential link between autophagy and AIM2 signaling, and targeting CHMP2A may provide new insights into neuroinflammation in the early phase during CA-ROSC. Supplementary Information The online version contains supplementary material available at 10.1186/s12974-021-02307-8.
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Affiliation(s)
- Rongjiao Shao
- Department of Anesthesiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No.600 Yishan Road, Xuhui District, Shanghai, 200233, China
| | - Xintao Wang
- Department of Anesthesiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No.600 Yishan Road, Xuhui District, Shanghai, 200233, China
| | - Tianhua Xu
- Department of Anesthesiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No.600 Yishan Road, Xuhui District, Shanghai, 200233, China
| | - Yiyang Xia
- Department of Anesthesiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No.600 Yishan Road, Xuhui District, Shanghai, 200233, China
| | - Derong Cui
- Department of Anesthesiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No.600 Yishan Road, Xuhui District, Shanghai, 200233, China.
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Acosta-Gutiérrez EG, Alba-Amaya AM, Roncancio-Rodríguez S, Navarro-Vargas JR. Post-cardiac arrest syndrome in adult hospitalized patients. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2021. [DOI: 10.5554/22562087.e972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Adult In-hospital Cardiac Arrest (IHCA) is defined as the loss of circulation of an in-patient. Following high-quality cardiopulmonary resuscitation (CPR), if the return of spontaneous circulation (ROSC) is achieved, the post-cardiac arrest syndrome develops (PCAS). This review is intended to discuss the current diagnosis and treatment of PCAS. To approach this topic, a bibliography search was conducted through direct digital access to the scientific literature published in English and Spanish between 2014 and 2020, in MedLine, SciELO, Embase and Cochrane. This search resulted in 248 articles from which original articles, systematic reviews, meta-analyses and clinical practice guidelines were selected for a total of 56 documents. The etiologies may be divided into 56% of in-hospital cardiac, and 44% of non-cardiac arrests. The incidence of this physiological collapse is up to 1.6 cases/1,000 patients admitted, and its frequency is higher in the intensive care units (ICU), with an overall survival rate of 13% at one year. The primary components of PCAS are brain injury, myocardial dysfunction and the persistence of the precipitating pathology. The mainstays for managing PCAS are the prevention of cardiac arrest, ventilation support, control of peri-cardiac arrest arrythmias, and interventions to optimize neurologic recovery. A knowledgeable healthcare staff in PCAS results in improved patient survival and future quality of life. Finally, there is clear need to do further research in the Latin American Population.
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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: 56] [Impact Index Per Article: 18.7] [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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Magliocca A, Rezoagli E, Zani D, Manfredi M, De Giorgio D, Olivari D, Fumagalli F, Langer T, Avalli L, Grasselli G, Latini R, Pesenti A, Bellani G, Ristagno G. Cardiopulmonary Resuscitation-associated Lung Edema (CRALE). A Translational Study. Am J Respir Crit Care Med 2021; 203:447-457. [PMID: 32897758 DOI: 10.1164/rccm.201912-2454oc] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Rationale: Cardiopulmonary resuscitation is the cornerstone of cardiac arrest (CA) treatment. However, lung injuries associated with it have been reported.Objectives: To assess 1) the presence and characteristics of lung abnormalities induced by cardiopulmonary resuscitation and 2) the role of mechanical and manual chest compression (CC) in its development.Methods: This translational study included 1) a porcine model of CA and cardiopulmonary resuscitation (n = 12) and 2) a multicenter cohort of patients with out-of-hospital CA undergoing mechanical or manual CC (n = 52). Lung computed tomography performed after resuscitation was assessed qualitatively and quantitatively along with respiratory mechanics and gas exchanges.Measurements and Main Results: The lung weight in the mechanical CC group was higher compared with the manual CC group in the experimental (431 ± 127 vs. 273 ± 66, P = 0.022) and clinical study (1,208 ± 630 vs. 837 ± 306, P = 0.006). The mechanical CC group showed significantly lower oxygenation (P = 0.043) and respiratory system compliance (P < 0.001) compared with the manual CC group in the experimental study. The variation of right atrial pressure was significantly higher in the mechanical compared with the manual CC group (54 ± 11 vs. 31 ± 6 mm Hg, P = 0.001) and significantly correlated with lung weight (r = 0.686, P = 0.026) and respiratory system compliance (r = -0.634, P = 0.027). Incidence of abnormal lung density was higher in patients treated with mechanical compared with manual CC (37% vs. 8%, P = 0.018).Conclusions: This study demonstrated the presence of cardiopulmonary resuscitation-associated lung edema in animals and in patients with out-of-hospital CA, which is more pronounced after mechanical as opposed to manual CC and correlates with higher swings of right atrial pressure during CC.
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Affiliation(s)
- Aurora Magliocca
- Dipartimento di Medicina Cardiovascolare, Istituto di Ricerche Farmacologiche Mario Negri, IRCCS, Milan, Italy.,Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Emanuele Rezoagli
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Davide Zani
- Department of Veterinary Medicine, University of Milan, Lodi, Italy
| | - Martina Manfredi
- Department of Veterinary Medicine, University of Milan, Lodi, Italy
| | - Daria De Giorgio
- Dipartimento di Medicina Cardiovascolare, Istituto di Ricerche Farmacologiche Mario Negri, IRCCS, Milan, Italy
| | - Davide Olivari
- Dipartimento di Medicina Cardiovascolare, Istituto di Ricerche Farmacologiche Mario Negri, IRCCS, Milan, Italy
| | - Francesca Fumagalli
- Dipartimento di Medicina Cardiovascolare, Istituto di Ricerche Farmacologiche Mario Negri, IRCCS, Milan, Italy
| | - Thomas Langer
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Leonello Avalli
- Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Giacomo Grasselli
- Department of Medical Physiopathology and Transplants, University of Milan, Milano, Italy; and.,Dipartimento di Anestesia-Rianimazione e Emergenza Urgenza, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Roberto Latini
- Dipartimento di Medicina Cardiovascolare, Istituto di Ricerche Farmacologiche Mario Negri, IRCCS, Milan, Italy
| | - Antonio Pesenti
- Department of Medical Physiopathology and Transplants, University of Milan, Milano, Italy; and.,Dipartimento di Anestesia-Rianimazione e Emergenza Urgenza, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Bellani
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Giuseppe Ristagno
- Department of Medical Physiopathology and Transplants, University of Milan, Milano, Italy; and.,Dipartimento di Anestesia-Rianimazione e Emergenza Urgenza, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
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Zhou D, Ye Y, Kong Y, Li Z, Shi G, Zhou J. The effect of mild hypercapnia on hospital mortality after cardiac arrest may be modified by chronic obstructive pulmonary disease. Am J Emerg Med 2021; 44:78-84. [PMID: 33582612 DOI: 10.1016/j.ajem.2021.01.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 01/09/2021] [Accepted: 01/31/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The main objective was to evaluate the effect of carbon dioxide on hospital mortality in chronic obstructive pulmonary disease (COPD) and non-COPD patients with out-of-hospital cardiac arrest (OHCA). METHODS We conducted a retrospective observational study in OHCA patients from the eICU database (eicu-crd.mit.edu). The main exposure was the partial pressure of arterial carbon dioxide (PaCO2). The proportion of time spent (PTS) within four predefined PaCO2 ranges (hypocapnia: <35 mmHg, normocapnia: 35-45 mmHg, mild hypercapnia: 46-55 mmHg, and severe hypercapnia: >55 mmHg) were calculated respectively. The primary outcome was hospital mortality. Multivariable logistic regression models were performed to assess the independent relationship between PTS within PaCO2 range and hospital mortality, and the interaction between PTS within PaCO2 range and COPD was explored. RESULTS A total of 1721 OHCA patients were included, of which 272 (15.8%) had COPD. After adjusted for the confounders, the PTS within mild hypercapnia was associated with lower odds ratio for hospital mortality in COPD patients (OR 0.923; 95% CI 0.857-0.992; P = 0.036); however, it was associated with higher odds ratio for hospital mortality in non-COPD patients (OR 1.053; 95% CI 1.012-1.097; P = 0.012; Pinteraction = 0.008). The PTS within normocapnia was not associated with hospital mortality in COPD patients (OR 0.987; 95% CI 0.914-1.067; P = 0.739); however, it was associated with lower odds ratio for hospital mortality in non-COPD patients (OR 0.944; 95% CI 0.916-0.973; P < 0.001; Pinteraction = 0.113). CONCLUSIONS The effect of carbon dioxide on hospital mortality differed between COPD and non-COPD patients. Mild hypercapnia was associated with increased hospital mortality for non-COPD patients but reduced hospital mortality for COPD patients. It would be reasonable to adjust PaCO2 targets in OHCA patients with COPD.
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Affiliation(s)
- Dawei Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yi Ye
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yueyue Kong
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhimin Li
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guangzhi Shi
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jianxin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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Kusadokoro S, Hori D, Yasuda T, Momose N, Yamaguchi A. Modified central extracorporeal membrane oxygenation for distended left ventricle. J Card Surg 2021; 36:1557-1559. [PMID: 33491196 DOI: 10.1111/jocs.15352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 12/26/2020] [Accepted: 01/10/2021] [Indexed: 11/29/2022]
Abstract
A 38-year-old man who was resuscitated from ventricular fibrillation was diagnosed with acute aortic dissection complicated by coronary malperfusion. He underwent total aortic arch replacement and coronary artery bypass grafting to the left anterior descending coronary artery. Due to low cardiac output syndrome from cardiac ischemia, central extracorporeal membrane oxygenator (ECMO) was established with aortic cannulation from the side branch of the implanted prosthetic graft and venous drainage from the femoral vein. Ventricular venting was added from the right upper pulmonary vein for the distended left ventricle. ECMO was weaned off on postoperative Day 4. The patient is back on his normal daily life for more than 1 year after the surgery.
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Affiliation(s)
- Sho Kusadokoro
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Daijiro Hori
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Toru Yasuda
- Department of Medical Engineering, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Naoki Momose
- Department of Medical Engineering, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Atsushi Yamaguchi
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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Chiu WT, Lin KC, Tsai MS, Hsu CH, Wang CH, Kuo LK, Chien YS, Wu CH, Lai CH, Huang WC, Wang CH, Wang TL, Hsu HH, Lin JJ, Hwang JJ, Ng CJ, Choi WM, Huang CH. Post-cardiac arrest care and targeted temperature management: A consensus of scientific statement from the Taiwan Society of Emergency & Critical Care Medicine, Taiwan Society of Critical Care Medicine and Taiwan Society of Emergency Medicine. J Formos Med Assoc 2021; 120:569-587. [PMID: 32829996 DOI: 10.1016/j.jfma.2020.07.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 06/07/2020] [Accepted: 07/26/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Post-cardiac arrest care is critically important in bringing cardiac arrest patients to functional recovery after the detrimental event. More high quality studies are published and evidence is accumulated for the post-cardiac arrest care in the recent years. It is still a challenge for the clinicians to integrate these scientific data into the real clinical practice for such a complicated intensive care involving many different disciplines. METHODS With the cooperation of the experienced experts from all disciplines relevant to post-cardiac arrest care, the consensus of the scientific statement was generated and supported by three major scientific groups for emergency and critical care in post-cardiac arrest care. RESULTS High quality post-cardiac arrest care, including targeted temperature management, early evaluation of possible acute coronary event and intensive care for hemodynamic and respiratory care are inevitably needed to get full recovery for cardiac arrest. Management of these critical issues were reviewed and proposed in the consensus CONCLUSION: The goal of the statement is to provide help for the clinical physician to achieve better quality and evidence-based care in post-cardiac arrest period.
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Affiliation(s)
- Wei-Ting Chiu
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taiwan; Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan, ROC
| | - Kun-Chang Lin
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Min-Shan Tsai
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Chih-Hsin Hsu
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital Dou Liou Branch, College of Medicine, National Cheng Kung University, Taiwan
| | - Chen-Hsu Wang
- Attending Physician, Coronary Care Unit, Cardiovascular Center, Cathay General Hospital, Taipei, Taiwan
| | - Li-Kuo Kuo
- Department of Critical Care Medicine, MacKay Memorial Hospital, Taipei Branch, Taiwan; Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
| | - Yu-San Chien
- Department of Critical Care Medicine, MacKay Memorial Hospital, Taipei Branch, Taiwan
| | - Cheng-Hsueh Wu
- Department of Critical Care Medicine, Taipei Veterans General Hospital, National Yang-Ming University, Taipei, Taiwan
| | - Chih-Hung Lai
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan; Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Chun Huang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan
| | - Chih-Hsien Wang
- Cardiovascular Surgery, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Tzong-Luen Wang
- Chang Bing Show Chwang Memorial Hospital, Changhua, Taiwan; School of Medicine and Law, Fu-Jen Catholic University, New Taipei City, Taiwan
| | - Hsin-Hui Hsu
- Department of Critical Care Medicine, Changhua Christian Hospital, Taiwan
| | - Jen-Jyh Lin
- Division of Cardiology, Department of Medicine, China Medical University Hospital, Taichung, Taiwan; Department of Respiratory Therapy, China Medical University, Taichung, Taiwan, ROC
| | - Juey-Jen Hwang
- Cardiovascular Division, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taiwan
| | - Chip-Jin Ng
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou and Chang Gung University College of Medicine, Tao-Yuan, Taiwan
| | - Wai-Mau Choi
- Department of Emergency Medicine, Hsinchu MacKay Memorial Hospital, Taiwan
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan; Cardiovascular Division, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taiwan.
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29
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Kim SH, Park KN, Youn CS, Chae MK, Kim WY, Lee BK, Lee DH, Jang TC, Lee JH, Choi YH, You JS, Cho IS, Kim SJ, Lee JS, Kim YH, Sim MS, Shin J, Park YS, Lee YH, Moon H, Jeong WJ, Oh JS, Choi SP, Cha KC. Outcome and status of postcardiac arrest care in Korea: results from the Korean Hypothermia Network prospective registry. Clin Exp Emerg Med 2020; 7:250-258. [PMID: 33440102 PMCID: PMC7808836 DOI: 10.15441/ceem.20.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 06/25/2020] [Indexed: 12/13/2022] Open
Abstract
Objective High-quality intensive care, including targeted temperature management (TTM) for patients with postcardiac arrest syndrome, is a key element for improving outcomes after out-of-hospital cardiac arrest (OHCA). We aimed to assess the status of postcardiac arrest syndrome care, including TTM and 6-month survival with neurologically favorable outcomes, after adult OHCA patients were treated with TTM, using data from the Korean Hypothermia Network prospective registry. Methods We used the Korean Hypothermia Network prospective registry, a web-based multicenter registry that includes data from 22 participating hospitals throughout the Republic of Korea. Adult comatose OHCA survivors treated with TTM between October 2015 and December 2018 were included. The primary outcome was neurological outcome at 6 months. Results Of the 1,354 registered OHCA survivors treated with TTM, 550 (40.6%) survived 6 months, and 413 (30.5%) had good neurological outcomes. We identified 839 (62.0%) patients with preClinsumed cardiac etiology. A total of 937 (69.2%) collapses were witnessed, shockable rhythms were demonstrated in 482 (35.6%) patients, and 421 (31.1%) patients arrived at the emergency department with prehospital return of spontaneous circulation. The most common target temperature was 33°C, and the most common target duration was 24 hours. Conclusion The survival and good neurologic outcome rates of this prospective registry show great improvements compared with those of an earlier registry. While the optimal target temperature and duration are still unknown, the most common target temperature was 33°C, and the most common target duration was 24 hours.
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Affiliation(s)
- Soo Hyun Kim
- Department of Emergency Medicine, Eunpyeong St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Kyu Nam Park
- Department of Emergency Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Chun Song Youn
- Department of Emergency Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Minjung Kathy Chae
- Department of Emergency Medicine, Ajou University Medical Center, Suwon, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Dong Hoon Lee
- Department of Emergency Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Tae Chang Jang
- Department of Emergency Medicine, Daegu Catholic University Medical Center, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Jae Hoon Lee
- Department of Emergency Medicine, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Yoon Hee Choi
- Department of Emergency Medicine, Ewha Womans University Mokdong Hospital, Ewha Womans School of Medicine, Seoul, Korea
| | - Je Sung You
- Department of Emergency Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - In Soo Cho
- Department of Emergency Medicine, Hanil General Hospital, Seoul, Korea
| | - Su Jin Kim
- Department of Emergency Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jong-Seok Lee
- Department of Emergency Medicine, Kyung Hee University Medical Center, Kyung Hee University School of Medicine, Seoul, Korea
| | - Yong Hwan Kim
- Department of Emergency Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Min Seob Sim
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jonghwan Shin
- Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Yoo Seok Park
- Department of Emergency Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Hwan Lee
- Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - HyungJun Moon
- Department of Emergency Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Won Jung Jeong
- Department of Emergency Medicine, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Joo Suk Oh
- Department of Emergency Medicine, Uijeongbu St. Mary's Hospital, The Catholic University of Korea College of Medicine, Uijeongbu, Korea
| | - Seung Pill Choi
- Department of Emergency Medicine, Eunpyeong St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea.,Department of Emergency Medicine, Yeouido St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Kyoung-Chul Cha
- Department of Emergency Medicine, Wonju Severance Christian Hospital, Yonsei University College of Medicine, Wonju, Korea
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30
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Robba C, Siwicka-Gieroba D, Sikter A, Battaglini D, Dąbrowski W, Schultz MJ, de Jonge E, Grim C, Rocco PR, Pelosi P. Pathophysiology and clinical consequences of arterial blood gases and pH after cardiac arrest. Intensive Care Med Exp 2020; 8:19. [PMID: 33336311 PMCID: PMC7746422 DOI: 10.1186/s40635-020-00307-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 05/21/2020] [Indexed: 12/11/2022] Open
Abstract
Post cardiac arrest syndrome is associated with high morbidity and mortality, which is related not only to a poor neurological outcome but also to respiratory and cardiovascular dysfunctions. The control of gas exchange, and in particular oxygenation and carbon dioxide levels, is fundamental in mechanically ventilated patients after resuscitation, as arterial blood gases derangement might have important effects on the cerebral blood flow and systemic physiology. In particular, the pathophysiological role of carbon dioxide (CO2) levels is strongly underestimated, as its alterations quickly affect also the changes of intracellular pH, and consequently influence metabolic energy and oxygen demand. Hypo/hypercapnia, as well as mechanical ventilation during and after resuscitation, can affect CO2 levels and trigger a dangerous pathophysiological vicious circle related to the relationship between pH, cellular demand, and catecholamine levels. The developing hypocapnia can nullify the beneficial effects of the hypothermia. The aim of this review was to describe the pathophysiology and clinical consequences of arterial blood gases and pH after cardiac arrest. According to our findings, the optimal ventilator strategies in post cardiac arrest patients are not fully understood, and oxygen and carbon dioxide targets should take in consideration a complex pattern of pathophysiological factors. Further studies are warranted to define the optimal settings of mechanical ventilation in patients after cardiac arrest.
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Affiliation(s)
- Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy.
| | - Dorota Siwicka-Gieroba
- Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
| | - Andras Sikter
- Internal Medicine, Municipal Clinic of Szentendre, Szentendre, Hungary
| | - Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy
| | - Wojciech Dąbrowski
- Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, location 'AMC', Amsterdam, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Chloe Grim
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Patricia Rm Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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31
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Yamamoto R, Yoshizawa J. Oxygen administration in patients recovering from cardiac arrest: a narrative review. J Intensive Care 2020; 8:60. [PMID: 32832091 PMCID: PMC7419438 DOI: 10.1186/s40560-020-00477-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 07/28/2020] [Indexed: 12/11/2022] Open
Abstract
High oxygen tension in blood and/or tissue affects clinical outcomes in several diseases. Thus, the optimal target PaO2 for patients recovering from cardiac arrest (CA) has been extensively examined. Many patients develop hypoxic brain injury after the return of spontaneous circulation (ROSC); this supports the need for oxygen administration in patients after CA. Insufficient oxygen delivery due to decreased blood flow to cerebral tissue during CA results in hypoxic brain injury. By contrast, hyperoxia may increase dissolved oxygen in the blood and, subsequently, generate reactive oxygen species that are harmful to neuronal cells. This secondary brain injury is particularly concerning. Although several clinical studies demonstrated that hyperoxia during post-CA care was associated with poor neurological outcomes, considerable debate is ongoing because of inconsistent results. Potential reasons for the conflicting results include differences in the definition of hyperoxia, the timing of exposure to hyperoxia, and PaO2 values used in analyses. Despite the conflicts, exposure to PaO2 > 300 mmHg through administration of unnecessary oxygen should be avoided because no obvious benefit has been demonstrated. The feasibility of titrating oxygen administration by targeting SpO2 at approximately 94% in patients recovering from CA has been demonstrated in pilot randomized controlled trials (RCTs). Such protocols should be further examined.
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Affiliation(s)
- Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582 Japan
| | - Jo Yoshizawa
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582 Japan
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32
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Baekgaard JS, Triba MN, Brandeis M, Steinmetz J, Cohen Y, Gorlicki J, Rasmussen LS, Deltour S, Lapostolle F, Adnet F. Early-onset pneumonia following bag-mask ventilation versus endotracheal intubation during cardiopulmonary resuscitation: A substudy of the CAAM trial. Resuscitation 2020; 154:12-18. [PMID: 32629091 DOI: 10.1016/j.resuscitation.2020.06.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 05/29/2020] [Accepted: 06/06/2020] [Indexed: 11/19/2022]
Abstract
AIM Early-onset pneumonia (EOP) is a common in-hospital complication in survivors of out-of-hospital cardiac arrest. In this substudy of the CAAM trial, we aimed to compare whether bag mask ventilation (BMV) compared to endotracheal intubation (ETI) performed during cardiopulmonary resuscitation increases the risk of developing EOP. METHODS Adult patients from the CAAM trial that survived beyond 12 h of hospitalization were included. Information about in-hospital management and outcome of study subjects was systematically collected. Our primary aim was to compare the incidence of EOP in the BMV and ETI group using a series of bivariate analysis adjusting for one variable at a time and a logistic regression controlled for survival beyond 96 h, age, gender, catecholamine administration, no flow time, and initial shockable rhythm. RESULTS Of 627 patients from the CAAM trial that survived to hospital admission, 409 patients were hospitalized beyond 12 h and thus included (202 randomized to BMV and 20 7 randomized to ETI). Patients in the BMV group had a significantly longer period of unsecured airway during prehospital cardiopulmonary resuscitation (BMV (median): 33 min; ETI (median): 17 min, p < 0.0001). No significant difference in the development of EOP according to airway management was identified on univariate analysis (BMV: 53%, ETI: 53%, Odds Ratio 1.0 [0.7-1.5], p = 1.0). We found no difference in the development of EOP according to airway management in the series of bivariate analyses or in the multivariable regression analysis either. CONCLUSION In this substudy of the CAAM trial, development of early-onset pneumonia in out-of-hospital cardiac arrest survivors did not depend on airway management technique during CPR.
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Affiliation(s)
- Josefine S Baekgaard
- Department of Anesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Denmark; Urgences et Samu 93, AP-HP, Hôpital Avicenne, Inserm U942, 93000 Bobigny, France.
| | - Mohamed N Triba
- Sorbonne Paris Cité, Equipe Nanomédecine Biomarqueurs Détection, Laboratoire de Chimie, Structures et Propriétés de Biomateriaux et d'Agents Therapeutiques, UMR CNRS 7244, University Paris 13 Bobigny, France
| | | | - Jacob Steinmetz
- Department of Anesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Denmark
| | - Yves Cohen
- Intensive Care Unit, AP-HP, Hôpital Avicenne, Inserm U942, 93000 Bobigny, France
| | - Judith Gorlicki
- Urgences et Samu 93, AP-HP, Hôpital Avicenne, Inserm U942, 93000 Bobigny, France
| | - Lars S Rasmussen
- Department of Anesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Denmark
| | - Sandrine Deltour
- Urgences et Samu 93, AP-HP, Hôpital Avicenne, Inserm U942, 93000 Bobigny, France
| | - Frédéric Lapostolle
- Urgences et Samu 93, AP-HP, Hôpital Avicenne, Inserm U942, 93000 Bobigny, France
| | - Frédéric Adnet
- Urgences et Samu 93, AP-HP, Hôpital Avicenne, Inserm U942, 93000 Bobigny, France
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Bell SM, Kovach C, Kataruka A, Brown J, Hira RS. Management of Out-of-Hospital Cardiac Arrest Complicating Acute Coronary Syndromes. Curr Cardiol Rep 2019; 21:146. [PMID: 31758275 DOI: 10.1007/s11886-019-1249-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF THE REVIEW Out-of-hospital cardiac arrest (OHCA) complicating acute coronary syndromes (ACS) continues to carry a high rate of morbidity and mortality despite significant advances in EMS and interventional cardiology services. In this review, we discuss an evidence-based approach to the initial care and management of patients with OHCA complicating ACS from the pre-hospital response and initial resuscitation strategy, to advanced therapies such as coronary angiography, targeted-temperature management, neuro-prognostication, and care of the post-arrest patient. RECENT FINDINGS Early recognition of cardiac arrest and prompt initiation of bystander CPR are the most important factors associated with improved survival. A comprehensive and coordinated approach to in-hospital management, including PCI, targeted temperature management, critical care, and hemodynamic support represents a significant critical link in the chain of survival. OHCA complicated by ACS continues to be one of the most challenging disease states facing healthcare practitioners and maintains a high mortality rate despite substantial advancements in healthcare delivery. A comprehensive approach to in-hospital management and further exploration of novel interventions, including ECMO, may yield opportunities to optimize care and improve outcomes for cardiac arrest patients.
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Affiliation(s)
- Sean M Bell
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Christopher Kovach
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Akash Kataruka
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Josiah Brown
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Ravi S Hira
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, USA. .,Cardiac Care Outcomes Assessment Program, Foundation for Health Care Quality, Seattle, WA, USA.
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35
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The modern cardiovascular care unit: the cardiologist managing multiorgan dysfunction. Curr Opin Crit Care 2019; 24:300-308. [PMID: 29916835 DOI: 10.1097/mcc.0000000000000522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
PURPOSE OF REVIEW Despite many advances in the management of critically ill patients, cardiogenic shock remains a challenge because it is associated with high mortality. Even if there is no universally accepted definition of cardiogenic shock, end-perfusion organ dysfunction is an obligatory and major criterion of its definition.Organ dysfunction is an indicator that cardiogenic shock is already at an advanced stage and is undergoing a rapid self-aggravating evolution. The aim of the review is to highlight the importance to diagnose and to manage the organ dysfunction occurring in the cardiogenic shock patients by providing the best literature published this year. RECENT FINDINGS The first step is to diagnose the organ dysfunction and to assess their severity. Echo has an important and increasing place regarding the assessment of end-organ impairment whereas no new biomarker popped up. SUMMARY In this review, we aimed to highlight for intensivists and cardiologists managing cardiogenic shock, the recent advances in the care of end-organ dysfunctions associated with cardiogenic shock. The management of organ dysfunction is based on the improvement of the cardiac function by etiologic therapy, inotropes and assist devices but will often necessitate organ supports in hospitals with the right level of equipment and multidisciplinary expertise.
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36
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Prophylactic antibiotic use following cardiac arrest: A systematic review and meta-analysis. Resuscitation 2019; 141:166-173. [PMID: 31085216 DOI: 10.1016/j.resuscitation.2019.04.047] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 04/18/2019] [Accepted: 04/30/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate the effect of prophylactic/ early antibiotics (intervention group) compared with clinically driven/ delayed antibiotics (control group) on patient and infectious outcomes in adult cardiac arrest patients admitted to hospital. DATA SOURCES We searched MEDLINE (1946-current), EMBASE (1947-current) and the Cochrane library (inception-current) on 8th May 2018. Additional citations were identified through forward and backward citation tracking. STUDY SELECTION Two reviewers independently screened titles, abstracts, and full-texts. We included observational and interventional primary research studies with a concurrent or retrospective control group that were relevant to our study objective. DATA EXTRACTION We extracted data using a piloted data extraction form. Risk of bias was assessed using the Cochrane tool for randomised controlled trials or the GRADE tool for risk of bias in observational studies. Overall evidence quality for each outcome was assessed using the GRADE system. DATA SYNTHESIS Databases searches and citation tracking identified 6825 citations, of which ten citations containing 11 studies (3 randomised controlled trials, 8 observational studies) were eligible for inclusion. Data were summarised in meta-analyses using random-effect models. The intervention was not associated with increased survival (odds ratio 1.16, 95% CI 0.97-1.40), survival with good neurological outcome (odds ratio 2.25, 95% CI 0.93-5.45), critical care length of stay (mean difference -0.6, 95% CI -3.6 to 2.4) or incidence of pneumonia (odds ratio 0.58, 95% CI 0.23-1.46). Findings were generally consistent between observational studies and randomised controlled trials. CONCLUSIONS Antibiotic prophylaxis following cardiac arrest is not associated with a change in key clinical outcomes. Further high-quality trials may be needed to address this important clinical question. Review registration: PROSPERO CRD42016039358.
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37
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Walker AC, Johnson NJ. Targeted Temperature Management and Postcardiac arrest Care. Emerg Med Clin North Am 2019; 37:381-393. [PMID: 31262410 DOI: 10.1016/j.emc.2019.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Despite recent advances, care of the post-cardiac arrest patient remains a challenge. In this article, the authors discuss an approach to the initial care of post-cardiac arrest patients with particular focus on targeted temperature management (TTM). The article starts with history, physiologic rationale, and the major randomized controlled trials that have shaped guidelines for post-cardiac arrest care. It also reviews controversial topics, including TTM for nonshockable rhythms, TTM dose, and surface versus endovascular cooling. The article concludes with a brief review of other key aspects of post-arrest care: coronary angiography, hemodynamic optimization, ventilator management, and prognostication.
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Affiliation(s)
- Amy C Walker
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA.
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA
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Affiliation(s)
- Lionel A Mandell
- From McMaster University, Hamilton, ON, Canada (L.A.M.); and Weill Cornell Medical College, New York (M.S.N.)
| | - Michael S Niederman
- From McMaster University, Hamilton, ON, Canada (L.A.M.); and Weill Cornell Medical College, New York (M.S.N.)
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39
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Johnson NJ, Caldwell E, Carlbom DJ, Gaieski DF, Prekker ME, Rea TD, Sayre M, Hough CL. The acute respiratory distress syndrome after out-of-hospital cardiac arrest: Incidence, risk factors, and outcomes. Resuscitation 2019; 135:37-44. [PMID: 30654012 DOI: 10.1016/j.resuscitation.2019.01.009] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 10/25/2018] [Accepted: 01/02/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To define the incidence of the acute respiratory distress syndrome (ARDS) following out-of-hospital cardiac arrest (OHCA) and characterize its impact on outcome. METHODS This was a retrospective cohort study conducted at two urban, tertiary, academic hospitals from 2007 to 2014. We included adults with non-traumatic OHCA and survived for ≥48 h. Patients who received mechanical ventilation for ≥24 h, had 2 consecutive arterial blood gases with a ratio of the partial pressure of oxygen to the fraction of inspired oxygen ≤300, and bilateral radiographic opacities within 48 h of hospital admission were defined as having ARDS. We examined the associations between ARDS and outcome using multivariable analyses and performed sensitivity analyses excluding patients with evidence of cardiac dysfunction. RESULTS Of 978 OHCA patients transported to the study hospitals, 600 were mechanically ventilated and survived ≥48 h. A total of 287 (48%, 95% CI 44-52%) met criteria for ARDS within 48 h of admission. There were no differences in demographics, OHCA etiology, or cardiac rhythm according to ARDS status. Patients with ARDS had higher hospital mortality, longer ICU stays, more ventilator days, and were less likely to survive with full neurologic recovery. Upon excluding patients with cardiac dysfunction, the incidence of ARDS was unchanged. CONCLUSION Nearly half of initial OHCA survivors develop ARDS within 48 h of hospital admission. ARDS was associated with poor outcome and increased resource utilization. OHCA should be considered among the traditional ARDS risk factors.
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Affiliation(s)
- Nicholas J Johnson
- Department of Emergency Medicine, University of Washington, Seattle, WA, United States; Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA, United States.
| | - Ellen Caldwell
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA, United States
| | - David J Carlbom
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA, United States
| | - David F Gaieski
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Matthew E Prekker
- Department of Emergency Medicine & Division Pulmonary and Critical Care Medicine, Hennepin County Medical Center, Minneapolis, MN, United States
| | - Thomas D Rea
- Division of General Internal Medicine, University of Washington, Seattle, WA, United States; King County Medic One, WA, United States
| | - Michael Sayre
- Department of Emergency Medicine, University of Washington, Seattle, WA, United States; Seattle Medic One, WA, United States
| | - Catherine L Hough
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA, United States
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