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Rauch S, Brugger H, Falk M, Zweifel B, Strapazzon G, Albrecht R, Pietsch U. Avalanche Survival Rates in Switzerland, 1981-2020. JAMA Netw Open 2024; 7:e2435253. [PMID: 39320893 PMCID: PMC11425148 DOI: 10.1001/jamanetworkopen.2024.35253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/26/2024] Open
Abstract
Importance Survival probability among individuals critically buried by avalanche is highly time dependent, which was demonstrated 30 years ago. However, it remains unclear whether avalanche survival probability has changed over time. Objective To assess the avalanche survival rate and probability as well as the rescue probability over the past 4 decades. Design, Setting, and Participants In this cohort study, avalanche data from Switzerland that were collected by the WSL Institute for Snow and Avalanche Research (SLF) in Davos were analyzed from the winter beginning in 1981 to that beginning in 2020 and compared with data from the period 1981 to 1990. Data were analyzed from January to April 2024. Exposure Critical avalanche burial (ie, burial involving the head and chest). Main Outcomes and Measures Survival rate among individuals critically buried by avalanche, survival probability, and rescue probability in relation to time buried under the avalanche. Results The study included 1643 individuals critically buried by avalanche (mean [SD] age, 37 [13.7] years; 1090 of 1342 with known sex [81.2%] were male) among 3805 avalanches involving 7059 persons. Compared with the period from 1981 to 1990, the total survival rate over the full study period increased from 43.5% (95% CI, 38.8%-48.3%) to 53.4% (95% CI, 51.0%-55.8%). Survival probability remained high at 91% (95% CI, 80%-100%) for rescue during the first 10 minutes but then decreased to 31% (95% CI, 11%-51%) for rescue between 10 and 30 minutes. The survival rate among those buried long term (>130 minutes) increased from 2.6% (95% CI, 0.7%-6.9%) to 7.3% (95% CI, 4.8%-10.7%). The median rescue time decreased from 45 (IQR, 15-148) minutes to 25 (IQR, 10-85) minutes. Survival rates among individuals rescued from avalanche by organized rescue teams increased from 14.0% (28 of 200) to 22.9% (161 of 704). Conclusions and Relevance This cohort study of 1643 individuals critically buried by avalanche found that over the past 4 decades, total survival rates considerably increased and rescue times decreased. Survival rates among those buried long term (>130 minutes) also increased. These findings are likely attributable to collaborative efforts among stakeholders to enhance avalanche search-and-rescue techniques and medical interventions.
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Affiliation(s)
- Simon Rauch
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
- Department of Anesthesia and Intensive Care Medicine, Hospital of Merano, Merano, Italy
| | - Hermann Brugger
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
- International Commission of Mountain Emergency Medicine, Zurich-Kloten, Switzerland
| | - Markus Falk
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - Benjamin Zweifel
- WSL Institute for Snow and Avalanche Research, Davos, Switzerland
| | - Giacomo Strapazzon
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
- International Commission of Mountain Emergency Medicine, Zurich-Kloten, Switzerland
- Department of Medicine, University of Padova, Padova, Italy
| | - Roland Albrecht
- Division of Perioperative Intensive Care Medicine, Cantonal Hospital St Gallen, St Gallen, Switzerland
- Department of Emergency Medicine, Bern University Hospital (Inselspital), University of Bern, Bern, Switzerland
- Swiss Air-Ambulance (Rega), Zurich, Switzerland
| | - Urs Pietsch
- Division of Perioperative Intensive Care Medicine, Cantonal Hospital St Gallen, St Gallen, Switzerland
- Department of Emergency Medicine, Bern University Hospital (Inselspital), University of Bern, Bern, Switzerland
- Swiss Air-Ambulance (Rega), Zurich, Switzerland
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2
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Falat C. Environmental Hypothermia. Emerg Med Clin North Am 2024; 42:493-511. [PMID: 38925770 DOI: 10.1016/j.emc.2024.02.011] [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] [Indexed: 06/28/2024]
Abstract
Although a rare diagnosis in the Emergency Department, hypothermia affects patients in all environments, from urban to mountainous settings. Classic signs of death cannot be interpreted in the hypothermic patient, thus resulting in the mantra, "No one is dead until they're warm and dead." This comprehensive review of environmental hypothermia covers the clinical significance and pathophysiology of hypothermia, pearls and pitfalls in the prehospital management of hypothermia (including temperature measurement techniques and advanced cardiac life support deviations), necessary Emergency Department diagnostics, available rewarming modalities including extracorporeal life support, and criteria for termination of resuscitation.
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Affiliation(s)
- Cheyenne Falat
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
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3
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Strapazzon G, Taboni A, Dietrichs ES, Luks AM, Brugger H. Avalanche burial pathophysiology - a unique combination of hypoxia, hypercapnia and hypothermia. J Physiol 2024. [PMID: 39073871 DOI: 10.1113/jp284607] [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: 09/01/2023] [Accepted: 06/17/2024] [Indexed: 07/30/2024] Open
Abstract
For often unclear reasons, the survival times of critically buried avalanche victims vary widely from minutes to hours. Individuals can survive and sustain organ function if they can breathe under the snow and maintain sufficient delivery of oxygen and efflux of carbon dioxide. We review the physiological responses of humans to critical avalanche burial, a model which shares similarities and differences with apnoea and accidental hypothermia. Within a few minutes of burial, an avalanche victim is exposed to hypoxaemia and hypercapnia, which have important effects on the respiratory and cardiovascular systems and pose a major threat to the central nervous system. As burial time increases, an avalanche victim also develops hypothermia. Despite progressively reduced metabolism, reduced oxygen and increased carbon dioxide tensions may exacerbate the pathophysiological consequences of hypothermia. Hypercapnia seems to be the main cause of cardiovascular instability, which, in turn, is the major reason for reduced cerebral oxygenation despite reductions in cerebral metabolic activity caused by hypothermia. 'Triple H syndrome' refers to the interaction of hypoxia, hypercapnia and hypothermia in a buried avalanche victim. Future studies should investigate how the respiratory gases entrapped in the porous snow structure influence the physiological responses of buried individuals and how haemoconcentration, blood viscosity and cell deformability affect blood flow and oxygen delivery. Attention should also be devoted to identifying strategies to prolong avalanche survival by either mitigating hypoxia and hypercapnia or reducing core temperature so that neuroprotection occurs before the onset of cerebral hypoxia.
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Affiliation(s)
- Giacomo Strapazzon
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
- Department of Medicine - DIMEM, University of Padova, Padova, Italy
| | - Anna Taboni
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | | | - Andrew M Luks
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Hermann Brugger
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
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4
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Van Tilburg C, Paal P, Strapazzon G, Grissom CK, Haegeli P, Hölzl N, McIntosh S, Radwin M, Smith WWR, Thomas S, Tremper B, Weber D, Wheeler AR, Zafren K, Brugger H. Wilderness Medical Society Clinical Practice Guidelines for Prevention and Management of Avalanche and Nonavalanche Snow Burial Accidents: 2024 Update. Wilderness Environ Med 2024; 35:20S-44S. [PMID: 37945433 DOI: 10.1016/j.wem.2023.05.014] [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: 11/09/2022] [Revised: 04/03/2023] [Accepted: 05/10/2023] [Indexed: 11/12/2023]
Abstract
To provide guidance to the general public, clinicians, and avalanche professionals about best practices, the Wilderness Medical Society convened an expert panel to revise the evidence-based guidelines for the prevention, rescue, and resuscitation of avalanche and nonavalanche snow burial victims. The original panel authored the Wilderness Medical Society Practice Guidelines for Prevention and Management of Avalanche and Nonavalanche Snow Burial Accidents in 2017. A second panel was convened to update these guidelines and make recommendations based on quality of supporting evidence.
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Affiliation(s)
- Christopher Van Tilburg
- Occupational Medicine, Mountain Clinic, and Emergency Medicine, Providence Hood River Memorial Hospital, Hood River, OR
- Mountain Rescue Association, San Diego, CA
- International Commission for Alpine Rescue
| | - Peter Paal
- International Commission for Alpine Rescue
- Department of Anesthesiology and Critical Care Medicine, St. John of God Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Giacomo Strapazzon
- International Commission for Alpine Rescue
- Department of Anesthesiology and Critical Care Medicine, University Hospital Innsbruck, Innsbruck, Austria
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - Colin K Grissom
- Department of Pulmonary and Critical Care, Intermountain Medical Center, Murray, UT
| | | | - Natalie Hölzl
- International Commission for Alpine Rescue
- German Association of Mountain and Expedition Medicine, Munich, Germany
| | - Scott McIntosh
- International Commission for Alpine Rescue
- Division of Emergency Medicine, University of Utah Health, Salt Lake City, UT
| | | | - William Will R Smith
- Mountain Rescue Association, San Diego, CA
- International Commission for Alpine Rescue
- Division of Emergency Medicine, University of Utah Health, Salt Lake City, UT
- Department of Emergency Medicine, St. Johns Health, Jackson, WY
- University of Washington School of Medicine, Seattle, WA
| | - Stephanie Thomas
- Mountain Rescue Association, San Diego, CA
- International Commission for Alpine Rescue
| | | | - David Weber
- Intermountain Life Flight, Salt Lake City, UT
| | - Albert R Wheeler
- Mountain Rescue Association, San Diego, CA
- International Commission for Alpine Rescue
- Division of Emergency Medicine, University of Utah Health, Salt Lake City, UT
- Department of Emergency Medicine, St. Johns Health, Jackson, WY
| | - Ken Zafren
- International Commission for Alpine Rescue
- Himalayan Rescue Association, Kathmandu, Nepal
- Stanford University Medical Center, Palo Alto, CA
| | - Hermann Brugger
- International Commission for Alpine Rescue
- Department of Anesthesiology and Critical Care Medicine, University Hospital Innsbruck, Innsbruck, Austria
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
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Kraai E, Wray TC, Ball E, Tawil I, Mitchell J, Guliani S, Dettmer T, Marinaro J. E-CPR in Cardiac Arrest due to Accidental Hypothermia Using Intensivist Cannulators: A Case Series of Nine Consecutive Patients. J Intensive Care Med 2023; 38:215-219. [PMID: 35876344 DOI: 10.1177/08850666221116594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background: Severe accidental hypothermia (AH) accounts for over 1300 deaths/year in the United States. Early extracorporeal life support (ECLS) is recommended for hypothermic cardiac arrest. We describe the use of a rapid-deployment extracorporeal cardiopulmonary resuscitation (E-CPR) team using intensivist physicians (IPs) as cannulators and report the outcomes of consecutive patients cannulated for ECLS to manage cardiac arrest due to AH. Methods: We reviewed all patients managed with veno-arterial (V-A) ECLS for hypothermic cardiac arrest between January 1, 2017 and November 1, 2021. For each patient- age, sex, cause of hypothermia, initial core temperature, initial rhythm, time from arrest to cannulation, cannula configuration, pH, lactate, potassium, cannulation complications, duration of ECLS, hospital length of stay, mortality, and cerebral performance category (CPC) at discharge were reviewed. Results: Nine consecutive patients were identified that underwent V-A ECLS for cardiac arrest due to AH. Seven (78%) were witnessed arrests. Initial rhythm was ventricular fibrillation (VF) in eight patients and pulseless electrical activity (PEA) in one. The mean initial core temperature was 23.8 degrees Celsius. The mean time from arrest to cannulation was 58 min (range 17 to 251 min). There were no complications related to cannulation. The mean duration of ECLS was 39.1 h. All nine patients were discharged alive with a Cerebral Performance score of one or two. Conclusion: In this case series of consecutive patients reporting intensivist-deployed E-CPR for cardiac arrest due to AH, all patients survived to discharge with a favorable neurologic outcome. A rapidly available E-CPR team utilizing intensivist cannulators may improve outcomes in patients with cardiac arrest due to AH.
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Affiliation(s)
- Erik Kraai
- Department of Internal Medicine, Center for Adult Critical Care, 21764University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Trenton C Wray
- Department of Emergency Medicine, Center for Adult Critical Care, 12289University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Emily Ball
- Department of Emergency Medicine, Center for Adult Critical Care, 12289University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Isaac Tawil
- Department of Emergency Medicine, Center for Adult Critical Care, 12289University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Jessica Mitchell
- Department of Emergency Medicine, Center for Adult Critical Care, 12289University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Sundeep Guliani
- Department of Surgery, Center for Adult Critical Care, 12289University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Todd Dettmer
- Department of Emergency Medicine, Center for Adult Critical Care, 12289University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Jonathan Marinaro
- Department of Emergency Medicine, Center for Adult Critical Care, 12289University of New Mexico Health Sciences Center, Albuquerque, NM, USA
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Prekker ME, Rischall M, Carlson M, Driver BE, Touroutoutoudis M, Boland J, Hu M, Heather B, Simpson NS. Extracorporeal membrane oxygenation versus conventional rewarming for severe hypothermia in an urban emergency department. Acad Emerg Med 2023; 30:6-15. [PMID: 36000288 DOI: 10.1111/acem.14585] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/28/2022] [Accepted: 08/19/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Severe hypothermia (core body temperature < 28°C) is life-threatening and predisposes to cardiac arrest. The comparative effectiveness of different active internal rewarming methods in an urban U.S. population is unknown. We aim to compare outcomes between hypothermic emergency department (ED) patients rewarmed conventionally using an intravascular rewarming catheter or warm fluid lavage versus those rewarmed using extracorporeal membrane oxygenation (ECMO). METHODS We performed a retrospective cohort analysis of adults with severe hypothermia due to outdoor exposure presenting to an urban ED in Minnesota, 2007-2021. The primary outcome was hospital survival. We also calculated the rewarming rate in the 4 h after ED arrival and compared these data between patients rewarmed with ECMO (the extracorporeal rewarming group) versus without ECMO (the conventional rewarming group). We repeated these analyses in the subgroup of patients with cardiac arrest. RESULTS We analyzed 44 hypothermic ED patients: 25 patients in the extracorporeal rewarming group (median temperature 24.1°C, 84% with cardiac arrest) and 19 patients in the conventional rewarming group (median temperature 26.3°C, 37% with cardiac arrest; 89% received an intravascular rewarming catheter). The median rewarming rate was greater in the extracorporeal versus conventional group (2.3°C/h vs. 1.5°C/h, absolute difference 0.8°C/h, 95% confidence interval [CI] 0.3-1.2°C/h) yet hospital survival was similar (68% vs. 74%). Among patients with cardiac arrest, hospital survival was greater in the extracorporeal versus conventional group (71% vs. 29%, absolute difference 42%, 95% CI 4%-82%). CONCLUSIONS Among ED patients with severe hypothermia and cardiac arrest, survival was significantly higher with ECMO versus conventional rewarming. Among all hypothermic patients, ECMO use was associated with faster rewarming than conventional methods.
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Affiliation(s)
- Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA.,Division of Pulmonary and Critical Care, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Megan Rischall
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Michelle Carlson
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | | | - Jessica Boland
- Department of Critical Care Medicine, Allina Health, Minneapolis, Minnesota, USA
| | - Michael Hu
- Department of Surgery, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Beth Heather
- Critical Care Nursing and the Extracorporeal Life Support Program, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Nicholas S Simpson
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA.,Hennepin Emergency Medical Services, Minneapolis, Minnesota, USA
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7
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Takauji S, Hayakawa M, Yamada D, Tian T, Minowa K, Inoue A, Fujimoto Y, Isokawa S, Miura N, Endo T, Irie J, Otomo G, Sato H, Bando K, Suzuki T, Toyohara T, Tomita A, Iwahara M, Murata S, Shimazaki J, Matsuyoshi T, Yoshizawa J, Nitta K, Sato Y. Outcome of extracorporeal membrane oxygenation use in severe accidental hypothermia with cardiac arrest and circulatory instability: A multicentre, prospective, observational study in Japan (ICE-CRASH study). Resuscitation 2023; 182:109663. [PMID: 36509361 DOI: 10.1016/j.resuscitation.2022.12.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/30/2022] [Accepted: 12/03/2022] [Indexed: 12/14/2022]
Abstract
AIM To elucidate the effectiveness of extracorporeal membrane oxygenation (ECMO) in accidental hypothermia (AH) patients with and without cardiac arrest (CA), including details of complications. METHODS This study was a multicentre, prospective, observational study of AH in Japan. All adult (aged ≥18 years) AH patients with body temperature ≤32 °C who presented to the emergency department between December 2019 and March 2022 were included. Among the patients, those with CA or circulatory instability, defined as severe AH, were selected and divided into the ECMO and non-ECMO groups. We compared 28-day survival and favourable neurological outcomes at discharge between the ECMO and non-ECMO groups by adjusting for the patients' background characteristics using multivariable logistic regression analysis. RESULTS Among the 499 patients in this study, 242 patients with severe AH were included in the analysis: 41 in the ECMO group and 201 in the non-ECMO group. Multivariable analysis showed that the ECMO group was significantly associated with better 28-day survival and favourable neurological outcomes at discharge in patients with CA compared to the non-ECMO group (odds ratio [OR] 0.17, 95% confidence interval [CI]: 0.05-0.58, and OR 0.22, 95%CI: 0.06-0.81). However, in patients without CA, ECMO not only did not improve 28-day survival and neurological outcomes, but also decreased the number of event-free days (ICU-, ventilator-, and catecholamine administration-free days) and increased the frequency of bleeding complications. CONCLUSIONS ECMO improved survival and neurological outcomes in AH patients with CA, but not in AH patients without CA.
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Affiliation(s)
- Shuhei Takauji
- Department of Emergency Medicine, Asahikawa Medical University Hospital, Asahikawa, Japan.
| | - Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Daisuke Yamada
- Senri Critical Care Medical Center, Saiseikai Senri Hospital, Suita, Japan
| | - Tian Tian
- Emergency and Critical Care Medical Center, Kishiwada Tokushukai Hospital, Osaka, Japan
| | - Keita Minowa
- Department of Emergency and Critical Care Medicine, Hachinohe City Hospital, Hachinohe, Japan
| | - Akihiko Inoue
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Japan
| | - Yoshihiro Fujimoto
- Department of Emergency Medicine, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Shutaro Isokawa
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Naoya Miura
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Tokai, Japan
| | - Tomoyuki Endo
- Department of Emergency and Disaster Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Jin Irie
- Department of Emergency and Disaster Medicine, Hirosaki University, Hirosaki, Japan
| | - Gen Otomo
- Emergency and Critical Care Medicine, Asahikawa Red Cross Hospital, Asahikawa, Japan
| | - Hiroki Sato
- Critical Care and Emergency Center National Hospital Organization Hokkaido Medical Center, Sapporo, Japan
| | - Keisuke Bando
- Department of Emergency Medicine and Critical Care, Sapporo City General Hospital, Sapporo, Japan
| | - Tsuyoshi Suzuki
- Department of Emergency and Critical Care Medicine, Fukushima Medical University, Fukushima City, Fukushima, Japan
| | - Takashi Toyohara
- Department of Emergency Medicine, Kushiro City General Hospital, Kushiro, Japan
| | - Akiko Tomita
- Department of Emergency Medicine, Sunagawa City Medical Center, Sunagawa, Japan
| | - Motoko Iwahara
- Department of Emergency Medicine, Nayoro City General Hospital, Nayoro, Japan
| | - Satoru Murata
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Junya Shimazaki
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takeo Matsuyoshi
- Emergency and Critical Care Center, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Jo Yoshizawa
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kenichi Nitta
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yuta Sato
- Emergency and Critical Care Center, Aomori Prefectural Central Hospital, Aomori, Japan
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Filseth OM, Kondratiev T, Sieck GC, Tveita T. Functional recovery after accidental deep hypothermic cardiac arrest: Comparison of different cardiopulmonary bypass rewarming strategies. Front Physiol 2022; 13:960652. [PMID: 36134333 PMCID: PMC9483155 DOI: 10.3389/fphys.2022.960652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 08/01/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction: Using a porcine model of accidental immersion hypothermia and hypothermic cardiac arrest (HCA), the aim of the present study was to compare effects of different rewarming strategies on CPB on need for vascular fluid supply, level of cardiac restitution, and cerebral metabolism and pressures. Materials and Methods: Totally sixteen healthy, anesthetized castrated male pigs were immersion cooled to 20°C to induce HCA, maintained for 75 min and then randomized into two groups: 1) animals receiving CPB rewarming to 30°C followed by immersion rewarming to 36°C (CPB30, n = 8), or 2) animals receiving CPB rewarming to 36°C (CPB36, n = 8). Measurements of cerebral metabolism were collected using a microdialysis catheter. After rewarming to 36°C, surviving animals in both groups were further warmed by immersion to 38°C and observed for 2 h. Results: Survival rate at 2 h after rewarming was 5 out of 8 animals in the CPB30 group, and 8 out of 8 in the CPB36 group. All surviving animals displayed significant acute cardiac dysfunction irrespective of rewarming method. Differences between groups in CPB exposure time or rewarming rate created no differences in need for vascular volume supply, in variables of cerebral metabolism, or in cerebral pressures and blood flow. Conclusion: As 3 out of 8 animals did not survive weaning from CPB at 30°C, early weaning gave no advantages over weaning at 36°C. Further, in surviving animals, the results showed no differences between groups in the need for vascular volume replacement, nor any differences in cerebral blood flow or pressures. Most prominent, after weaning from CPB, was the existence of acute cardiac failure which was responsible for the inability to create an adequate perfusion irrespective of rewarming strategy.
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Affiliation(s)
- Ole Magnus Filseth
- Anesthesia and Critical Care Research Group, Faculty of Health Sciences, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
- Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
- Emergency Medical Services, University Hospital of North Norway, Tromsø, Norway
| | - Timofei Kondratiev
- Anesthesia and Critical Care Research Group, Faculty of Health Sciences, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Gary C. Sieck
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, United States
| | - Torkjel Tveita
- Anesthesia and Critical Care Research Group, Faculty of Health Sciences, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
- Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, United States
- *Correspondence: Torkjel Tveita,
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Filseth OM, Hermansen SE, Kondratiev T, Sieck GC, Tveita T. Cooling to Hypothermic Circulatory Arrest by Immersion vs. Cardiopulmonary Bypass (CPB): Worse Outcome After Rewarming in Immersion Cooled Pigs. Front Physiol 2022; 13:862729. [PMID: 35431978 PMCID: PMC9008231 DOI: 10.3389/fphys.2022.862729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 02/25/2022] [Indexed: 12/04/2022] Open
Abstract
Introduction Cooling by cardiopulmonary bypass (CPB) to deep hypothermic cardiac arrest (HCA) for cardiac surgical interventions, followed by CPB-rewarming is performed on a routine basis with relatively low mortality. In contrast, victims of deep accidental hypothermia rewarmed with CPB generally have a much worse prognosis. Thus, we have developed an intact pig model to compare effects on perfusion pressures and global oxygen delivery (DO2) during immersion cooling versus cooling by CPB. Further, we compared the effects of CPB-rewarming between groups, to restitute cardiovascular function, brain blood flow, and brain metabolism. Materials and Methods Total sixteen healthy, anesthetized juvenile (2–3 months) castrated male pigs were randomized in a prospective, open placebo-controlled experimental study to immersion cooling (IMMc, n = 8), or cooling by CPB (CPBc, n = 8). After 75 minutes of deep HCA in both groups, pigs were rewarmed by CPB. After weaning from CPB surviving animals were observed for 2 h before euthanasia. Results Survival rates at 2 h after completed rewarming were 4 out of 8 in the IMMc group, and 8 out of 8 in the CPBc group. Compared with the CPBc-group, IMMc animals showed significant reduction in DO2, mean arterial pressure (MAP), cerebral perfusion pressure, and blood flow during cooling below 25°C as well as after weaning from CPB after rewarming. After rewarming, brain blood flow returned to control in CPBc animals only, and brain micro dialysate-data showed a significantly increase in the lactate/pyruvate ratio in IMMc vs. CPBc animals. Conclusion Our data indicate that, although global O2 consumption was independent of DO2, regional ischemic damage may have taken place during cooling in the brain of IMMc animals below 25°C. The need for prolonged extracorporeal membrane oxygenation (ECMO) should be considered in all victims of accidental hypothermic arrest that cannot be weaned from CPB immediately after rewarming.
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Affiliation(s)
- Ole Magnus Filseth
- Anesthesia and Critical Care Research Group, Faculty of Health Sciences, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
- Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
- Emergency Medical Services, University Hospital of North Norway, Tromsø, Norway
| | - Stig Eggen Hermansen
- Cardiothoracic Research Group, Faculty of Health Sciences, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
- Cardiothoracic and Respiratory Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Timofei Kondratiev
- Anesthesia and Critical Care Research Group, Faculty of Health Sciences, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Gary C. Sieck
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine & Science, Rochester, MN, United States
| | - Torkjel Tveita
- Anesthesia and Critical Care Research Group, Faculty of Health Sciences, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
- Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine & Science, Rochester, MN, United States
- *Correspondence: Torkjel Tveita,
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A Comparison between Conventional and Extracorporeal Cardiopulmonary Resuscitation in Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis. Healthcare (Basel) 2022; 10:healthcare10030591. [PMID: 35327068 PMCID: PMC8955421 DOI: 10.3390/healthcare10030591] [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: 01/25/2022] [Revised: 03/09/2022] [Accepted: 03/14/2022] [Indexed: 12/04/2022] Open
Abstract
There is limited evidence comparing the use of extracorporeal cardiopulmonary resuscitation (ECPR) to CPR in the management of refractory out-of-hospital cardiac arrest (OHCA). We conducted a systematic review and meta-analysis to compare survival and neurologic outcomes associated with ECPR versus CPR in the management of OHCA. We searched PubMed, EMBASE, and Scopus to identify observational studies and randomized controlled trials comparing ECPR and CPR. We used the Newcastle−Ottawa Scale and Cochrane’s risk-of-bias tool to assess studies’ quality. We used random-effects models to compare outcomes between the pooled populations and moderator analysis to identify sources of heterogeneity and perform subgroup analysis. We identified 2088 articles and included 13, with 18,620 patients with OHCA. A total of 16,701 received CPR and 1919 received ECPR. Compared with CPR, ECPR was associated with higher odds of achieving favorable neurologic outcomes at 3 (OR 5, 95% CI 1.90−13.1, p < 0.01) and 6 months (OR 4.44, 95% CI 2.3−8.5, p < 0.01). We did not find a significant survival benefit or impact on neurologic outcomes at hospital discharge or 1 month following arrest. ECPR is a promising but resource-intensive intervention with the potential to improve long-term outcomes among patients with OHCA.
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11
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Bjertnæs LJ, Næsheim TO, Reierth E, Suborov EV, Kirov MY, Lebedinskii KM, Tveita T. Physiological Changes in Subjects Exposed to Accidental Hypothermia: An Update. Front Med (Lausanne) 2022; 9:824395. [PMID: 35280892 PMCID: PMC8904885 DOI: 10.3389/fmed.2022.824395] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/28/2022] [Indexed: 12/01/2022] Open
Abstract
Background Accidental hypothermia (AH) is an unintended decrease in body core temperature (BCT) to below 35°C. We present an update on physiological/pathophysiological changes associated with AH and rewarming from hypothermic cardiac arrest (HCA). Temperature Regulation and Metabolism Triggered by falling skin temperature, Thyrotropin-Releasing Hormone (TRH) from hypothalamus induces release of Thyroid-Stimulating Hormone (TSH) and Prolactin from pituitary gland anterior lobe that stimulate thyroid generation of triiodothyronine and thyroxine (T4). The latter act together with noradrenaline to induce heat production by binding to adrenergic β3-receptors in fat cells. Exposed to cold, noradrenaline prompts degradation of triglycerides from brown adipose tissue (BAT) into free fatty acids that uncouple metabolism to heat production, rather than generating adenosine triphosphate. If BAT is lacking, AH occurs more readily. Cardiac Output Assuming a 7% drop in metabolism per °C, a BCT decrease of 10°C can reduce metabolism by 70% paralleled by a corresponding decline in CO. Consequently, it is possible to maintain adequate oxygen delivery provided correctly performed cardiopulmonary resuscitation (CPR), which might result in approximately 30% of CO generated at normal BCT. Liver and Coagulation AH promotes coagulation disturbances following trauma and acidosis by reducing coagulation and platelet functions. Mean prothrombin and partial thromboplastin times might increase by 40-60% in moderate hypothermia. Rewarming might release tissue factor from damaged tissues, that triggers disseminated intravascular coagulation. Hypothermia might inhibit platelet aggregation and coagulation. Kidneys Renal blood flow decreases due to vasoconstriction of afferent arterioles, electrolyte and fluid disturbances and increasing blood viscosity. Severely deranged renal function occurs particularly in the presence of rhabdomyolysis induced by severe AH combined with trauma. Conclusion Metabolism drops 7% per °C fall in BCT, reducing CO correspondingly. Therefore, it is possible to maintain adequate oxygen delivery after 10°C drop in BCT provided correctly performed CPR. Hypothermia may facilitate rhabdomyolysis in traumatized patients. Victims suspected of HCA should be rewarmed before being pronounced dead. Rewarming avalanche victims of HCA with serum potassium > 12 mmol/L and a burial time >30 min with no air pocket, most probably be futile.
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Affiliation(s)
- Lars J. Bjertnæs
- Department of Clinical Medicine, Faculty of Health Sciences, Anesthesia and Critical Care Research Group, University of Tromsø, UiT The Arctic University of Norway, Tromsø, Norway
- Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
| | - Torvind O. Næsheim
- Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, Faculty of Health Sciences, Cardiovascular Research Group, University of Tromsø, UiT The Arctic University of Norway, Tromsø, Norway
| | - Eirik Reierth
- Science and Health Library, University of Tromsø, UiT The Arctic University of Norway, Tromsø, Norway
| | - Evgeny V. Suborov
- The Nikiforov Russian Center of Emergency and Radiation Medicine, St. Petersburg, Russia
| | - Mikhail Y. Kirov
- Department of Anesthesiology and Intensive Care, Northern State Medical University, Arkhangelsk, Russia
| | - Konstantin M. Lebedinskii
- Department of Anesthesiology and Intensive Care, North-Western State Medical University named after I.I. Mechnikov, St. Petersburg, Russia
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Torkjel Tveita
- Department of Clinical Medicine, Faculty of Health Sciences, Anesthesia and Critical Care Research Group, University of Tromsø, UiT The Arctic University of Norway, Tromsø, Norway
- Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
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12
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Swol J, Darocha T, Paal P, Brugger H, Podsiadło P, Kosiński S, Puślecki M, Ligowski M, Pasquier M. Extracorporeal Life Support in Accidental Hypothermia with Cardiac Arrest-A Narrative Review. ASAIO J 2022; 68:153-162. [PMID: 34261875 PMCID: PMC8797003 DOI: 10.1097/mat.0000000000001518] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Severely hypothermic patients, especially suffering cardiac arrest, require highly specialized treatment. The most common problems affecting the recognition and treatment seem to be awareness, logistics, and proper planning. In severe hypothermia, pathophysiologic changes occur in the cardiovascular system leading to dysrhythmias, decreased cardiac output, decreased central nervous system electrical activity, cold diuresis, and noncardiogenic pulmonary edema. Cardiac arrest, multiple organ dysfunction, and refractory vasoplegia are indicative of profound hypothermia. The aim of these narrative reviews is to describe the peculiar pathophysiology of patients suffering cardiac arrest from accidental hypothermia. We describe the good chances of neurologic recovery in certain circumstances, even in patients presenting with unwitnessed cardiac arrest, asystole, and the absence of bystander cardiopulmonary resuscitation. Guidance on patient selection, prognostication, and treatment, including extracorporeal life support, is given.
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Affiliation(s)
- Justyna Swol
- From the Deparment of Respiratory Medicine, Allergology and Sleep Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Tomasz Darocha
- Department of Anesthesiology and Intensive Care, Severe Accidental Hypothermia Center, Medical University of Silesia, Katowice, Poland
| | - Peter Paal
- Department of Anesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Hermann Brugger
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - Paweł Podsiadło
- Department of Emergency Medicine, Jan Kochanowski University, Kielce, Poland
| | - Sylweriusz Kosiński
- Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Mateusz Puślecki
- Department of Medical Rescue, Poznan University of Medical Sciences, Poznan, Poland
- Departmentf Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Marcin Ligowski
- Departmentf Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Mathieu Pasquier
- Emergency Department, Lausanne University Hospital, Lausanne, Switzerland
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13
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Paal P, Pasquier M, Darocha T, Lechner R, Kosinski S, Wallner B, Zafren K, Brugger H. Accidental Hypothermia: 2021 Update. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:501. [PMID: 35010760 PMCID: PMC8744717 DOI: 10.3390/ijerph19010501] [Citation(s) in RCA: 63] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 12/08/2021] [Accepted: 12/09/2021] [Indexed: 12/13/2022]
Abstract
Accidental hypothermia is an unintentional drop of core temperature below 35 °C. Annually, thousands die of primary hypothermia and an unknown number die of secondary hypothermia worldwide. Hypothermia can be expected in emergency patients in the prehospital phase. Injured and intoxicated patients cool quickly even in subtropical regions. Preventive measures are important to avoid hypothermia or cooling in ill or injured patients. Diagnosis and assessment of the risk of cardiac arrest are based on clinical signs and core temperature measurement when available. Hypothermic patients with risk factors for imminent cardiac arrest (temperature < 30 °C in young and healthy patients and <32 °C in elderly persons, or patients with multiple comorbidities), ventricular dysrhythmias, or systolic blood pressure < 90 mmHg) and hypothermic patients who are already in cardiac arrest, should be transferred directly to an extracorporeal life support (ECLS) centre. If a hypothermic patient arrests, continuous cardiopulmonary resuscitation (CPR) should be performed. In hypothermic patients, the chances of survival and good neurological outcome are higher than for normothermic patients for witnessed, unwitnessed and asystolic cardiac arrest. Mechanical CPR devices should be used for prolonged rescue, if available. In severely hypothermic patients in cardiac arrest, if continuous or mechanical CPR is not possible, intermittent CPR should be used. Rewarming can be accomplished by passive and active techniques. Most often, passive and active external techniques are used. Only in patients with refractory hypothermia or cardiac arrest are internal rewarming techniques required. ECLS rewarming should be performed with extracorporeal membrane oxygenation (ECMO). A post-resuscitation care bundle should complement treatment.
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Affiliation(s)
- Peter Paal
- Department of Anesthesiology and Intensive Care Medicine, St. John of God Hospital, Paracelsus Medical University, 5020 Salzburg, Austria
- International Commission for Mountain Emergency Medicine (ICAR MedCom), 8302 Kloten, Switzerland; (M.P.); (K.Z.); (H.B.)
| | - Mathieu Pasquier
- International Commission for Mountain Emergency Medicine (ICAR MedCom), 8302 Kloten, Switzerland; (M.P.); (K.Z.); (H.B.)
- Department of Emergency Medicine, Lausanne University Hospital, 1011 Lausanne, Switzerland
| | - Tomasz Darocha
- Department of Anesthesiology and Intensive Care, Medical University of Silesia, 40-001 Katowice, Poland;
| | - Raimund Lechner
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Military Hospital, 89081 Ulm, Germany;
| | - Sylweriusz Kosinski
- Faculty of Health Sciences, Jagiellonian University Medical College, 34-500 Krakow, Poland;
| | - Bernd Wallner
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria;
| | - Ken Zafren
- International Commission for Mountain Emergency Medicine (ICAR MedCom), 8302 Kloten, Switzerland; (M.P.); (K.Z.); (H.B.)
- Department of Emergency Medicine, Alaska Native Medical Center, Anchorage, AK 99508, USA
- Department of Emergency Medicine, Stanford University Medical Center, Stanford University, Palo Alto, CA 94304, USA
| | - Hermann Brugger
- International Commission for Mountain Emergency Medicine (ICAR MedCom), 8302 Kloten, Switzerland; (M.P.); (K.Z.); (H.B.)
- Institute of Mountain Emergency Medicine, Eurac Research, 39100 Bolzano, Italy
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria
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14
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Wyckoff MH, Singletary EM, Soar J, Olasveengen TM, Greif R, Liley HG, Zideman D, Bhanji F, Andersen LW, Avis SR, Aziz K, Bendall JC, Berry DC, Borra V, Böttiger BW, Bradley R, Bray JE, Breckwoldt J, Carlson JN, Cassan P, Castrén M, Chang WT, Charlton NP, Cheng A, Chung SP, Considine J, Costa-Nobre DT, Couper K, Dainty KN, Davis PG, de Almeida MF, de Caen AR, de Paiva EF, Deakin CD, Djärv T, Douma MJ, Drennan IR, Duff JP, Eastwood KJ, El-Naggar W, Epstein JL, Escalante R, Fabres JG, Fawke J, Finn JC, Foglia EE, Folke F, Freeman K, Gilfoyle E, Goolsby CA, Grove A, Guinsburg R, Hatanaka T, Hazinski MF, Heriot GS, Hirsch KG, Holmberg MJ, Hosono S, Hsieh MJ, Hung KKC, Hsu CH, Ikeyama T, Isayama T, Kapadia VS, Kawakami MD, Kim HS, Kloeck DA, Kudenchuk PJ, Lagina AT, Lauridsen KG, Lavonas EJ, Lockey AS, Malta Hansen C, Markenson D, Matsuyama T, McKinlay CJD, Mehrabian A, Merchant RM, Meyran D, Morley PT, Morrison LJ, Nation KJ, Nemeth M, Neumar RW, Nicholson T, Niermeyer S, Nikolaou N, Nishiyama C, O'Neil BJ, Orkin AM, Osemeke O, Parr MJ, Patocka C, Pellegrino JL, Perkins GD, Perlman JM, Rabi Y, Reynolds JC, Ristagno G, Roehr CC, Sakamoto T, Sandroni C, Sawyer T, Schmölzer GM, Schnaubelt S, Semeraro F, Skrifvars MB, Smith CM, Smyth MA, Soll RF, Sugiura T, Taylor-Phillips S, Trevisanuto D, Vaillancourt C, Wang TL, Weiner GM, Welsford M, Wigginton J, Wyllie JP, Yeung J, Nolan JP, Berg KM. 2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group. Resuscitation 2021; 169:229-311. [PMID: 34933747 PMCID: PMC8581280 DOI: 10.1016/j.resuscitation.2021.10.040] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.
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15
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Wyckoff MH, Singletary EM, Soar J, Olasveengen TM, Greif R, Liley HG, Zideman D, Bhanji F, Andersen LW, Avis SR, Aziz K, Bendall JC, Berry DC, Borra V, Böttiger BW, Bradley R, Bray JE, Breckwoldt J, Carlson JN, Cassan P, Castrén M, Chang WT, Charlton NP, Cheng A, Chung SP, Considine J, Costa-Nobre DT, Couper K, Dainty KN, Davis PG, de Almeida MF, de Caen AR, de Paiva EF, Deakin CD, Djärv T, Douma MJ, Drennan IR, Duff JP, Eastwood KJ, El-Naggar W, Epstein JL, Escalante R, Fabres JG, Fawke J, Finn JC, Foglia EE, Folke F, Freeman K, Gilfoyle E, Goolsby CA, Grove A, Guinsburg R, Hatanaka T, Hazinski MF, Heriot GS, Hirsch KG, Holmberg MJ, Hosono S, Hsieh MJ, Hung KKC, Hsu CH, Ikeyama T, Isayama T, Kapadia VS, Kawakami MD, Kim HS, Kloeck DA, Kudenchuk PJ, Lagina AT, Lauridsen KG, Lavonas EJ, Lockey AS, Malta Hansen C, Markenson D, Matsuyama T, McKinlay CJD, Mehrabian A, Merchant RM, Meyran D, Morley PT, Morrison LJ, Nation KJ, Nemeth M, Neumar RW, Nicholson T, Niermeyer S, Nikolaou N, Nishiyama C, O'Neil BJ, Orkin AM, Osemeke O, Parr MJ, Patocka C, Pellegrino JL, Perkins GD, Perlman JM, Rabi Y, Reynolds JC, Ristagno G, Roehr CC, Sakamoto T, Sandroni C, Sawyer T, Schmölzer GM, Schnaubelt S, Semeraro F, Skrifvars MB, Smith CM, Smyth MA, Soll RF, Sugiura T, Taylor-Phillips S, Trevisanuto D, Vaillancourt C, Wang TL, Weiner GM, Welsford M, Wigginton J, Wyllie JP, Yeung J, Nolan JP, Berg KM. 2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group. Circulation 2021; 145:e645-e721. [PMID: 34813356 DOI: 10.1161/cir.0000000000001017] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.
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16
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Takauji S, Hayakawa M. Intensive care with extracorporeal membrane oxygenation rewarming in accident severe hypothermia (ICE-CRASH) study: a protocol for a multicentre prospective, observational study in Japan. BMJ Open 2021; 11:e052200. [PMID: 34711600 PMCID: PMC8557292 DOI: 10.1136/bmjopen-2021-052200] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Accidental hypothermia (AH) is a rare but critical disease, leading to death in severe cases. In recent decades, extracorporeal membrane oxygenation (ECMO) has been successfully used to rewarm hypothermic patients with cardiac arrest or circulation instability. However, data on the efficacy of rewarming using ECMO for patients with AH are limited. Therefore, a large-scale, multicentre, prospective study is warranted. The primary objective of this study will be to clarify the effectiveness of rewarming using ECMO for patients with AH. Our secondary objectives will be to compare the incidence of adverse effects between ECMO rewarming and non-ECMO rewarming and to identify the most appropriate management of ECMO for AH. METHODS AND ANALYSES The Intensive Care with ExtraCorporeal membrane oxygenation Rewarming in Accidentally Severe Hypothermia study is taking place in 35 tertiary emergency medical facilities in Japan. The inclusion criteria are patients ≥18 years old with a body temperature ≤32°C. We will include patients with AH who present to the emergency department from December 2019 to March 2022. The research personnel at each hospital will collect several variables, including patient demographics, rewarming method, ECMO data and complications. Our primary outcome is to compare the 28-day survival rate between the ECMO and non-ECMO (other treatments) groups among patients with severe AH. Our secondary outcomes are to compare the following values between the ECMO and non-ECMO groups: length of stay in the intensive-care unit and complications. Furthermore, in patients with cardiac arrest, the Cerebral Performance Category score at discharge will be compared between both groups. ETHICS AND DISSEMINATION This study received research ethics approval from Asahikawa Medical University (18194 and 19115). The study was approved by the institutional review board of each hospital, and the requirement for informed consent was waived due to the observational nature of the study. TRIAL REGISTRATION NUMBER UMIN000036132.
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Affiliation(s)
- Shuhei Takauji
- Department of Emergency Medicine, Asahikawa Medical University Hospital, Asahikawa, Japan
| | - Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan
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17
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Nivfors JO, Mohyuddin R, Schanche T, Nilsen JH, Valkov S, Kondratiev TV, Sieck GC, Tveita T. Rewarming With Closed Thoracic Lavage Following 3-h CPR at 27°C Failed to Reestablish a Perfusing Rhythm. Front Physiol 2021; 12:741241. [PMID: 34658927 PMCID: PMC8511428 DOI: 10.3389/fphys.2021.741241] [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: 07/14/2021] [Accepted: 08/30/2021] [Indexed: 11/20/2022] Open
Abstract
Introduction: Previously, we showed that the cardiopulmonary resuscitation (CPR) for hypothermic cardiac arrest (HCA) maintained cardiac output (CO) and mean arterial pressure (MAP) to the same reduced level during normothermia (38°C) vs. hypothermia (27°C). In addition, at 27°C, the CPR for 3-h provided global O2 delivery (DO2) to support aerobic metabolism. The present study investigated if rewarming with closed thoracic lavage induces a perfusing rhythm after 3-h continuous CPR at 27°C. Materials and Methods: Eight male pigs were anesthetized, and immersion-cooled. At 27°C, HCA was electrically induced, CPR was started and continued for a 3-h period. Thereafter, the animals were rewarmed by combining closed thoracic lavage and continued CPR. Organ blood flow was measured using microspheres. Results: After cooling with spontaneous circulation to 27°C, MAP and CO were initially reduced by 37 and 58% from baseline, respectively. By 15 min after the onset of CPR, MAP, and CO were further reduced by 58 and 77% from baseline, respectively, which remained unchanged throughout the rest of the 3-h period of CPR. During CPR at 27°C, DO2 and O2 extraction rate (VO2) fell to critically low levels, but the simultaneous small increase in lactate and a modest reduction in pH, indicated the presence of maintained aerobic metabolism. During rewarming with closed thoracic lavage, all animals displayed ventricular fibrillation, but only one animal could be electro-converted to restore a short-lived perfusing rhythm. Rewarming ended in circulatory collapse in all the animals at 38°C. Conclusion: The CPR for 3-h at 27°C managed to sustain lower levels of CO and MAP sufficient to support global DO2. Rewarming accidental hypothermia patients following prolonged CPR for HCA with closed thoracic lavage is not an alternative to rewarming by extra-corporeal life support as these patients are often in need of massive cardio-pulmonary support during as well as after rewarming.
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Affiliation(s)
- Joar O Nivfors
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway
| | - Rizwan Mohyuddin
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway
| | - Torstein Schanche
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway.,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, United States
| | - Jan Harald Nilsen
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway.,Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway.,Department of Research and Education, Norwegian Air Ambulance Foundation, Drøbak, Norway
| | - Sergei Valkov
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway
| | - Timofei V Kondratiev
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway
| | - Gary C Sieck
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, United States
| | - Torkjel Tveita
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway.,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, United States.,Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
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18
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Tveita T, Sieck GC. Physiological Impact of Hypothermia: The Good, the Bad and the Ugly. Physiology (Bethesda) 2021; 37:69-87. [PMID: 34632808 DOI: 10.1152/physiol.00025.2021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Hypothermia is defined as a core body temperature of < 35°C, and as body temperature is reduced the impact on physiological processes can be beneficial or detrimental. The beneficial effect of hypothermia enables circulation of cooled experimental animals to be interrupted for 1-2 h without creating harmful effects, while tolerance of circulation arrest in normothermia is between 4 and 5 min. This striking difference has attracted so many investigators, experimental as well as clinical, to this field, and this discovery was fundamental for introducing therapeutic hypothermia in modern clinical medicine in the 1950's. Together with the introduction of cardiopulmonary bypass, therapeutic hypothermia has been the cornerstone in the development of modern cardiac surgery. Therapeutic hypothermia also has an undisputed role as a protective agent in organ transplantation and as a therapeutic adjuvant for cerebral protection in neonatal encephalopathy. However, the introduction of therapeutic hypothermia for organ protection during neurosurgical procedures or as a scavenger after brain and spinal trauma has been less successful. In general, the best neuroprotection seems to be obtained by avoiding hyperthermia in injured patients. Accidental hypothermia occurs when endogenous temperature control mechanisms are incapable of maintaining core body temperature within physiologic limits and core temperature becomes dependent on ambient temperature. During hypothermia spontaneous circulation is considerably reduced and with deep and/or prolonged cooling, circulatory failure may occur, which may limit safe survival of the cooled patient. Challenges that limit safe rewarming of accidental hypothermia patients include cardiac arrhythmias, uncontrolled bleeding, and "rewarming shock".
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Affiliation(s)
- Torkjel Tveita
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.,Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
| | - Gary C Sieck
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, United States
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Soar J, Becker LB, Berg KM, Einav S, Ma Q, Olasveengen TM, Paal P, Parr MJA. Cardiopulmonary resuscitation in special circumstances. Lancet 2021; 398:1257-1268. [PMID: 34454688 DOI: 10.1016/s0140-6736(21)01257-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 05/13/2021] [Accepted: 05/24/2021] [Indexed: 12/21/2022]
Abstract
Cardiopulmonary resuscitation prioritises treatment for cardiac arrests from a primary cardiac cause, which make up the majority of treated cardiac arrests. Early chest compressions and, when indicated, a defibrillation shock from a bystander give the best chance of survival with a good neurological status. Cardiac arrest can also be caused by special circumstances, such as asphyxia, trauma, pulmonary embolism, accidental hypothermia, anaphylaxis, or COVID-19, and during pregnancy or perioperatively. Cardiac arrests in these circumstances represent an increasing proportion of all treated cardiac arrests, often have a preventable cause, and require additional interventions to correct a reversible cause during resuscitation. The evidence for treating these conditions is mostly of low or very low certainty and further studies are needed. Irrespective of the cause, treatments for cardiac arrest are time sensitive and most effective when given early-every minute counts.
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Affiliation(s)
- Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
| | - Lance B Becker
- Emergency Medicine, Zucker School of Medicine at Hofstra-Northwell, Northwell Health, New Hyde Park, NY, USA
| | | | - Sharon Einav
- Surgical Intensive Care, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Qingbian Ma
- Emergency Medicine, Peking University Third Hospital, Beijing, China
| | | | - Peter Paal
- Anaesthesiology and Intensive Care, St John of God Hospital, Paracelsus, Salzburg, Austria
| | - Michael J A Parr
- Intensive Care, Liverpool University Hospital, University of New South Wales, Sydney, NSW, Australia; Macquarie University Hospital, Macquarie University, Sydney, NSW, Australia
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20
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Bauman BD, Louiselle A, Nygaard RM, Vakayil V, Acton R, Hess D, Saltzman D, Kreykes N, Fischer G, Louie J, Segura B. Treatment of Hypothermic Cardiac Arrest in the Pediatric Drowning Victim, a Case Report, and Systematic Review. Pediatr Emerg Care 2021; 37:e653-e659. [PMID: 30702645 DOI: 10.1097/pec.0000000000001735] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Drowning is the second leading cause of death in children. Extracorporeal membrane oxygenation (ECMO) has become the criterion standard therapy to resuscitate the hypothermic drowning victim in cardiac arrest. We present our own experience treating 5 children with hypothermic cardiac arrest in conjunction with a systematic review to analyze clinical features predictive of survival. METHODS Our search resulted in 55 articles. Inclusion criteria were as follows: (1) younger than 18 years, (2) ECMO therapy, and (3) drowning. Ten articles met our inclusion criteria. We included studies using both central and peripheral ECMO and salt or fresh water submersions. We compared clinical features of survivors to nonsurvivors. RESULTS A total of 29 patients from the 10 different studies met our criteria. Data analyzed included presenting cardiac rhythm, time to initiation of ECMO, submersion time, pH, potassium, lactate, duration of chest compressions, and survival. There was a significant increase in mortality for presenting rhythm of asystole and with hyperkalemia (P < 0.05). CONCLUSIONS Extracorporeal membrane oxygenation is an important resuscitation tool for the hypothermic drowning victim. Hyperkalemia and presenting cardiac rhythm correlate with survival although they are not reasons to end resuscitation. More studies are needed to compare the outcomes in using ECMO for the hypothermic drowning victim.
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Affiliation(s)
| | | | | | | | | | | | | | - Nathaniel Kreykes
- Department of Pediatric Surgery, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN
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21
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Nilsen JH, Schanche T, Valkov S, Mohyuddin R, Haaheim B, Kondratiev TV, Næsheim T, Sieck GC, Tveita T. Effects of rewarming with extracorporeal membrane oxygenation to restore oxygen transport and organ blood flow after hypothermic cardiac arrest in a porcine model. Sci Rep 2021; 11:18918. [PMID: 34556695 PMCID: PMC8460815 DOI: 10.1038/s41598-021-98044-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 08/26/2021] [Indexed: 02/08/2023] Open
Abstract
We recently documented that cardiopulmonary resuscitation (CPR) generates the same level of cardiac output (CO) and mean arterial pressure (MAP) during both normothermia (38 °C) and hypothermia (27 °C). Furthermore, continuous CPR at 27 °C provides O2 delivery (ḊO2) to support aerobic metabolism throughout a 3-h period. The aim of the present study was to investigate the effects of extracorporeal membrane oxygenation (ECMO) rewarming to restore ḊO2 and organ blood flow after prolonged hypothermic cardiac arrest. Eight male pigs were anesthetized and immersion cooled to 27 °C. After induction of hypothermic cardiac arrest, CPR was started and continued for a 3-h period. Thereafter, the animals were rewarmed with ECMO. Organ blood flow was measured using microspheres. After cooling with spontaneous circulation to 27 °C, MAP and CO were initially reduced to 66 and 44% of baseline, respectively. By 15 min after the onset of CPR, there was a further reduction in MAP and CO to 42 and 25% of baseline, respectively, which remained unchanged throughout the rest of 3-h CPR. During CPR, ḊO2 and O2 uptake (V̇O2) fell to critical low levels, but the simultaneous small increase in lactate and a modest reduction in pH, indicated the presence of maintained aerobic metabolism. Rewarming with ECMO restored MAP, CO, ḊO2, and blood flow to the heart and to parts of the brain, whereas flow to kidneys, stomach, liver and spleen remained significantly reduced. CPR for 3-h at 27 °C with sustained lower levels of CO and MAP maintained aerobic metabolism sufficient to support ḊO2. Rewarming with ECMO restores blood flow to the heart and brain, and creates a "shockable" cardiac rhythm. Thus, like continuous CPR, ECMO rewarming plays a crucial role in "the chain of survival" when resuscitating victims of hypothermic cardiac arrest.
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Affiliation(s)
- Jan Harald Nilsen
- grid.10919.300000000122595234Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, 9037 Tromsø, Norway ,grid.420120.50000 0004 0481 3017Department of Research and Education, Norwegian Air Ambulance Foundation, 1441 Drøbak, Norway ,grid.412244.50000 0004 4689 5540Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, 9038 Tromsø, Norway
| | - Torstein Schanche
- grid.10919.300000000122595234Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, 9037 Tromsø, Norway ,grid.66875.3a0000 0004 0459 167XDepartment of Physiology & Biomedical Engineering, Mayo Clinic, Rochester, MN USA
| | - Sergei Valkov
- grid.10919.300000000122595234Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, 9037 Tromsø, Norway
| | - Rizwan Mohyuddin
- grid.10919.300000000122595234Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, 9037 Tromsø, Norway
| | - Brage Haaheim
- grid.10919.300000000122595234Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, 9037 Tromsø, Norway
| | - Timofei V. Kondratiev
- grid.10919.300000000122595234Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, 9037 Tromsø, Norway
| | - Torvind Næsheim
- grid.412244.50000 0004 4689 5540Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, 9038 Tromsø, Norway
| | - Gary C. Sieck
- grid.66875.3a0000 0004 0459 167XDepartment of Physiology & Biomedical Engineering, Mayo Clinic, Rochester, MN USA
| | - Torkjel Tveita
- grid.10919.300000000122595234Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, 9037 Tromsø, Norway ,grid.412244.50000 0004 4689 5540Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, 9038 Tromsø, Norway ,grid.66875.3a0000 0004 0459 167XDepartment of Physiology & Biomedical Engineering, Mayo Clinic, Rochester, MN USA
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22
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How effective is extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest? A systematic review and meta-analysis. Am J Emerg Med 2021; 51:127-138. [PMID: 34735971 DOI: 10.1016/j.ajem.2021.08.072] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/17/2021] [Accepted: 08/26/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Extracorporeal cardiopulmonary resuscitation (ECPR) has gained increasing as a promising but resource-intensive intervention for out-of-hospital cardiac arrest (OHCA). There is little data to quantify the impact of this intervention and the patients likely to benefit from its use. We conducted a meta-analysis of the literature to assess the survival benefit associated with ECPR for OHCA. METHODS We searched PubMed, Embase, and Scopus databases to identify relevant observational studies and randomized control trials. We used the Newcastle-Ottawa Scale and Cochrane risk-of-bias tool to assess studies' quality. We performed random-effects meta-analysis for the primary outcome of survival to hospital discharge and used meta-regressions to assess heterogeneity. RESULTS We identified 1287 articles, reviewed the full text of 209 and included 44 in our meta-analysis. Our analysis included 3097 patients with OHCA. Patients' mean age was 52, 79% were male, and 60% had primary ventricular fibrillation/ventricular tachycardia arrest. We identified a survival-to-discharge rate of 24%; 18% survived with favorable neurologic function. 30- and 90-days survival rates were both around 18%. The majority of included articles were high quality studies. CONCLUSIONS Extracorporeal cardiopulmonary resuscitation is a promising but resource-intensive intervention that may increase rates of survival to hospital discharge among patients who experience OHCA.
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Walpoth BH, Maeder MB, Courvoisier DS, Meyer M, Cools E, Darocha T, Blancher M, Champly F, Mantovani L, Lovis C, Mair P. Hypothermic Cardiac Arrest - Retrospective cohort study from the International Hypothermia Registry. Resuscitation 2021; 167:58-65. [PMID: 34416307 DOI: 10.1016/j.resuscitation.2021.08.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 08/01/2021] [Accepted: 08/12/2021] [Indexed: 11/25/2022]
Abstract
AIM The International Hypothermia Registry (IHR) was created to increase knowledge of accidental hypothermia, particularly to develop evidence-based guidelines and find reliable outcome predictors. The present study compares hypothermic patients with and without cardiac arrest included in the IHR. METHODS Demographic, pre-hospital and in-hospital data, method of rewarming and outcome data were collected anonymously in the IHR between 2010 and 2020. RESULTS Two hundred and one non-consecutive cases were included. The major causeof hypothermia was mountain accidents, predominantly in young men. Hypothermic Cardiac Arrest (HCA) occurred in 73 of 201 patients. Core temperature was significantly lower in the patients in cardiac arrest (25.0 vs. 30.0 °C, p < 0.001). One hundred and fifteen patients were rewarmed externally (93% with ROSC), 53 by extra-corporeal life support (ECLS) (40% with ROSC) and 21 with invasive internal techniques (71% with ROSC). The overall survival rate was 95% for patients with preserved circulation and 36% for those in cardiac arrest. Witnessed cardiac arrest and ROSC before rewarming were positive outcome predictors, asphyxia, coagulopathy, high potassium and lactate negative outcome predictors. CONCLUSIONS This first analysis of 201 IHR patients with moderate to severe accidental hypothermia shows an excellent 95% survival rate for patients with preserved circulation and 36% for HCA patients. Witnessed cardiac arrest, restoration of spontaneous circulation, low potassium and lactate and absence of asphyxia were positive survival predictors despite hypothermia in young, healthy adults after mountaineering accidents. However, accidental hypothermia is a heterogenous entity that should be considered in both treatment strategies and prognostication.
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Affiliation(s)
- Beat H Walpoth
- Dept. of Cardiovascular Surgery, University Hospitals, Geneva, Switzerland (Emeritus).
| | - Monika Brodmann Maeder
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Switzerland; Institute of Mountain Emergency Medicine, EURAC Research, Bolzano, Italy
| | | | - Marie Meyer
- Dept. of Anesthesia, University Hospital, Lausanne, Switzerland
| | - Evelien Cools
- Division of Anesthesia, University Hospitals, Geneva, Switzerland
| | - Tomasz Darocha
- Dept. Anesthesiology & Intensive Care, Medical University of Silesia, Katowice, Poland
| | | | | | | | - Christian Lovis
- Division of Medical Information Sciences, University Hospitals, Geneva, Switzerland
| | - Peter Mair
- Dept. of Anesthesia, University Hospitals, Innsbruck, Austria
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Amacher SA, Quitt J, Hammel E, Zenklusen U, Darwisch A, Siegemund M. Case Report: Left Ventricular Unloading Using a Mechanical CPR Device in a Prolonged Accidental Hypothermic Cardiac Arrest Treated by VA-ECMO - a Novel Approach. Front Cardiovasc Med 2021; 8:707663. [PMID: 34250052 PMCID: PMC8263907 DOI: 10.3389/fcvm.2021.707663] [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: 05/10/2021] [Accepted: 06/03/2021] [Indexed: 11/17/2022] Open
Abstract
We recently treated a 36-year-old previously healthy male with a prolonged hypothermic (lowest temperature 22.3°C) cardiac arrest after an alcohol intoxication with a return of spontaneous circulation after 230min of mechanical cardiopulmonary resuscitation and rewarming by veno-arterial ECMO with femoral cannulation and retrograde perfusion of the aortic arch. Despite functional veno-arterial ECMO, we continued mechanical cardiopulmonary resuscitation (Auto Pulse™ device, ZOLL Medical Corporation, Chelmsford, USA) until return of spontaneous circulation to prevent left ventricular distention from persistent ventricular fibrillation. The case was further complicated by extensive trauma caused by mechanical cardiopulmonary resuscitation (multiple rib fractures, significant hemothorax, and a liver laceration requiring massive transfusion), lung failure necessitating a secondary switch to veno-venous ECMO, and acute kidney injury with the need for renal replacement therapy. Shortly after return of spontaneous circulation, the patient was already following commands and could be discharged 3 weeks later without neurologic, cardiac, or renal sequelae and being entirely well. Prolonged accidental hypothermic cardiac arrest might present with excellent outcomes when supported with veno-arterial ECMO. Until return of spontaneous circulation, one might consider continuing with mechanical cardiopulmonary resuscitation in addition to ECMO to allow some left ventricular unloading. However, the clinician should keep in mind that prolonged mechanical cardiopulmonary resuscitation may cause severe injuries.
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Affiliation(s)
- Simon A. Amacher
- Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
| | - Jonas Quitt
- Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
| | - Eva Hammel
- Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
| | - Urs Zenklusen
- Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Ayham Darwisch
- Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Martin Siegemund
- Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
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Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J, Zideman DA, Soar J. [Cardiac arrest under special circumstances]. Notf Rett Med 2021; 24:447-523. [PMID: 34127910 PMCID: PMC8190767 DOI: 10.1007/s10049-021-00891-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 01/10/2023]
Abstract
These guidelines of the European Resuscitation Council (ERC) Cardiac Arrest under Special Circumstances are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required for basic and advanced life support for the prevention and treatment of cardiac arrest under special circumstances; in particular, specific causes (hypoxia, trauma, anaphylaxis, sepsis, hypo-/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), specific settings (operating room, cardiac surgery, cardiac catheterization laboratory, dialysis unit, dental clinics, transportation [in-flight, cruise ships], sport, drowning, mass casualty incidents), and specific patient groups (asthma and chronic obstructive pulmonary disease, neurological disease, morbid obesity, pregnancy).
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Affiliation(s)
- Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Mainz, Deutschland
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Tschechien
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Tschechien
| | - Anette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife Großbritannien
| | - Alessandro Barelli
- Anaesthesiology and Intensive Care, Teaching and research Unit, Emergency Territorial Agency ARES 118, Catholic University School of Medicine, Rom, Italien
| | - Violeta González-Salvado
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Institute of Health Research of Santiago de Compostela (IDIS), Biomedical Research Networking Centres on Cardiovascular Disease (CIBER-CV), A Coruña, Spanien
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Köln, Deutschland
| | - Jerry P. Nolan
- Resuscitation Medicine, Warwick Medical School, University of Warwick, CV4 7AL Coventry, Großbritannien
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, BA1 3NG Bath, Großbritannien
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Österreich
| | - Gavin D. Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, Großbritannien
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
| | - Karl-Christian Thies
- Dep. of Anesthesiology and Critical Care, Bethel Evangelical Hospital, University Medical Center OLW, Bielefeld University, Bielefeld, Deutschland
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, Großbritannien
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
| | | | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, Großbritannien
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26
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Bjertnæs LJ, Hindberg K, Næsheim TO, Suborov EV, Reierth E, Kirov MY, Lebedinskii KM, Tveita T. Rewarming From Hypothermic Cardiac Arrest Applying Extracorporeal Life Support: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2021; 8:641633. [PMID: 34055829 PMCID: PMC8155640 DOI: 10.3389/fmed.2021.641633] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 03/04/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction: This systematic review and meta-analysis aims at comparing outcomes of rewarming after accidental hypothermic cardiac arrest (HCA) with cardiopulmonary bypass (CPB) or/and extracorporeal membrane oxygenation (ECMO). Material and Methods: Literature searches were limited to references with an abstract in English, French or German. Additionally, we searched reference lists of included papers. Primary outcome was survival to hospital discharge. We assessed neurological outcome, differences in relative risks (RR) of surviving, as related to the applied rewarming technique, sex, asphyxia, and witnessed or unwitnessed HCA. We calculated hypothermia outcome prediction probability score after extracorporeal life support (HOPE) in patients in whom we found individual data. P < 0.05 considered significant. Results: Twenty-three case observation studies comprising 464 patients were included in a meta-analysis comparing outcomes of rewarming with CPB or/and ECMO. One-hundred-and-seventy-two patients (37%) survived to hospital discharge, 76 of 245 (31%) after CPB and 96 of 219 (44 %) after ECMO; 87 and 75%, respectively, had good neurological outcomes. Overall chance of surviving was 41% higher (P = 0.005) with ECMO as compared with CPB. A man and a woman had 46% (P = 0.043) and 31% (P = 0.115) higher chance, respectively, of surviving with ECMO as compared with CPB. Avalanche victims had the lowest chance of surviving, followed by drowning and people losing consciousness in cold environments. Assessed by logistic regression, asphyxia, unwitnessed HCA, male sex, high initial body temperature, low pH and high serum potassium (s-K+) levels were associated with reduced chance of surviving. In patients displaying individual data, overall mean predictive surviving probability (HOPE score; n = 134) was 33.9 ± 33.6% with no significant difference between ECMO and CPB-treated patients. We also surveyed 80 case reports with 96 victims of HCA, who underwent resuscitation with CPB or ECMO, without including them in the meta-analysis. Conclusions: The chance of surviving was significantly higher after rewarming with ECMO, as compared to CPB, and in patients with witnessed compared to unwitnessed HCA. Avalanche victims had the lowest probability of surviving. Male sex, high initial body temperature, low pH, and high s-K+ were factors associated with low surviving chances.
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Affiliation(s)
- Lars J. Bjertnæs
- Anesthesia and Critical Care Research Group, University of Tromsø (UiT), The Arctic University of Norway, Tromsø, Norway
| | - Kristian Hindberg
- K. G. Jebsen Thrombosis Research and Expertise Center, University of Tromsø (UiT), The Arctic University of Norway, Tromsø, Norway
| | - Torvind O. Næsheim
- Cardiovascular Research Group, Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø (UiT), The Arctic University of Norway, Tromsø, Norway
| | - Evgeny V. Suborov
- The Nikiforov Russian Federation Center of Emergency and Radiation Medicine, St. Petersburg, Russia
| | - Eirik Reierth
- Science and Health Library, University of Tromsø, The Arctic University of Norway, Tromsø, Norway
| | - Mikhail Y. Kirov
- Department of Anesthesiology and Intensive Care, Northern State Medical University, Arkhangelsk, Russia
| | - Konstantin M. Lebedinskii
- Department of Anesthesiology and Intensive Care, North-Western State Medical University Named After I. I. Mechnikov, St. Petersburg, Russia
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Torkjel Tveita
- Anesthesia and Critical Care Research Group, University of Tromsø (UiT), The Arctic University of Norway, Tromsø, Norway
- Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
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27
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Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J, Zideman DA, Soar J. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Resuscitation 2021; 161:152-219. [PMID: 33773826 DOI: 10.1016/j.resuscitation.2021.02.011] [Citation(s) in RCA: 328] [Impact Index Per Article: 109.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
These European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required to basic and advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma, anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special patient groups (asthma and COPD, neurological disease, obesity, pregnancy).
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Affiliation(s)
- Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Germany.
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, Charles University in Prague, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Annette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife, UK
| | - Alessandro Barelli
- Anaesthesiology and Intensive Care, Catholic University School of Medicine, Teaching and Research Unit, Emergency Territorial Agency ARES 118, Rome, Italy
| | - Violeta González-Salvado
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Institute of Health Research of Santiago de Compostela (IDIS), Biomedical Research Networking Centres on Cardiovascular Disease (CIBER-CV), A Coruña, Spain
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Jerry P Nolan
- Resuscitation Medicine, University of Warwick, Warwick Medical School, Coventry, CV4 7AL, UK; Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, BA1 3NG, UK
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Karl-Christian Thies
- Department of Anesthesiology, Critical Care and Emergency Medicine, Bethel Medical Centre, OWL University Hospitals, Bielefeld University, Germany
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, UK
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28
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Resuscitation and emergency care in drowning: A scoping review. Resuscitation 2021; 162:205-217. [PMID: 33549689 DOI: 10.1016/j.resuscitation.2021.01.033] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 01/23/2021] [Accepted: 01/24/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND The ILCOR Basic Life Support Task Force and the international drowning research community considered it timely to undertake a scoping review of the literature to identify evidence relating to the initial resuscitation, hospital-based interventions and criteria for safe discharge related to drowning. METHODS Medline, PreMedline, Embase, Cochrane Reviews and Cochrane CENTRAL were searched from 2000 to June 2020 to identify relevant literature. Titles and abstracts and if necessary full text were reviewed in duplicate. Studies were eligible for inclusion if they reported on the population (adults and children who are submerged in water), interventions (resuscitation in water/boats, airway management, oxygen administration, AED use, bystander CPR, ventilation strategies, ECMO, protocols for hospital discharge (I), comparator (standard care) and outcomes (O) survival, survival with a favourable neurological outcome, CPR quality, physiological end-points). RESULTS The database search yielded 3242 references (Medline 1104, Pre-Medline 202, Embase 1722, Cochrane reviews 12, Cochrane CENTRAL 202). After removal of duplicates 2377 papers were left for screening titles and abstracts. In total 65 unique papers were included. The evidence identified was from predominantly high-income countries and lacked consistency in the populations, interventions and outcomes reported. Clinical studies were exclusively observational in nature. CONCLUSION This scoping review found that there is very limited evidence from observational studies to inform evidence based clinical practice guidelines for drowning. The review highlights an urgent need for high quality research in drowning.
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Daniel N, Weinberg N, Carus F, Church B, Zafren K. Witnessed Cardiac Arrest in a Hypothermic Avalanche Victim Completely Buried for 2 Hours. Wilderness Environ Med 2021; 32:92-97. [PMID: 33518494 DOI: 10.1016/j.wem.2020.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 09/23/2020] [Accepted: 10/29/2020] [Indexed: 11/18/2022]
Abstract
A 34-y-old skier triggered a wind slab avalanche and was completely buried for over 2 h. After extrication by rescuers, the victim was breathing and conscious. Despite directions from the rescuers against standing up, the victim struggled to free himself and ultimately stood upright before collapsing in cardiac arrest. The rescuers performed cardiopulmonary resuscitation during transport to a nearby trailhead, where a helicopter emergency medical services crew found that the victim was in ventricular fibrillation. After further resuscitative efforts, including advanced life support, the victim was declared dead at the scene. Afterdrop and circumrescue collapse were the most likely triggers of cardiac arrest. This case highlights a need for rescuers, emergency medical services, and hospitals to be prepared to care for victims with hypothermia. To prevent circumrescue collapse, victims with hypothermia should be extricated gently, should not be allowed to stand, and should be placed flat. This may be difficult or impossible, as in this case. Hypothermic victims in cardiac arrest may require prolonged cardiopulmonary resuscitation, preferably with mechanical compressions, during transport to a hospital that has protocols for rewarming using extracorporeal life support. Resuscitation from hypothermic cardiac arrest should not be terminated before the victim has been rewarmed.
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Affiliation(s)
- Nicholas Daniel
- Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
| | - Nicholas Weinberg
- Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Frank Carus
- United States Forest Service, Mount Washington Avalanche Center, Gorham, NH
| | - Benjamin Church
- Department of Emergency Medicine, Baystate Medical Center - University of Massachusetts Medical School, Springfield, MA
| | - Ken Zafren
- Department of Emergency Medicine, Stanford University, Palo Alto, CA
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30
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Podsiadło P, Darocha T, Svendsen ØS, Kosiński S, Silfvast T, Blancher M, Sawamoto K, Pasquier M. Outcomes of patients suffering unwitnessed hypothermic cardiac arrest rewarmed with extracorporeal life support: A systematic review. Artif Organs 2020; 45:222-229. [PMID: 32920881 DOI: 10.1111/aor.13818] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 08/12/2020] [Accepted: 09/03/2020] [Indexed: 12/16/2022]
Abstract
Prolonged cardiac arrest (CA) may lead to neurologic deficit in survivors. Good outcome is especially rare when CA was unwitnessed. However, accidental hypothermia is a very specific cause of CA. Our goal was to describe the outcomes of patients who suffered from unwitnessed hypothermic cardiac arrest (UHCA) supported with Extracorporeal Life Support (ECLS). We included consecutive patients' cohorts identified by systematic literature review concerning patients suffering from UHCA and rewarmed with ECLS. Patients were divided into four subgroups regarding the mechanism of cooling, namely: air exposure; immersion; submersion; and avalanche. A statistical analysis was performed in order to identify the clinical parameters associated with good outcome (survival and absence of neurologic impairment). A total of 221 patients were included into the study. The overall survival rate was 27%. Most of the survivors (83%), had no neurologic deficit. Asystole was the presenting CA rhythm in 48% survivors, of which 79% survived with good neurologic outcome. Variables associated with survival included the following: female gender (P < .001); low core temperature (P = .005); non-asphyxia-related mechanism of cooling (P < .001); pulseless electrical activity as an initial rhythm (P < .001); high blood pH (P < .001); low lactate levels (P = .003); low serum potassium concentration (P < .001); and short resuscitation duration (P = .004). Severely hypothermic patients with unwitnessed CA may survive with good neurologic outcome, including those presenting as asystole. The initial blood pH, potassium, and lactate concentration may help predict outcome in hypothermic CA.
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Affiliation(s)
- Paweł Podsiadło
- Department of Emergency Medicine, Jan Kochanowski University, Kielce, Poland
| | - Tomasz Darocha
- Department of Anaesthesiology and Intensive Care, Medical University of Silesia, Katowice, Poland
| | - Øyvind S Svendsen
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Sylweriusz Kosiński
- Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Tom Silfvast
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marc Blancher
- Department of Emergency Medicine, SAMU 38, University Hospital of Grenoble Alps, Grenoble, France
| | - Keigo Sawamoto
- Department of Emergency Medicine, Sapporo Medical University, Sapporo, Japan
| | - Mathieu Pasquier
- Emergency Department, Lausanne University Hospital, Lausanne, Switzerland
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31
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Willmore R. Cardiac Arrest Secondary to Accidental Hypothermia: Who Should We Resuscitate? Air Med J 2020; 39:205-211. [PMID: 32540113 DOI: 10.1016/j.amj.2019.09.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 09/03/2019] [Indexed: 06/11/2023]
Abstract
Cardiac arrest with a degree of concurrent hypothermia is not a rare presentation. This presentation, often in remote areas, poses a challenge for the prehospital physician because the cause of the arrest will significantly alter decision making and prognostication. Survival from cardiac arrest secondary to accidental hypothermia is significantly greater than that of normothermic arrests when appropriate triage and management decisions are made. The complexity of this decision benefits from a specific algorithm to follow in the event of such a casualty presenting. This article systematically reviews the literature on cardiac arrest secondary to accidental hypothermia and provides recommendations in addition to a novel algorithm to aid the responding prehospital clinician in deciding if a hypothermic resuscitation standard operating procedure should be implemented.
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Affiliation(s)
- Robert Willmore
- Institute of Pre-Hospital Care at London's Air Ambulance, The Royal London Hospital, London, UK.
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32
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Ledoux A, Saint Leger P. Therapeutic management of severe hypothermia with veno-arterial ECMO: where do we stand? Case report and review of the current literature. Scand J Trauma Resusc Emerg Med 2020; 28:30. [PMID: 32316980 PMCID: PMC7175497 DOI: 10.1186/s13049-020-00723-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 04/13/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Severe accidental hypothermia is associated with high morbidity and mortality. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides an efficient rewarming method with complete cardiopulmonary support. The use of VA-ECMO for this indication has greatly improved the vital and functional prognosis of patients. CASE PRESENTATION We report a case of a 46-year-old patient who was treated for severe hypothermia with a temperature of 22.4 °C along with initial cardiac arrest, whose progression was favorable after the implementation of VA-ECMO support. Two months after initial cardiac arrest, the patient was reassessed and showed signs of complete recovery with regard to his mental and physical capacities. CONCLUSIONS The recent international publications and groups of experts recommend the use of VA ECMO as the gold standard therapy to treat severe hypothermia. Therefore, it seems suitable to update the current knowledge on the topic by analysing the latest international publications. The performance of this technique calls into question ethical and economic factors. Two distinct medical teams tried to identify and regroup prognosis factors in predictive survival scores. They raise the question of the utility of these scores in clinical practice. Indeed, according to which survival rate should we proceed to prolonged resuscitation and implement VA-ECMO? Additional studies will be needed for external approval of these survival scores, and additional reflection by experts will be required.
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Affiliation(s)
- Aurélien Ledoux
- Department of Intensive Care Medicine, General Hospital of Valenciennes, Valenciennes, France
| | - Piehr Saint Leger
- Department of Intensive Care Medicine, General Hospital of Valenciennes, Valenciennes, France.
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Dow J, Giesbrecht GG, Danzl DF, Brugger H, Sagalyn EB, Walpoth B, Auerbach PS, McIntosh SE, Némethy M, McDevitt M, Schoene RB, Rodway GW, Hackett PH, Zafren K, Bennett BL, Grissom CK. Wilderness Medical Society Clinical Practice Guidelines for the Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia: 2019 Update. Wilderness Environ Med 2019; 30:S47-S69. [PMID: 31740369 DOI: 10.1016/j.wem.2019.10.002] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 10/03/2019] [Accepted: 10/09/2019] [Indexed: 01/16/2023]
Abstract
To provide guidance to clinicians, the Wilderness Medical Society convened an expert panel to develop evidence-based guidelines for the out-of-hospital evaluation and treatment of victims of accidental hypothermia. The guidelines present the main diagnostic and therapeutic modalities and provide recommendations for the management of hypothermic patients. The panel graded the recommendations based on the quality of supporting evidence and a balance between benefits and risks/burdens according to the criteria published by the American College of Chest Physicians. The guidelines also provide suggested general approaches to the evaluation and treatment of accidental hypothermia that incorporate specific recommendations. This is the 2019 update of the Wilderness Medical Society Practice Guidelines for the Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia: 2014 Update.
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Affiliation(s)
- Jennifer Dow
- Alaska Regional Hospital Anchorage, Anchorage, AK; National Park Service: Alaska Region, Anchorage, AK.
| | - Gordon G Giesbrecht
- Faculty of Kinesiology and Recreation Management, Departments of Anesthesia and Emergency Medicine, University of Manitoba, Winnipeg, Canada
| | - Daniel F Danzl
- Department of Emergency Medicine, University of Louisville, School of Medicine, Louisville, KY
| | - Hermann Brugger
- International Commission for Mountain Emergency Medicine (ICAR MEDCOM), Bolzano, Italy; Institute of Mountain Emergency Medicine, EURAC Research, Bolzano, Italy
| | | | - Beat Walpoth
- Service of Cardiovascular Surgery, University Hospital of Geneva, Geneva, Switzerland
| | - Paul S Auerbach
- Departments of Emergency Medicine and Surgery, Stanford University School of Medicine, Stanford, CA
| | - Scott E McIntosh
- Division of Emergency Medicine, University of Utah, Salt Lake City, UT
| | | | | | | | - George W Rodway
- School of Nursing, University of California, Davis, Sacramento, CA
| | - Peter H Hackett
- Division of Emergency Medicine, Altitude Research Center, University of Colorado School of Medicine, Denver, CO; Institute for Altitude Medicine, Telluride, CO
| | - Ken Zafren
- International Commission for Mountain Emergency Medicine (ICAR MEDCOM), Bolzano, Italy; Departments of Emergency Medicine and Surgery, Stanford University School of Medicine, Stanford, CA
| | - Brad L Bennett
- Military & Emergency Medicine Department, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Colin K Grissom
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City, UT
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Kandori K, Okada Y, Matsuyama T, Morita S, Ehara N, Miyamae N, Jo T, Sumida Y, Okada N, Watanabe M, Nozawa M, Tsuruoka A, Fujimoto Y, Okumura Y, Kitamura T, Iiduka R. Prognostic ability of the sequential organ failure assessment score in accidental hypothermia: a multi-institutional retrospective cohort study. Scand J Trauma Resusc Emerg Med 2019; 27:103. [PMID: 31718708 PMCID: PMC6849316 DOI: 10.1186/s13049-019-0681-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 10/31/2019] [Indexed: 12/05/2022] Open
Abstract
Background Severe accidental hypothermia (AH) is life threatening. Thus, prognostic prediction in AH is essential to rapidly initiate intensive care. Several studies on prognostic factors for AH are known, but none have been established. We clarified the prognostic ability of the Sequential Organ Failure Assessment (SOFA) score in comparison with previously reported prognostic factors among patients with AH. Methods The J-point registry database is a multi-institutional retrospective cohort study for AH in 12 Japanese emergency departments. From this registry, we enrolled patients who were treated at the intensive care unit (ICU) in various critical care medical centers. In-hospital mortality was the primary outcome. We investigated the discrimination ability of each candidate prognostic factor and the in-hospital mortality by applying the logistic regression models with areas under the receiver operating characteristic curve (AUROC) with 95% confidence interval (CI). Results Of the 572 patients with AH registered in the J-point registry, 220 were eligible for the analyses. The in-hospital mortality was 23.2%. The AUROC of the SOFA score (0.80; 95% CI: 0.72–0.86) was the highest among all factors. The other factors were serum potassium (0.65; 95% CI: 0.55–0.73), lactate (0.67; 95% CI: 0.57–0.75), quick SOFA (qSOFA) (0.55; 95% CI: 0.46–0.65), systemic inflammatory response syndrome (SIRS) (0.60; 95% CI: 0.50–0.69), and 5A severity scale (0.77; 95% CI: 0.68–0.84). Discussion Although serum potassium and lactate had relatively good discrimination ability as mortality predictors, the SOFA score had slightly better discrimination ability. The reason is that lactate and serum potassium were mainly reflected by the hemodynamic state; conversely, the SOFA score is a comprehensive score of organ failure, basing on six different scores from the respiratory, cardiovascular, hepatic, coagulation, renal, and neurological systems. Meanwhile, the qSOFA and SIRS scores underestimated the severity, with low discrimination abilities for mortality. Conclusions The SOFA score demonstrated better discrimination ability as a mortality predictor among all known prognostic factors in patients with AH.
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Affiliation(s)
- Kenji Kandori
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Society, Kyoto Daini Hospital, Kyoto, Japan
| | - Yohei Okada
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Society, Kyoto Daini Hospital, Kyoto, Japan. .,Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Sachiko Morita
- Senri Critical Care Medical Center, Saiseikai Senri Hospital, Suita, Japan
| | - Naoki Ehara
- Department of Emergency, Japanese Red Cross Society, Kyoto Daiichi Red Cross Hospital, Kyoto, Japan
| | - Nobuhiro Miyamae
- Department of Emergency Medicine, Rakuwa-kai Otowa Hospital, Kyoto, Japan
| | - Takaaki Jo
- Department of Emergency Medicine, Uji-Tokushukai Medical Center, Uji, Japan
| | - Yasuyuki Sumida
- Department of Emergency Medicine, North Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nobunaga Okada
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan.,Department of Emergency and Critical Care Medicine, National Hospital Organization, Kyoto Medical Center, Kyoto, Japan
| | - Makoto Watanabe
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masahiro Nozawa
- Department of Emergency and Critical Care Medicine, Saiseikai Shiga Hospital, Ritto, Japan
| | - Ayumu Tsuruoka
- Department of Emergency and Critical Care Medicine, Kyoto Min-Iren Chuo Hospital, Kyoto, Japan
| | - Yoshihiro Fujimoto
- Department of Emergency Medicine, Yodogawa Christian Hospital, Osaka, Japan
| | - Yoshiki Okumura
- Department of Emergency Medicine, Fukuchiyama City Hospital, Fukuchiyama, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Ryoji Iiduka
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Society, Kyoto Daini Hospital, Kyoto, Japan
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35
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Ohbe H, Isogai S, Jo T, Matsui H, Fushimi K, Yasunaga H. Extracorporeal membrane oxygenation improves outcomes of accidental hypothermia without vital signs: A nationwide observational study. Resuscitation 2019; 144:27-32. [DOI: 10.1016/j.resuscitation.2019.08.041] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 08/17/2019] [Accepted: 08/25/2019] [Indexed: 10/26/2022]
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36
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Murakami T, Yoshida T, Kurokochi A, Takamatsu K, Teranishi Y, Shigeta K, Tamaki S, Morita S, Mizuno R, Oya M. Accidental Hypothermia Treated by Hemodialysis in the Acute Phase: Three Case Reports and a Review of the Literature. Intern Med 2019; 58:2743-2748. [PMID: 31178478 PMCID: PMC6794177 DOI: 10.2169/internalmedicine.1945-18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Accidental hypothermia is defined as a core body temperature <35°C. Even with the use of multiple active rewarming methods, it has a high mortality rate. No standard treatment strategy for moderate or severe hypothermia in the absence of cardiac arrest has yet been established. We herein report three patients with severe or moderate accidental hypothermia who were treated by hemodialysis in the acute phase. This case report with a literature review describes the usefulness of hemodialysis for the treatment of moderate and severe accidental hypothermia without cardiac arrest.
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Affiliation(s)
| | - Tadashi Yoshida
- Apheresis and Dialysis Center, Keio University School of Medicine, Japan
| | - Arata Kurokochi
- Department of Internal Medicine, Keio University School of Medicine, Japan
| | | | - Yu Teranishi
- Department of Urology, Keio University School of Medicine, Japan
| | - Keisuke Shigeta
- Department of Urology, Keio University School of Medicine, Japan
| | - Satoshi Tamaki
- Department of Urology, Keio University School of Medicine, Japan
- Apheresis and Dialysis Center, Keio University School of Medicine, Japan
| | - Shinya Morita
- Department of Urology, Keio University School of Medicine, Japan
- Apheresis and Dialysis Center, Keio University School of Medicine, Japan
| | - Ryuichi Mizuno
- Department of Urology, Keio University School of Medicine, Japan
| | - Mototsugu Oya
- Department of Urology, Keio University School of Medicine, Japan
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37
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Wagner J, Tiller C, Dietl M, Ulmer H, Brenner C, Stastny L, Sommerauer F, Mair P, Ruttmann E. Extracorporeal Life Support in Myocardial Infarction-Induced Cardiogenic Shock: Weaning Success. Ann Thorac Surg 2019; 108:1383-1390. [PMID: 31175870 DOI: 10.1016/j.athoracsur.2019.04.049] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 03/27/2019] [Accepted: 04/15/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Outcome data of patients with acute myocardial infarction (AMI)-induced cardiogenic shock (CS) receiving extracorporeal life support (ECLS) are sparse. METHODS A consecutive series of 106 patients with AMI-induced CS receiving ECLS was evaluated regarding ECLS weaning success, hospital mortality, and long-term outcome. The Intraaortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II) risk score was applied, and multivariable Cox regression analysis was performed. RESULTS Mean patient age was 58.2 ± 11.2 years, and 78.3% were men. In 34 patients (32.1%), ECLS was implemented during ongoing cardiopulmonary resuscitation. De novo AMI was present in 58 patients (54.7%), and percutaneous coronary intervention complications were causative among 48 patients (45.3%). Multivessel coronary artery disease was diagnosed among 73.6% with mean Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) scores of 30.8 ± 4.8. Actuarial survival was 54.4% at 30 days, 42.2% at 1 year, and 38.0% at 5 years and was significantly higher among patients with low and intermediate IABP-SHOCK II risk scores at ECLS onset (log-rank P = .017). ECLS weaning with curative intention after a mean perfusion time of 6.6 ± 5.1 days was feasible in 51 patients (48.1%) and more likely among patients with complete revascularization (P = .026). Multivariable Cox regression analysis identified complete revascularization (hazard ratio, 2.38; 95% confidence interval, 1.1 to 5.1; P = .028) and absence of relevant mitral regurgitation at ECLS discontinuation (hazard ratio, 2.71; 95% confidence interval, 1.2 to 6.0; P = .014) to be associated with beneficial long-term survival after ECLS discontinuation. CONCLUSIONS Emergency ECLS is a valuable option among patients with AMI-induced CS with low and intermediate IABP-SHOCK II risk scores. ECLS weaning is manageable, but additional revascularization of all nonculprit lesions is mandatory after ECLS implementation.
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Affiliation(s)
- Julian Wagner
- Department of Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Christina Tiller
- Department of Cardiology, Innsbruck Medical University, Innsbruck, Austria
| | - Marion Dietl
- Department of Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Hanno Ulmer
- Department of Medical Statistics, Informatics and Health Economics, Innsbruck Medical University, Innsbruck, Austria
| | - Christoph Brenner
- Department of Cardiology, Innsbruck Medical University, Innsbruck, Austria
| | - Lukas Stastny
- Department of Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Florian Sommerauer
- Department of Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Peter Mair
- Department of Anaesthesiology and Intensive Care Medicine, Innsbruck Medical University, Innsbruck, Austria
| | - Elfriede Ruttmann
- Department of Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria.
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38
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Okada Y, Matsuyama T, Morita S, Ehara N, Miyamae N, Jo T, Sumida Y, Okada N, Watanabe M, Nozawa M, Tsuruoka A, Fujimoto Y, Okumura Y, Kitamura T, Yamamoto S, Iiduka R, Koike K. The development and validation of a "5A" severity scale for predicting in-hospital mortality after accidental hypothermia from J-point registry data. J Intensive Care 2019; 7:27. [PMID: 31073406 PMCID: PMC6499959 DOI: 10.1186/s40560-019-0384-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 04/23/2019] [Indexed: 12/23/2022] Open
Abstract
Background Accidental hypothermia is a serious condition that requires immediate and accurate assessment to determine severity and treatment. Currently, accidental hypothermia is evaluated using the Swiss grading system which uses core body temperature and clinical findings; however, research has shown that core body temperature is not associated with in-hospital mortality in urban settings. Therefore, we developed and validated a severity scale for predicting in-hospital mortality among urban Japanese patients with accidental hypothermia. Methods Data for this multi-center retrospective cohort study were obtained from the J-point registry. We included patients with accidental hypothermia who were admitted to an emergency department. The total cohort was divided into a development cohort and validation cohort, based on the location of each institution. We developed a logistic regression model for predicting in-hospital mortality using the development cohort and assessed its internal validity using bootstrapping. The model was then subjected to external validation using the validation cohorts. Results Among the 572 patients in the J-point registry, 532 were ultimately included and divided into the development cohort (N = 288, six hospitals, in-hospital mortality 22.0%) and the validation cohort (N = 244, six hospitals, in-hospital mortality 27.0%). The 5 “A” scoring system based on age, activities-of-daily-living status, near arrest, acidemia, and serum albumin level was developed based on the variables’ coefficients in the development cohort. In the validation cohort, the prediction performance was validated. Conclusion Our “5A” severity scoring system could accurately predict the risk of in-hospital mortality among patients with accidental hypothermia. Electronic supplementary material The online version of this article (10.1186/s40560-019-0384-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yohei Okada
- 1Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, 606-8501, Yoshidakonoe-cho, Sakyo, Kyoto, Japan.,2Department of Emergency and Critical Care Medicine, Japanese Red Cross Society, Kyoto Daini Hospital, Kyoto, Japan
| | - Tasuku Matsuyama
- 3Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Sachiko Morita
- Senri Critical Care Medical Center, Saiseikai Senri Hospital, Suita, Japan
| | - Naoki Ehara
- Department of Emergency, Japanese Red Cross Society, Kyoto Daiichi Red Cross Hospital, Kyoto, Japan
| | - Nobuhiro Miyamae
- 6Department of Emergency Medicine, Rakuwa-kai Otowa Hospital, Kyoto, Japan
| | - Takaaki Jo
- Department of Emergency Medicine, Uji-Tokushukai Medical Center, Uji, Japan
| | - Yasuyuki Sumida
- 8Department of Emergency Medicine, North Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nobunaga Okada
- 3Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan.,9Department of Emergency and Critical Care Medicine, National Hospital Organization, Kyoto Medical Center, Kyoto, Japan
| | - Makoto Watanabe
- 3Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masahiro Nozawa
- 10Department of Emergency and Critical Care Medicine, Saiseikai Shiga Hospital, Ritto, Japan
| | - Ayumu Tsuruoka
- Department of Emergency and Critical Care Medicine, Kyoto Min-Iren Chuo Hospital, Kyoto, Japan
| | - Yoshihiro Fujimoto
- 12Department of Emergency Medicine, Yodogawa Christian Hospital, Osaka, Japan
| | - Yoshiki Okumura
- Department of Emergency Medicine, Fukuchiyama City Hospital, Fukuchiyama, Japan
| | - Tetsuhisa Kitamura
- 14Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Shungo Yamamoto
- 15Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ryoji Iiduka
- 2Department of Emergency and Critical Care Medicine, Japanese Red Cross Society, Kyoto Daini Hospital, Kyoto, Japan
| | - Kaoru Koike
- 1Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, 606-8501, Yoshidakonoe-cho, Sakyo, Kyoto, Japan
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39
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Brugger H, Bouzat P, Pasquier M, Mair P, Fieler J, Darocha T, Blancher M, de Riedmatten M, Falk M, Paal P, Strapazzon G, Zafren K, Brodmann Maeder M. Cut-off values of serum potassium and core temperature at hospital admission for extracorporeal rewarming of avalanche victims in cardiac arrest: A retrospective multi-centre study. Resuscitation 2019; 139:222-229. [PMID: 31022496 DOI: 10.1016/j.resuscitation.2019.04.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 03/19/2019] [Accepted: 04/08/2019] [Indexed: 12/18/2022]
Abstract
AIM Evidence of existing guidelines for the on-site triage of avalanche victims is limited and adherence suboptimal. This study attempted to find reliable cut-off values for the identification of hypothermic avalanche victims with reversible out-of-hospital cardiac arrest (OHCA) at hospital admission. This may enable hospitals to allocate extracorporeal life support (ECLS) resources more appropriately while increasing the proportion of survivors among rewarmed victims. METHODS All avalanche victims with OHCA admitted to seven centres in Europe capable of ECLS from 1995 to 2016 were included. Optimal cut-off values, for parameters identified by logistic regression, were determined by means of bootstrapping and exact binomial distribution and served to calculate sensitivity, rate of overtriage, positive and negative predictive values, and receiver operating curves. RESULTS In total, 103 avalanche victims with OHCA were included. Of the 103 patients 61 (58%) were rewarmed by ECLS. Six (10%) of the rewarmed patients survived whilst 55 (90%) died. We obtained optimal cut-off values of 7 mmol/L for serum potassium and 30 °C for core temperature. CONCLUSION For in-hospital triage of avalanche victims admitted with OHCA, serum potassium accurately predicts survival. The combination of the cut-offs 7 mmol/L for serum potassium and 30 °C for core temperature achieved the lowest overtriage rate (47%) and the highest positive predictive value (19%), with a sensitivity of 100% for survivors. The presence of vital signs at extrication is strongly associated with survival. For further optimisation of in-hospital triage, larger datasets are needed to include additional parameters.
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Affiliation(s)
- Hermann Brugger
- Institute of Mountain Emergency Medicine, EURAC research, Drususallee 1, 39100 Bolzano, Italy; Medical University Innsbruck, Austria; International Commission for Mountain Emergency Medicine ICAR MEDCOM.
| | - Pierre Bouzat
- Department of Anaesthesiology and Critical Care, Grenoble Alps Trauma Center, University Hospital of Grenoble- Alpes, 38043 Grenoble Cedex 09, France.
| | - Mathieu Pasquier
- International Commission for Mountain Emergency Medicine ICAR MEDCOM; Emergency Service, Lausanne University Hospital Center, BH 09, CHUV, CH-1011 Lausanne, Switzerland.
| | - Peter Mair
- Department of Anaesthesiology and Critical Care Medicine, Medical University Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria.
| | - Julia Fieler
- International Commission for Mountain Emergency Medicine ICAR MEDCOM; Division of Surgical Medicine and Intensive Care, University hospital of North Norway, Tromsø, Norway; Anaesthesia and critical care research group, The Artic University of Norway, 9037 Tromsø, Norway.
| | - Tomasz Darocha
- Department of Anaesthesiology and Intensive Care, Medical University of Silesia, Medykow 14, 40-752 Katowice, Poland.
| | - Marc Blancher
- International Commission for Mountain Emergency Medicine ICAR MEDCOM; Department of Emergency Medicine, University Hospital of Grenoble-Alpes, France; French Mountain Rescue Association ANMSM, 38043 Grenoble Cedex 09, France.
| | | | - Markus Falk
- Institute of Mountain Emergency Medicine, EURAC research, Drususallee 1, 39100 Bolzano, Italy.
| | - Peter Paal
- International Commission for Mountain Emergency Medicine ICAR MEDCOM; Department of Anaesthesiology and Intensive Care, Hospitallers Brothers Hospital, Paracelsus Medical University, Kajetanerplatz 1, 5020 Salzburg, Austria.
| | - Giacomo Strapazzon
- Institute of Mountain Emergency Medicine, EURAC research, Drususallee 1, 39100 Bolzano, Italy; International Commission for Mountain Emergency Medicine ICAR MEDCOM.
| | - Ken Zafren
- International Commission for Mountain Emergency Medicine ICAR MEDCOM; Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA.
| | - Monika Brodmann Maeder
- Institute of Mountain Emergency Medicine, EURAC research, Drususallee 1, 39100 Bolzano, Italy; Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 16C, 3010 Bern, Switzerland.
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Pasquier M, Rousson V, Darocha T, Bouzat P, Kosiński S, Sawamoto K, Champigneulle B, Wiberg S, Wanscher MCJ, Brodmann Maeder M, Paal P, Hugli O. Hypothermia outcome prediction after extracorporeal life support for hypothermic cardiac arrest patients: An external validation of the HOPE score. Resuscitation 2019; 139:321-328. [PMID: 30940473 DOI: 10.1016/j.resuscitation.2019.03.017] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/04/2019] [Accepted: 03/11/2019] [Indexed: 10/27/2022]
Abstract
AIMS The HOPE score, based on covariates available at hospital admission, predicts the probability of in-hospital survival after extracorporeal life support (ECLS) rewarming of a given hypothermic cardiac arrest patient with accidental hypothermia. Our goal was to externally validate the HOPE score. METHODS We included consecutive hypothermic arrested patients who underwent rewarming with ECLS. The sample comprised 122 patients. The six independent predictors of survival included in the HOPE score were collected for each patient: age, sex, mechanism of hypothermia, core temperature at admission, serum potassium level at admission and duration of CPR. The primary outcome parameter was survival to hospital discharge. RESULTS Overall, 51 of the 122 included patients survived, resulting in an empirical (global) probability of survival of 42% (95% CI = [33-51%]). This was close to the average HOPE survival probability of 38% calculated for patients from the validation cohort, while the Hosmer-Lemeshow test comparing empirical and HOPE (i.e. estimated) probabilities of survival was not significant (p = 0.08), suggesting good calibration. The corresponding area under the receiver operating characteristic curve was 0.825 (95% CI = [0.753-0.897]), confirming the excellent discrimination of the model. The negative predictive value of a HOPE score cut-off of <0.10 was excellent (97%). CONCLUSIONS This study provides the first external validation of the HOPE score reaching good calibration and excellent discrimination. Clinically, the prediction of the HOPE score remains accurate in the validation sample. The HOPE score may replace serum potassium in the future as the triage tool when considering ECLS rewarming of a hypothermic cardiac arrest victim.
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Affiliation(s)
- Mathieu Pasquier
- Emergency Department, Lausanne University Hospital, Lausanne, Switzerland.
| | - Valentin Rousson
- Institute of Social and Preventive Medicine, Lausanne University Hospital, route de la Corniche 10, 1010 Lausanne, Switzerland.
| | - Tomasz Darocha
- Severe Accidental Hypothermia Center, Department of Anaesthesiology and Intensive Care, Medical University of Silesia, Poniatowskiego 15, 055 Katowice, Poland.
| | - Pierre Bouzat
- Department of anesthesiology and critical care, Grenoble Alps Trauma Center, University Hospital of Grenoble, French Mountain Rescue Association ANMSM, International Commission for Mountain Emergency Medicine ICAR MEDCOM, 38043 Grenoble Cedex 09, France.
| | - Sylweriusz Kosiński
- Severe Accidental Hypothermia Center, Cracow, Faculty of Health Sciences, Jagiellonian University, Cracow, Poland.
| | - Keigo Sawamoto
- Department of Emergency Medicine, Sapporo Medical University, S1W16 Chuoku Sapporo, 060-8543 Hokkaido, Japan.
| | - Benoit Champigneulle
- Surgical Intensive Care Unit, Georges Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.
| | - Sebastian Wiberg
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Denmark.
| | - Michael C Jaeger Wanscher
- Dept. of Cardiothoracic Anaesthesia, 4142 The Heart Center, Copenhagen University Hospital, Copenhagen, Denmark.
| | | | - Peter Paal
- Department of Anesthesiology and Intensive Care Medicine, Hospitaller Brothers Hospital, Paracelsus Medical University, 5020 Salzburg, Austria.
| | - Olivier Hugli
- Emergency Department, Lausanne University Hospital, Lausanne, Switzerland.
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Mazur P, Kosiński S, Podsiadło P, Jarosz A, Przybylski R, Litiwnowicz R, Piątek J, Konstanty-Kalandyk J, Gałązkowski R, Darocha T. Extracorporeal membrane oxygenation for accidental deep hypothermia-current challenges and future perspectives. Ann Cardiothorac Surg 2019; 8:137-142. [PMID: 30854323 DOI: 10.21037/acs.2018.10.12] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The incidence of accidental hypothermia (core temperature ≤35 °C) is difficult to estimate, as the affected population is heterogeneous. Both temperature and clinical presentation should be considered while determining severity, which is difficult in a prehospital setting. Extracorporeal rewarming is advocated for all Swiss Staging System class IV (hypothermic cardiac arrest) and class III (hypothermic cardiac instability) patients. Veno-arterial extracorporeal membrane oxygenation (ECMO) is the method of choice, as it not only allows a gradual, controlled increase of core body temperature, but also provides respiratory and hemodynamic support during the unstable period of rewarming and reperfusion. This poses difficulties with the coordination of patient management, as usually only cardiac referral centers can deliver such advanced treatment. Further special considerations apply to subgroups of patients, including drowning or avalanche victims. The principle of ECMO implantation in severely hypothermic patients is no different from any other indication, although establishing vascular access in a timely manner during ongoing resuscitation and maintaining adequate flow may require modification of the operating technique, as well as aggressive fluid resuscitation. Further studies are needed in order to determine the optimal rewarming rate and flow that would favor brain and lung protection. Recent analysis shows an overall survival rate of 40.3%, while additional prognostic factors are being sought for determining those patients in whom the treatment is futile. New cannulas, along with ready-to-use ECMO sets, are being developed that would enable easy, safe and efficient out-reach ECMO implantation, thus shortening resuscitation times. Moreover, national guidelines for the management of accidental hypothermia are needed in order that all patients that would benefit from extracorporeal rewarming would be provided with such treatment. In this perspective article, we discuss burning problems in ECMO therapy in hypothermic patients, outlining the important research goals to improve the outcomes.
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Affiliation(s)
- Piotr Mazur
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Cracow, Poland.,Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland
| | - Sylweriusz Kosiński
- Faculty of Health Sciences, Jagiellonian University Medical College, Cracow, Poland
| | - Paweł Podsiadło
- Emergency Medicine Department, Jan Kochanowski University, Kielce, Poland
| | - Anna Jarosz
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Cracow, Poland
| | - Roman Przybylski
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Cracow, Poland
| | - Radosław Litiwnowicz
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Cracow, Poland
| | - Jacek Piątek
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Cracow, Poland
| | - Janusz Konstanty-Kalandyk
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Cracow, Poland.,Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland
| | - Robert Gałązkowski
- Department of Emergency Medical Services, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Darocha
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Silesia, Katowice, Poland
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Kosiński S, Darocha T, Czerw A, Paal P, Pasquier M, Krawczyk P, Drwiła R, Gałązkowski R. Cost-utility of extracorporeal membrane oxygenation rewarming in accidentally hypothermic patients-A single-centre retrospective study. Acta Anaesthesiol Scand 2018; 62:1105-1111. [PMID: 29687446 DOI: 10.1111/aas.13137] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 01/22/2018] [Accepted: 04/01/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has become the treatment of choice for severely hypothermic patients in cardiac arrest or acute cardiac failure. Highly specialized ECMO centres have been established, however, no centre has ever reported the costs of extracorporeal rewarming. The aim of this study was to assess the costs of the treatment of patients in Swiss Stage III and IV rewarmed with veno-arterial ECMO. METHODS A retrospective exploratory cohort study analysed twenty-nine consecutive patients treated for hypothermia in the Severe Accidental Hypothermia Centre in Cracow, Poland. The main outcome parameters were the overall and specific costs of the ICU treatment of patients rewarmed with veno-arterial ECMO. The secondary outcome parameter was cost utility, determined by the costs involved for every year of life gained. Costs were processed using the bottom-up method and classified into six categories. Survivors were followed up after 1 year. RESULTS The mean cost of VA-ECMO was $5133 USD, which equalled 35% of all ICU expenditures ($14 668 USD). One year after discharge, 13 of 29 patients were still alive (45%). The overall gain of life of the thirteen 1-year survivors was 28 years, while the mean cost related to treatment with VA-ECMO for each year of life gained was 1138 USD. CONCLUSIONS In this study, the costs of VA-ECMO rewarming and intensive care treatment per patient were substantially lower than in other studies reporting ECMO and intensive care treatment of other causes.
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Affiliation(s)
- S Kosiński
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Hospital, Zakopane, Poland
| | - T Darocha
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Silesia, Katowice, Poland
| | - A Czerw
- Department of Public Health, Medical University of Warsaw, Warsaw, Poland
- National Institute of Public Health - National Institute of Hygiene, Warsaw, Poland
| | - P Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitaller Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
- Barts Heart Centre, William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - M Pasquier
- Emergency Service, University Hospital Centre, Lausanne, Switzerland
| | - P Krawczyk
- Department of Anaesthesiology and Intensive Care, John Paul II Hospital, Medical College of Jagiellonian University, Krakow, Poland
| | - R Drwiła
- Department of Anaesthesiology and Intensive Care, John Paul II Hospital, Medical College of Jagiellonian University, Krakow, Poland
| | - R Gałązkowski
- Department of Emergency Medical Services, Medical University of Warsaw, Warsaw, Poland
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Okada Y, Matsuyama T, Morita S, Ehara N, Miyamae N, Jo T, Sumida Y, Okada N, Kitamura T, Iiduka R. Prognostic factors for patients with accidental hypothermia: A multi-institutional retrospective cohort study. Am J Emerg Med 2018; 37:565-570. [PMID: 29950275 DOI: 10.1016/j.ajem.2018.06.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 06/11/2018] [Accepted: 06/11/2018] [Indexed: 10/28/2022] Open
Abstract
INTRODUCTION In cases of severe accidental hypothermia (AH) in urban areas, the prognostic factors are unknown. We identified factors associated with in-hospital mortality in patients with moderate-to-severe AH in urban areas of Japan. METHOD The J-Point registry database is a multi-institutional retrospective cohort study for AH in 12 Japanese emergency departments. From this registry, we enrolled patients whose core body temperature was 32 °C or less on admission. In-hospital death was the primary outcome of this study. We investigated the association between each candidate prognostic factor and in-hospital death by applying the multivariate logistic regression analyses with adjusted odds ratios (AORs) and their 95% confidence interval [CI] as the effect variables. RESULTS Of 572 patients registered in the J-point registry, 358 hypothermic patients were eligible for analyses. Median body temperature was 29.2 °C (interquartile range, 27.0 °C-30.8 °C). In-hospital deaths comprised 26.3% (94/358) of all study patients. Factors associated with in-hospital death were age ≥ 75 years (AOR, 3.09; 95% CI, 1.31-7.27), need for assistance with activities of daily living (ADL; AOR, 3.06; 95% CI, 1.68-5.59), hemodynamic instability (AOR, 2.49; 95% CI, 1.32-4.68), and hyperkalemia (≥5.6 mEq/L; AOR, 2.65; 95% CI, 1.13-6.21). CONCLUSION The independent prognostic factors associated with in-hospital mortality of patients with moderate-to-severe AH in urban areas of Japan were age ≥ 75 years, need for assistance with ADL, hemodynamic instability, and hyperkalemia.
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Affiliation(s)
- Yohei Okada
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Society Kyoto Daini Red Cross Hospital, Japan.
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Sachiko Morita
- Senri Critical Care Medical Center, SaiseikaiSenri Hospital, Suita, Japan
| | - Naoki Ehara
- Department of Emergency, Japanese Red Cross Society Kyoto Daiichi Red Cross Hospital, Kyoto, Japan
| | - Nobuhiro Miyamae
- Department of Emergency Medicine, Rakuwa-kai Otowa Hospital, Kyoto, Japan
| | - Takaaki Jo
- Department of Emergency Medicine, Uji-Tokushukai Medical Center, Uji, Japan
| | - Yasuyuki Sumida
- Department of Emergency Medicine, North Medical Center, Kyoto Prefectural University of Medicine, Japan
| | - Nobunaga Okada
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan; Department of Emergency and Critical Care Medicine, National Hospital Organization, Kyoto Medical Center, Kyoto, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Japan
| | - Ryoji Iiduka
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Society Kyoto Daini Red Cross Hospital, Japan
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Saczkowski RS, Brown DJ, Abu-Laban RB, Fradet G, Schulze CJ, Kuzak ND. Prediction and risk stratification of survival in accidental hypothermia requiring extracorporeal life support: An individual patient data meta-analysis. Resuscitation 2018; 127:51-57. [DOI: 10.1016/j.resuscitation.2018.03.028] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 03/16/2018] [Accepted: 03/20/2018] [Indexed: 10/17/2022]
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Brunet J, Valette X, Daubin C. Place de l’assistance circulatoire extracorporelle dans l’arrêt cardiaque réfractaire. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Le bénéfice d’une réanimation cardiopulmonaire (RCP) extracorporelle en comparaison d’une réanimation conventionnelle sur la survie et le pronostic neurologique à long terme des patients victimes d’un arrêt cardiaque réfractaire reste encore incertain. Il pourrait être très différent selon que la RCP soit considérée dans les arrêts cardiaques extrahospitaliers ou intrahospitaliers, d’origine cardiaque ou pas, en contexte toxicologique ou d’hypothermie. L’objectif de cet article est une mise au point sur l’apport de l’assistance circulatoire extracorporelle dans la prise en charge des arrêts cardiaques réfractaires à partir des recherches cliniques les plus récentes. Ainsi, l’apport d’une RCP extracorporelle dans les arrêts cardiaques réfractaires extrahospitaliers d’origine cardiaque est probablement limité, même au sein de populations hautement sélectionnées. En revanche, son intérêt est probablement plus important dans les arrêts cardiaques réfractaires intrahospitaliers d’origine cardiaque sous réserve d’une bonne sélection des patients. Enfin, si des résultats encourageants ont été rapportés dans les cas d’arrêt cardiaque réfractaire de cause toxique ; en revanche, ils sont plus contrastés concernant les arrêts cardiaques réfractaires associés à une hypothermie profonde suite à une exposition accidentelle au froid, à une noyade ou une avalanche. Des recherches bien conduites sont encore nécessaires pour préciser les contextes et les indications pour lesquels les patients seraient en droit d’attendre un bénéfice médical d’une RCP extracorporelle.
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Pasquier M, Hugli O, Paal P, Darocha T, Blancher M, Husby P, Silfvast T, Carron PN, Rousson V. Hypothermia outcome prediction after extracorporeal life support for hypothermic cardiac arrest patients: The HOPE score. Resuscitation 2018; 126:58-64. [DOI: 10.1016/j.resuscitation.2018.02.026] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 02/15/2018] [Accepted: 02/20/2018] [Indexed: 10/17/2022]
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47
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Brunet J, Valette X, Daubin C. Place de l’assistance circulatoire extracorporelle dans l’arrêt cardiaque réfractaire. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Le bénéfice d’une réanimation cardiopulmonaire (RCP) extracorporelle en comparaison d’une réanimation conventionnelle sur la survie et le pronostic neurologique à long terme des patients victimes d’un arrêt cardiaque réfractaire reste encore incertain. Il pourrait être très différent selon que la RCP soit considérée dans les arrêts cardiaques extrahospitaliers ou intrahospitaliers, d’origine cardiaque ou pas, en contexte toxicologique ou d’hypothermie. L’objectif de cet article est une mise au point sur l’apport de l’assistance circulatoire extracorporelle dans la prise en charge des arrêts cardiaques réfractaires à partir des recherches cliniques les plus récentes. Ainsi, l’apport d’une RCP extracorporelle dans les arrêts cardiaques réfractaires extrahospitaliers d’origine cardiaque est probablement limité, même au sein de populations hautement sélectionnées. En revanche, son intérêt est probablement plus important dans les arrêts cardiaques réfractaires intrahospitaliers d’origine cardiaque sous réserve d’une bonne sélection des patients. Enfin, si des résultats encourageants ont été rapportés dans les cas d’arrêt cardiaque réfractaire de cause toxique ; en revanche, ils sont plus contrastés concernant les arrêts cardiaques réfractaires associés à une hypothermie profonde suite à une exposition accidentelle au froid, à une noyade ou à une avalanche. Des recherches bien conduites sont encore nécessaires pour préciser les contextes et les indications pour lesquels les patients seraient en droit d’attendre un bénéfice médical d’une RCP extracorporelle.
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Abstract
Accidental hypothermia causes profound changes to the body's physiology. After an initial burst of agitation (e.g., 36-37°C), vital functions will slow down with further cooling, until they vanish (e.g. <20-25°C). Thus, a deeply hypothermic person may appear dead, but may still be able to be resuscitated if treated correctly. The hospital use of minimally invasive rewarming for nonarrested, otherwise healthy patients with primary hypothermia and stable vital signs has the potential to substantially decrease morbidity and mortality for these patients. Extracorporeal life support (ECLS) has revolutionized the management of hypothermic cardiac arrest, with survival rates approaching 100%. Hypothermic patients with risk factors for imminent cardiac arrest (i.e., temperature <28°C, ventricular arrhythmia, systolic blood pressure <90 mmHg), and those who have already arrested, should be transferred directly to an ECLS center. Cardiac arrest patients should receive continuous cardiopulmonary resuscitation (CPR) during transfer. If prolonged transport is required or terrain is difficult, mechanic CPR can be helpful. Intermittent CPR may be appropriate in hypothermic arrest when continuous CPR is impossible. Modern postresuscitation care should be implemented following hypothermic arrest. Structured protocols should be in place to optimize prehospital triage, transport, and treatment as well as in-hospital management, including detailed criteria and protocols for the use of ECLS and postresuscitation care.
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Affiliation(s)
- Peter Paal
- Department of Anaesthesia and Intensive Care Medicine, Hospitallers Brothers Hospital, Salzburg, Austria.
| | - Hermann Brugger
- Institute of Mountain Emergency Medicine, EURAC Research, Bolzano, Italy
| | - Giacomo Strapazzon
- Institute of Mountain Emergency Medicine, EURAC Research, Bolzano, Italy
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Svendsen ØS, Grong K, Husby P. Neuroprotective treatment strategies after rewarming from accidental hypothermia. Resuscitation 2018; 122:e9-e10. [DOI: 10.1016/j.resuscitation.2017.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 10/21/2017] [Indexed: 10/18/2022]
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Kriz D, Piantino J, Fields D, Williams C. Pediatric Hypothermic Submersion Injury and Protective Factors Associated with Optimal Outcome: A Case Report and Literature Review. CHILDREN-BASEL 2017; 5:children5010004. [PMID: 29280985 PMCID: PMC5789286 DOI: 10.3390/children5010004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 12/15/2017] [Accepted: 12/15/2017] [Indexed: 11/25/2022]
Abstract
Drowning is the 3rd leading cause of unintentional injury death worldwide, with the highest rates of fatality among young children. Submersion injuries with cardiac arrest can lead to long-term neurologic morbidity. Severe hypothermic submersion injuries have complex treatment courses and survivors have variable neurocognitive outcomes. We describe the course of a hypothermic submersion injury in a 6-year-old previously healthy boy. The description includes premorbid and post-injury neurocognitive functioning. A review of the literature of pediatric cold-water submersion injury was performed. Despite prolonged cardiopulmonary resuscitation (>100 min) and water temperature well above freezing, our patient had an optimal neurocognitive outcome following hypothermic submersion injury. Available literature is limited but suggests that increased submersion time, increased duration of resuscitation, and higher water temperatures are associated with worse outcomes. Care guidelines have been created, but outcomes related to these guidelines have not been studied. Our case highlights potential important determinants of outcome after drowning. Incident specific characteristics and therapeutic interventions should be considered when evaluating this population. Treatment guidelines based on currently available literature may fail to incorporate all potential variables, and consideration should be given to prolonged resuscitative efforts based on individual case characteristics until further data is available.
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Affiliation(s)
- Daniel Kriz
- Department of Pediatrics, Division of Psychology, Neuro-Critical Care Program, Oregon Health and Science University, Portland, OR 97239, USA.
- Programs for Evaluation, Development and Learning, St. Charles Healthcare Systems, Bend, OR 97701, USA.
| | - Juan Piantino
- Department of Pediatrics, Division Pediatric Neurology, Neuro-Critical Care Program, Oregon Health and Science University, Portland, OR 97239, USA.
| | - Devin Fields
- Department of Pediatrics, Division of Psychology, Neuro-Critical Care Program, Oregon Health and Science University, Portland, OR 97239, USA.
| | - Cydni Williams
- Department of Pediatrics, Division Pediatric Critical Care, Neuro-Critical Care Program, Oregon Health and Science University, Portland, OR 97239, USA.
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