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Behringer W, Böttiger BW, Biasucci DG, Chalkias A, Connolly J, Dodt C, Khoury A, Laribi S, Leach R, Ristagno G. Temperature control after successful resuscitation from cardiac arrest in adults: a joint statement from the European Society for Emergency Medicine (EUSEM) and the European Society of Anaesthesiology and Intensive Care (ESAIC). Eur J Emerg Med 2024; 31:86-89. [PMID: 38126247 PMCID: PMC10901227 DOI: 10.1097/mej.0000000000001106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 10/24/2023] [Indexed: 12/23/2023]
Affiliation(s)
- Wilhelm Behringer
- Department of Emergency Medicine, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - Bernd W. Böttiger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Cologne, Cologne, Germany
| | - Daniele G. Biasucci
- Department of Clinical Science and Translational Medicine, ‘Tor Vergata’ University of Rome, Rome, Italy
| | - Athanasios Chalkias
- Institute for Translational Medicine and Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
- Outcomes Research Consortium, Cleveland, Ohio, USA
| | - Jim Connolly
- Accident and Emergency, Great North Trauma and Emergency Care, Newcastle-upon-Tyne, UK
| | - Christoph Dodt
- Department of Emergency Medicine, München Klinik, Munich, Germany
| | - Abdo Khoury
- Department of Emergency Medicine and Critical Care, Besançon University Hospital, Besançon
| | - Said Laribi
- Department of Emergency Medicine, Tours University Hospital, Tours, France
| | - Robert Leach
- Department of Emergency Medicine, Centre Hospitalier de Wallonie Picarde, Tournai, Belgium
| | - Giuseppe Ristagno
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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Behringer W, Böttiger BW, Biasucci DG, Chalkias A, Connolly J, Dodt C, Khoury A, Laribi S, Leach R, Ristagno G. Temperature control after successful resuscitation from cardiac arrest in adults: A joint statement from the European Society for Emergency Medicine and the European Society of Anaesthesiology and Intensive Care. Eur J Anaesthesiol 2024; 41:278-281. [PMID: 38126249 PMCID: PMC10906202 DOI: 10.1097/eja.0000000000001948] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
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Meyer MAS, Hassager C, Mølstrøm S, Borregaard B, Grand J, Nyholm B, Obling LER, Beske RP, Meyer ASP, Bekker-Jensen D, Winther-Jensen M, Jørgensen VL, Schmidt H, Møller JE, Kjaergaard J. Combined effects of targeted blood pressure, oxygenation, and duration of device-based fever prevention after out-of-hospital cardiac arrest on 1-year survival: post hoc analysis of a randomized controlled trial. Crit Care 2024; 28:20. [PMID: 38216985 PMCID: PMC10785348 DOI: 10.1186/s13054-023-04794-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 12/29/2023] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND The "Blood Pressure and Oxygenation Targets in Post Resuscitation Care" (BOX) trial investigated whether a low versus high blood pressure target, a restrictive versus liberal oxygenation target, and a shorter versus longer duration of device-based fever prevention in comatose patients could improve outcomes. No differences in rates of discharge from hospital with severe disability or 90-day mortality were found. However, long-term effects and potential interaction of the interventions are unknown. Accordingly, the objective of this study is to investigate both individual and combined effects of the interventions on 1-year mortality rates. METHODS The BOX trial was a randomized controlled two-center trial that assigned comatose resuscitated out-of-hospital cardiac arrest patients to the following three interventions at admission: A blood pressure target of either 63 mmHg or 77 mmHg; An arterial oxygenation target of 9-10 kPa or 13-14 kPa; Device-based fever prevention administered as an initial 24 h at 36 °C and then either 12 or 48 h at 37 °C; totaling 36 or 72 h of temperature control. Randomization occurred in parallel and simultaneously to all interventions. Patients were followed for the occurrence of death from all causes for 1 year. Analyzes were performed by Cox proportional models, and assessment of interactions was performed with the interventions stated as an interaction term. RESULTS Analysis for all three interventions included 789 patients. For the intervention of low compared to high blood pressure targets, 1-year mortality rates were 35% (138 of 396) and 36% (143 of 393), respectively, hazard ratio (HR) 0.92 (0.73-1.16) p = 0.47. For the restrictive compared to liberal oxygenation targets, 1-year mortality rates were 34% (135 of 394) and 37% (146 of 395), respectively, HR 0.92 (0.73-1.16) p = 0.46. For device-based fever prevention for a total of 36 compared to 72 h, 1-year mortality rates were 35% (139 of 393) and 36% (142 of 396), respectively, HR 0.98 (0.78-1.24) p = 0.89. There was no sign of interaction between the interventions, and accordingly, no combination of randomizations indicated differentiated treatment effects. CONCLUSIONS There was no difference in 1-year mortality rates for a low compared to high blood pressure target, a liberal compared to restrictive oxygenation target, or a longer compared to shorter duration of device-based fever prevention after cardiac arrest. No combination of the interventions affected these findings. Trial registration ClinicalTrials.gov NCT03141099, Registered 30 April 2017.
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Affiliation(s)
- Martin A S Meyer
- Department of Cardiology, The Heart Center, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Christian Hassager
- Department of Cardiology, The Heart Center, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Simon Mølstrøm
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Britt Borregaard
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Johannes Grand
- Department of Cardiology, The Heart Center, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Benjamin Nyholm
- Department of Cardiology, The Heart Center, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Laust E R Obling
- Department of Cardiology, The Heart Center, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Rasmus P Beske
- Department of Cardiology, The Heart Center, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Anna Sina P Meyer
- Department of Cardiology, The Heart Center, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Ditte Bekker-Jensen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Matilde Winther-Jensen
- Department of Cardiology, The Heart Center, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Data, Biostatistics and Pharmacoepidemiology, Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
| | - Vibeke L Jørgensen
- Department of Cardiothoracic Anesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Henrik Schmidt
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jacob E Møller
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, The Heart Center, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Trummer G, Benk C, Pooth JS, Wengenmayer T, Supady A, Staudacher DL, Damjanovic D, Lunz D, Wiest C, Aubin H, Lichtenberg A, Dünser MW, Szasz J, Dos Reis Miranda D, van Thiel RJ, Gummert J, Kirschning T, Tigges E, Willems S, Beyersdorf F. Treatment of Refractory Cardiac Arrest by Controlled Reperfusion of the Whole Body: A Multicenter, Prospective Observational Study. J Clin Med 2023; 13:56. [PMID: 38202063 PMCID: PMC10780178 DOI: 10.3390/jcm13010056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/12/2024] Open
Abstract
Background: Survival following cardiac arrest (CA) remains poor after conventional cardiopulmonary resuscitation (CCPR) (6-26%), and the outcomes after extracorporeal cardiopulmonary resuscitation (ECPR) are often inconsistent. Poor survival is a consequence of CA, low-flow states during CCPR, multi-organ injury, insufficient monitoring, and delayed treatment of the causative condition. We developed a new strategy to address these issues. Methods: This all-comers, multicenter, prospective observational study (69 patients with in- and out-of-hospital CA (IHCA and OHCA) after prolonged refractory CCPR) focused on extracorporeal cardiopulmonary support, comprehensive monitoring, multi-organ repair, and the potential for out-of-hospital cannulation and treatment. Result: The overall survival rate at hospital discharge was 42.0%, and a favorable neurological outcome (CPC 1+2) at 90 days was achieved for 79.3% of survivors (CPC 1+2 survival 33%). IHCA survival was very favorable (51.7%), as was CPC 1+2 survival at 90 days (41%). Survival of OHCA patients was 35% and CPC 1+2 survival at 90 days was 28%. The subgroup of OHCA patients with pre-hospital cannulation showed a superior survival rate of 57.1%. Conclusions: This new strategy focusing on repairing damage to multiple organs appears to improve outcomes after CA, and these findings should provide a sound basis for further research in this area.
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Affiliation(s)
- Georg Trummer
- Department of Cardiovascular Surgery, University Medical Center Freiburg, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany; (G.T.)
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
| | - Christoph Benk
- Department of Cardiovascular Surgery, University Medical Center Freiburg, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany; (G.T.)
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
| | - Jan-Steffen Pooth
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
- Department of Emergency Medicine, Medical Center—University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Tobias Wengenmayer
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
- Interdisciplinary Medical Intensive Care, Medical Center—University of Freiburg, 79106 Freiburg, Germany
| | - Alexander Supady
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
- Interdisciplinary Medical Intensive Care, Medical Center—University of Freiburg, 79106 Freiburg, Germany
| | - Dawid L. Staudacher
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
- Interdisciplinary Medical Intensive Care, Medical Center—University of Freiburg, 79106 Freiburg, Germany
| | - Domagoj Damjanovic
- Department of Cardiovascular Surgery, University Medical Center Freiburg, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany; (G.T.)
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Medical Center, 93042 Regensburg, Germany;
| | - Clemens Wiest
- Department of Internal Medicine II, University Medical Center, 93042 Regensburg, Germany
| | - Hug Aubin
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany (A.L.)
| | - Artur Lichtenberg
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany (A.L.)
| | - Martin W. Dünser
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020 Linz, Austria
| | - Johannes Szasz
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020 Linz, Austria
| | - Dinis Dos Reis Miranda
- Department of Adult Intensive Care, Erasmus MC University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Robert J. van Thiel
- Department of Adult Intensive Care, Erasmus MC University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Jan Gummert
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, University Hospital of the Ruhr University Bochum, 44791 Bad Oeynhausen, Germany
| | - Thomas Kirschning
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, University Hospital of the Ruhr University Bochum, 44791 Bad Oeynhausen, Germany
| | - Eike Tigges
- Asklepios Klinik St. Georg, Heart and Vascular Center, Department of Cardiology and Intensive Care Medicine, 20099 Hamburg, Germany
| | - Stephan Willems
- Asklepios Klinik St. Georg, Heart and Vascular Center, Department of Cardiology and Intensive Care Medicine, 20099 Hamburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Medical Center Freiburg, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany; (G.T.)
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
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Busch HJ, Behringer W, Biever P, Böttiger BW, Eisenburger P, Fink K, Herkner H, Kreimeier U, Pin M, Wolfrum S. [Hypothermic temperature control after successful resuscitation of out-of-hospital cardiac arrest in adults : Statement from the resuscitation and postresuscitation treatment working groups of the German Society of Medical Intensive Care and Emergency Medicine (DGIIN) and the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI), the German Society for Interdisciplinary Emergency and Acute Medicine (DGINA) and the Austrian Association of Emergency Medicine (AAEM)]. Med Klin Intensivmed Notfmed 2023; 118:59-63. [PMID: 38051382 DOI: 10.1007/s00063-023-01092-x] [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] [Accepted: 11/09/2023] [Indexed: 12/07/2023]
Abstract
In Germany per year approximately 60,000 and in Austria 5,000 adult patients suffer from out-of-hospital cardiac arrest. Only 10-15% of these patients survive without neurological damage. For decades hypothermic temperature control has been a central component of post-resuscitation treatment, but is controversial due to recently published studies.
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Affiliation(s)
- Hans-Jörg Busch
- Zentrum für Notfall- und Rettungsmedizin, Universitätsnotfallzentrum, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität, Sir Hans-A-Krebs-Straße, 79180, Freiburg, Deutschland.
| | - Wilhelm Behringer
- Universitätsklinik für Notfallmedizin, MedUni Wien, Wien, Österreich
| | - Paul Biever
- Medizinische Interdisziplinäre Intensivtherapie Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
| | - Bernd W Böttiger
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universität zu Köln, Köln, Deutschland
| | | | - Katrin Fink
- Zentrum für Notfall- und Rettungsmedizin, Universitätsnotfallzentrum, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität, Sir Hans-A-Krebs-Straße, 79180, Freiburg, Deutschland
| | - Harald Herkner
- Universitätsklinik für Notfallmedizin, MedUni Wien, Wien, Österreich
| | - Uwe Kreimeier
- Klinik für Anästhesiologie, LMU Klinikum, LMU München, München, Deutschland
| | - Martin Pin
- Zentrale Interdisziplinäre Notaufnahme und Akutstation, Florence-Nightingale-Krankenhaus, Kaiserswerther Diakonie, Düsseldorf, Deutschland
| | - Sebastian Wolfrum
- Interdisziplinäre Notaufnahme, Universitätsklinikum Schleswig-Holstein, Lübeck, Deutschland
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Behringer W, Skrifvars MB, Taccone FS. Postresuscitation management. Curr Opin Crit Care 2023; 29:640-647. [PMID: 37909369 DOI: 10.1097/mcc.0000000000001116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
PURPOSE OF REVIEW To describe the most recent scientific evidence on ventilation/oxygenation, circulation, temperature control, general intensive care, and prognostication after successful resuscitation from adult cardiac arrest. RECENT FINDINGS Targeting a lower oxygen target (90-94%) is associated with adverse outcome. Targeting mild hypercapnia is not associated with improved functional outcomes or survival. There is no compelling evidence supporting improved outcomes associated with a higher mean arterial pressure target compared to a target of >65 mmHg. Noradrenalin seems to be the preferred vasopressor. A low cardiac index is common over the first 24 h but aggressive fluid loading and the use of inotropes are not associated with improved outcome. Several meta-analyses of randomized clinical trials show conflicting results whether hypothermia in the 32-34°C range as compared to normothermia or no temperature control improves functional outcome. The role of sedation is currently under evaluation. Observational studies suggest that the use of neuromuscular blockade may be associated with improved survival and functional outcome. Prophylactic antibiotic does not impact on outcome. No single predictor is entirely accurate to determine neurological prognosis. The presence of at least two predictors of severe neurological injury indicates that an unfavorable neurological outcome is very likely. SUMMARY Postresuscitation care aims for normoxemia, normocapnia, and normotension. The optimal target core temperature remains a matter of debate, whether to implement temperature management within the 32-34°C range or focus on fever prevention, as recommended in the latest European Resuscitation Council/European Society of Intensive Care Medicine guidelines Prognostication of neurological outcome demands a multimodal approach.
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Affiliation(s)
- Wilhelm Behringer
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Finland
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium
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Kotani Y, Turi S, Ortalda A, Baiardo Redaelli M, Marchetti C, Landoni G, Bellomo R. Positive single-center randomized trials and subsequent multicenter randomized trials in critically ill patients: a systematic review. Crit Care 2023; 27:465. [PMID: 38017475 PMCID: PMC10685543 DOI: 10.1186/s13054-023-04755-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 11/21/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND It is unclear how often survival benefits observed in single-center randomized controlled trials (sRCTs) involving critically ill patients are confirmed by subsequent multicenter randomized controlled trials (mRCTs). We aimed to perform a systemic literature review of sRCTs with a statistically significant mortality reduction and to evaluate whether subsequent mRCTs confirmed such reduction. METHODS We searched PubMed for sRCTs published in the New England Journal of Medicine, JAMA, or Lancet, from inception until December 31, 2016. We selected studies reporting a statistically significant mortality decrease using any intervention (drug, technique, or strategy) in adult critically ill patients. We then searched for subsequent mRCTs addressing the same research question tested by the sRCT. We compared the concordance of results between sRCTs and mRCTs when any mRCT was available. We registered this systematic review in the PROSPERO International Prospective Register of Systematic Reviews (CRD42023455362). RESULTS We identified 19 sRCTs reporting a significant mortality reduction in adult critically ill patients. For 16 sRCTs, we identified at least one subsequent mRCT (24 trials in total), while the interventions from three sRCTs have not yet been addressed in a subsequent mRCT. Only one out of 16 sRCTs (6%) was followed by a mRCT replicating a significant mortality reduction; 14 (88%) were followed by mRCTs with no mortality difference. The positive finding of one sRCT (6%) on intensive glycemic control was contradicted by a subsequent mRCT showing a significant mortality increase. Of the 14 sRCTs referenced at least once in international guidelines, six (43%) have since been either removed or suggested against in the most recent versions of relevant guidelines. CONCLUSION Mortality reduction shown by sRCTs is typically not replicated by mRCTs. The findings of sRCTs should be considered hypothesis-generating and should not contribute to guidelines.
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Affiliation(s)
- Yuki Kotani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Via Olgettina 58, 20132, Milan, Italy
- Department of Intensive Care Medicine, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba, 296-8602, Japan
| | - Stefano Turi
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Alessandro Ortalda
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Martina Baiardo Redaelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Cristiano Marchetti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
- School of Medicine, Vita-Salute San Raffaele University, Via Olgettina 58, 20132, Milan, Italy.
| | - Rinaldo Bellomo
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
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Vadeyar S, Buckle A, Hooper A, Booth S, Deakin CD, Fothergill R, Ji C, Nolan JP, Brown M, Cowley A, Harris E, Ince M, Marriott R, Pike J, Spaight R, Perkins GD, Couper K. Trends in use of intraosseous and intravenous access in out-of-hospital cardiac arrest across English ambulance services: A registry-based, cohort study. Resuscitation 2023; 191:109951. [PMID: 37648146 DOI: 10.1016/j.resuscitation.2023.109951] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/17/2023] [Accepted: 08/21/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION The optimum route for drug administration in cardiac arrest is unclear. Recent data suggest that use of the intraosseous route may be increasing. This study aimed to explore changes over time in use of the intraosseous and intravenous drug routes in out-of-hospital cardiac arrest in England. METHODS We extracted data from the UK Out-of-Hospital Cardiac Arrest Outcomes registry. We included adult out-of-hospital cardiac arrest patients between 2015-2020 who were treated by an English Emergency Medical Service that submitted vascular access route data to the registry. The primary outcome was any use of the intraosseous route during cardiac arrest. We used logistic regression models to describe the association between time (calendar month) and intraosseous use. RESULTS We identified 75,343 adults in cardiac arrest treated by seven Emergency Medical Service systems between January 2015 and December 2020. The median age was 72 years, 64% were male and 23% presented in a shockable rhythm. Over the study period, the percentage of patients receiving intraosseous access increased from 22.8% in 2015 to 42.5% in 2020. For each study-month, the odds of receiving any intraosseous access increased by 1.019 (95% confidence interval 1.019 to 1.020, p < 0.001). This observed effect was consistent across sensitivity analyses. We observed a corresponding decrease in use of intravenous access. CONCLUSION In England, the use of intraosseous access in out-of-hospital cardiac arrest has progressively increased over time. There is an urgent need for randomised controlled trials to evaluate the clinical effectiveness of the different vascular access routes in cardiac arrest.
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Affiliation(s)
- Sharvari Vadeyar
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alexandra Buckle
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Amy Hooper
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Scott Booth
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Charles D Deakin
- South Central Ambulance Service NHS Foundation Trust, Otterbourne, UK; University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Rachael Fothergill
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK; Clinical Audit & Research Unit, London Ambulance Service NHS Trust, London, UK
| | - Chen Ji
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Jerry P Nolan
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK; Intensive Care Unit, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Martina Brown
- South Central Ambulance Service NHS Foundation Trust, Otterbourne, UK
| | - Alan Cowley
- South East Coast Ambulance Service NHS Foundation Trust, Crawley, UK
| | - Emma Harris
- West Midlands Ambulance Service University NHS Foundation Trust, Brierley Hill, UK
| | - Maureen Ince
- North West Ambulance Service NHS Trust, Bolton, UK
| | - Robert Marriott
- North East Ambulance Service NHS Foundation Trust, Newcastle upon Tyne, UK
| | - John Pike
- Isle of Wight NHS Trust, Newport, Isle of Wight, UK
| | - Robert Spaight
- East Midlands Ambulance Service NHS Trust, Nottingham, UK
| | - Gavin D Perkins
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Keith Couper
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Warwick Clinical Trials Unit, University of Warwick, Coventry, UK.
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Chiu PY, Chung CC, Tu YK, Tseng CH, Kuan YC. Therapeutic hypothermia in patients after cardiac arrest: A systematic review and meta-analysis of randomized controlled trials. Am J Emerg Med 2023; 71:182-189. [PMID: 37421815 DOI: 10.1016/j.ajem.2023.06.040] [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: 02/07/2023] [Revised: 05/18/2023] [Accepted: 06/22/2023] [Indexed: 07/10/2023] Open
Abstract
OBJECTIVE Targeted temperature management (TTM) with therapeutic hypothermia (TH) has been used to improve neurological outcomes in patients after cardiac arrest; however, several trials have reported conflicting results regarding its effectiveness. This systematic review and meta-analysis assessed whether TH was associated with better survival and neurological outcomes after cardiac arrest. METHOD We searched online databases for relevant studies published before May 2023. Randomized controlled trials (RCTs) comparing TH and normothermia in post-cardiac-arrest patients were selected. Neurological outcomes and all-cause mortality were assessed as the primary and secondary outcomes, respectively. A subgroup analysis according to initial electrocardiography (ECG) rhythm was performed. RESULT Nine RCTs (4058 patients) were included. The neurological prognosis was significantly better in patients with an initial shockable rhythm after cardiac arrest (RR = 0.87, 95% confidence interval [CI] = 0.76-0.99, P = 0.04), especially in those with earlier TH initiation (<120 min) and prolonged TH duration (≥24 h). However, the mortality rate after TH was not lower than that after normothermia (RR = 0.91, 95% CI = 0.79-1.05). In patients with an initial nonshockable rhythm, TH did not provide significantly more neurological or survival benefits (RR = 0.98, 95% CI = 0.93-1.03 and RR = 1.00, 95% CI = 0.95-1.05, respectively). CONCLUSION Current evidence with a moderate level of certainty suggests that TH has potential neurological benefits for patients with an initial shockable rhythm after cardiac arrest, especially in those with faster TH initiation and longer TH maintenance.
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Affiliation(s)
- Po-Yun Chiu
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Division of General Medicine, Department of Medical Education, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chen-Chih Chung
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan; Department of Neurology, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan; Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yu-Kang Tu
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taiwan
| | - Chien-Hua Tseng
- Division of Critical Care Medicine, Department of Emergency and Critical Care Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan; Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yi-Chun Kuan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan; Department of Neurology, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan; Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taiwan; Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan; Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan.
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10
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Nielsen N, Friberg H. Changes in Practice of Controlled Hypothermia after Cardiac Arrest in the Past 20 Years: A Critical Care Perspective. Am J Respir Crit Care Med 2023; 207:1558-1564. [PMID: 37104654 DOI: 10.1164/rccm.202211-2142cp] [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: 11/22/2022] [Accepted: 04/26/2023] [Indexed: 04/29/2023] Open
Abstract
For 20 years, induced hypothermia and targeted temperature management have been recommended to mitigate brain injury and increase survival after cardiac arrest. On the basis of animal research and small clinical trials, the International Liaison Committee on Resuscitation strongly advocated hypothermia at 32-34 °C for 12-24 hours for comatose patients with out-of-hospital cardiac arrest with initial rhythm of ventricular fibrillation or nonperfusing ventricular tachycardia. The intervention was implemented worldwide. In the past decade, hypothermia and targeted temperature management have been investigated in larger clinical randomized trials focusing on target temperature depth, target temperature duration, prehospital versus in-hospital initiation, nonshockable rhythms, and in-hospital cardiac arrest. Systematic reviews suggest little or no effect of delivering the intervention on the basis of the summary of evidence, and the International Liaison Committee on Resuscitation today recommends only to treat fever and keep body temperature below 37.5 °C (weak recommendation, low-certainty evidence). Here we describe the evolution of temperature management for patients with cardiac arrest during the past 20 years and how the accrued evidence has influenced not only the recommendations but also the guideline process. We also discuss possible paths forward in this field, bringing up both whether fever management is at all beneficial for patients with cardiac arrest and which knowledge gaps future clinical trials in temperature management should address.
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Affiliation(s)
- Niklas Nielsen
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anesthesiology and Intensive Care, Helsingborg Hospital, Helsingborg, Sweden; and
| | - Hans Friberg
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anesthesiology and Intensive Care, Skåne University Hospital, Malmö, Sweden
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11
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Aranda-García S, Otero-Agra M, Fernández-Méndez F, Herrera-Pedroviejo E, Darné M, Barcala-Furelos R, Rodríguez-Núñez A. Augmented reality training in basic life support with the help of smart glasses. A pilot study. Resusc Plus 2023; 14:100391. [PMID: 37128627 PMCID: PMC10148024 DOI: 10.1016/j.resplu.2023.100391] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023] Open
Abstract
Introduction Laypeople should be trained in basic life support and traditional and innovative methodologies may help to obtain this goal. However, there is a knowledge gap about the ideal basic life support training methods. Smart glasses could have a role facilitating laypeople learning of basic life support. Aim To analyze the potential impact on basic life support learning of a very brief training supported by smart glasses video communication. Methods Twelve laypeople were basic life support tele-trained by means of smart glasses by an instructor in this pilot study. During training (assisted trough smart glasses) and after the training (unassisted) participants' performance and quality of basic life support and automated external defibrillation procedure were assessed on a standardized simulated scenario. Results After the training all participants were able to deliver good quality basic life support, with results comparable to those obtained when real time remotely guided by the instructor through the smart glasses. Mean chest compression rate was significantly higher when not guided (113 /min vs. 103 /min, p = 0.001). When not assisted, the participants spent less time delivering the sequential basic life support steps than when assisted while training. Conclusions A very brief remote training supported by instructor and smart glasses seems to be an effective educational method that could facilitate basic life support learning by laypeople. This technology could be considered in cases where instructors are not locally available or in general in remote areas, providing basic internet connection is available. Smart glasses could also be useful for laypeople rolling-refreshers.
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Affiliation(s)
- Silvia Aranda-García
- GRAFAIS Research Group, Institut Nacional d'Educació Física de Catalunya (INEFC), University of Barcelona, Barcelona, Spain
- CLINURSID Research Group, University of Santiago de Compostela, Santiago de Compostela, Spain
- Corresponding author at: Institut Nacional d'Educació Física de Catalunya (INEFC), Universitat de Barcelona (UB), Av de l’Estadi 22, 08038, Barcelona, Spain.
| | - Martín Otero-Agra
- REMOSS Research Group, Faculty of Physical Activity and Educational Science, University of Vigo, Pontevedra, Spain
- Pontevedra School of Nursing, University of Vigo, Pontevedra, Spain
| | - Felipe Fernández-Méndez
- CLINURSID Research Group, University of Santiago de Compostela, Santiago de Compostela, Spain
- REMOSS Research Group, Faculty of Physical Activity and Educational Science, University of Vigo, Pontevedra, Spain
- Pontevedra School of Nursing, University of Vigo, Pontevedra, Spain
| | | | - Marc Darné
- GRAFAIS Research Group, Institut Nacional d'Educació Física de Catalunya (INEFC), University of Barcelona, Barcelona, Spain
| | - Roberto Barcala-Furelos
- CLINURSID Research Group, University of Santiago de Compostela, Santiago de Compostela, Spain
- REMOSS Research Group, Faculty of Physical Activity and Educational Science, University of Vigo, Pontevedra, Spain
| | - Antonio Rodríguez-Núñez
- CLINURSID Research Group, University of Santiago de Compostela, Santiago de Compostela, Spain
- Pediatric Critical, Intermediate and Palliative Care Section, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin (RICORS), RD21/0012/0025, Instituto de Salud Carlos III, Madrid, Spain
- SICRUS Research Group, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
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12
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Monaco T, Fischer M, Michael M, Hubar I, Westenfeld R, Rauch S, Gräsner JT, Bernhard M. Impact of the route of adrenaline administration in patients suffering from out-of-hospital cardiac arrest on 30-day survival with good neurological outcome (ETIVIO study). Scand J Trauma Resusc Emerg Med 2023; 31:14. [PMID: 36997973 PMCID: PMC10061896 DOI: 10.1186/s13049-023-01079-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 03/21/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Over the past decades, international guidelines for cardiopulmonary resuscitation (CPR) have changed the recommendation for alternative routes for drug administration. Until now, evidence for the substantial superiority of one route with respect to treatment outcome after CPR has been lacking. The present study compares the effects of intravenous (IV), intraosseous (IO) and endotracheal (ET) adrenaline application during CPR in out-of-hospital cardiac arrest (OHCA) on clinical outcomes within the database of the German Resuscitation Registry (GRR). METHODS This registry analysis was based on the GRR cohort of 212,228 OHCA patients between 1989 and 2020. Inclusion criteria were: OHCA, application of adrenaline, and out-of-hospital CPR. Excluded from the study were patients younger than 18 years, those who had trauma or bleeding as suspected causes of cardiac arrest, and incomplete data sets. The clinical endpoint was hospital discharge with good neurological outcome [cerebral performance category (CPC) 1/2]. Four routes of adrenaline administration were compared: IV, IO, IO + IV, ET + IV. Group comparisons were done using matched-pair analysis and binary logistic regression. RESULTS In matched-pair group comparisons of the primary clinical outcome hospital discharge with CPC 1/2, the IV group (n = 2416) showed better results compared to IO (n = 1208), [odds ratio (OR): 2.43, 95% confidence interval (CI): 1.54-3.84, p < 0.01] and when comparing IV (n = 8706) to IO + IV (n = 4353), [OR: 1.33, 95% CI: 1.12-1.59, p < 0.01]. In contrast, no significant difference was found between IV (n = 532) and ET + IV (n = 266), [OR: 1.26, 95% CI: 0.55-2.90, p = 0.59]. Concurrently, binary logistic regression yielded a highly significant effect of vascular access type (χ² = 67.744(3), p < 0.001) on hospital discharge with CPC1/2, with negative effects for IO (regression coefficient (r.c.) = - 0.766, p = 0.001) and IO + IV (r.c. = - 0.201, p = 0,028) and no significant effect for ET + IV (r.c. = 0.117, p = 0.770) compared to IV. CONCLUSIONS The GRR data, collected over a period of 31 years, seem to emphasize the relevance of an IV access during out-of-hospital CPR, in the event that adrenaline had to be administered. IO administration of adrenaline might be less effective. ET application, though removed in 2010 from international guidelines, could gain importance as an alternative route again.
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Affiliation(s)
- Tobias Monaco
- Emergency Department, University Hospital of Düsseldorf, Heinrich Heine University, Moorenstrasse 5, D-40225, Düsseldorf, Germany
| | - Matthias Fischer
- Department of Anaesthesiology and Intensive Care, ALB FILS Kliniken, Eichertstraße 3, 73035, Göppingen, Germany
| | - Mark Michael
- Emergency Department, University Hospital of Düsseldorf, Heinrich Heine University, Moorenstrasse 5, D-40225, Düsseldorf, Germany
| | - Iryna Hubar
- Emergency Department, University Hospital of Düsseldorf, Heinrich Heine University, Moorenstrasse 5, D-40225, Düsseldorf, Germany
| | - Ralf Westenfeld
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hsopital of Düsseldorf, Heinrich Heine University, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Stefan Rauch
- Department of Anaesthesiology and Intensive Care, ALB FILS Kliniken, Eichertstraße 3, 73035, Göppingen, Germany
| | - Jan-Thorsten Gräsner
- Institute for Emergency Medicine, Department of Anesthesiology and Intensive Care Medicine, University-Hospital Schleswig-Holstein, Arnold-Heller-Straße 3, 24105, Kiel, Germany
| | - Michael Bernhard
- Emergency Department, University Hospital of Düsseldorf, Heinrich Heine University, Moorenstrasse 5, D-40225, Düsseldorf, Germany.
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13
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Hassager C, Schmidt H, Møller JE, Grand J, Mølstrøm S, Beske RP, Boesgaard S, Borregaard B, Bekker-Jensen D, Dahl JS, Frydland MS, Høfsten DE, Isse YA, Josiassen J, Lind Jørgensen VR, Kondziella D, Lindholm MG, Moser E, Nyholm BC, Obling LER, Sarkisian L, Søndergaard FT, Thomsen JH, Thune JJ, Venø S, Wiberg SC, Winther-Jensen M, Meyer MAS, Kjaergaard J. Duration of Device-Based Fever Prevention after Cardiac Arrest. N Engl J Med 2023; 388:888-897. [PMID: 36342119 DOI: 10.1056/nejmoa2212528] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Guidelines recommend active fever prevention for 72 hours after cardiac arrest. Data from randomized clinical trials of this intervention have been lacking. METHODS We randomly assigned comatose patients who had been resuscitated after an out-of-hospital cardiac arrest of presumed cardiac cause to device-based temperature control targeting 36°C for 24 hours followed by targeting of 37°C for either 12 or 48 hours (for total intervention times of 36 and 72 hours, respectively) or until the patient regained consciousness. The primary outcome was a composite of death from any cause or hospital discharge with a Cerebral Performance Category of 3 or 4 (range, 1 to 5, with higher scores indicating more severe disability; a category of 3 or 4 indicates severe cerebral disability or coma) within 90 days after randomization. Secondary outcomes included death from any cause and the Montreal Cognitive Assessment score (range, 0 to 30, with higher scores indicating better cognitive ability) at 3 months. RESULTS A total of 393 patients were randomly assigned to temperature control for 36 hours, and 396 patients were assigned to temperature control for 72 hours. At 90 days after randomization, a primary end-point event had occurred in 127 of 393 patients (32.3%) in the 36-hour group and in 133 of 396 patients (33.6%) in the 72-hour group (hazard ratio, 0.99; 95% confidence interval, 0.77 to 1.26; P = 0.70) and mortality was 29.5% in the 36-hour group and 30.3% in the 72-hour group. At 3 months, the median Montreal Cognitive Assessment score was 26 (interquartile range, 24 to 29) and 27 (interquartile range, 24 to 28), respectively. There was no significant between-group difference in the incidence of adverse events. CONCLUSIONS Active device-based fever prevention for 36 or 72 hours after cardiac arrest did not result in significantly different percentages of patients dying or having severe disability or coma. (Funded by the Novo Nordisk Foundation; BOX ClinicalTrials.gov number, NCT03141099.).
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Affiliation(s)
- Christian Hassager
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Henrik Schmidt
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Jacob E Møller
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Johannes Grand
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Simon Mølstrøm
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Rasmus P Beske
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Søren Boesgaard
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Britt Borregaard
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Ditte Bekker-Jensen
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Jordi S Dahl
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Martin S Frydland
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Dan E Høfsten
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Yusuf A Isse
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Jakob Josiassen
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Vibeke R Lind Jørgensen
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Daniel Kondziella
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Matias G Lindholm
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Emil Moser
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Benjamin C Nyholm
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Laust E R Obling
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Laura Sarkisian
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Frederik T Søndergaard
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Jakob H Thomsen
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Jens J Thune
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Søren Venø
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Sebastian C Wiberg
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Matilde Winther-Jensen
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Martin A S Meyer
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Jesper Kjaergaard
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
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Li P, Sun Z, Tian T, Yu D, Tian H, Gong P. Recent developments and controversies in therapeutic hypothermia after cardiopulmonary resuscitation. Am J Emerg Med 2023; 64:1-7. [PMID: 36435004 DOI: 10.1016/j.ajem.2022.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/23/2022] [Accepted: 11/01/2022] [Indexed: 11/13/2022] Open
Abstract
Therapeutic hypothermia was recommended as the only neuroprotective treatment in comatose patients after return of spontaneous circulation (ROSC). With new evidence suggesting a similar neuroprotective effect of 36 °C and 33 °C, the term "therapeutic hypothermia" was substituted by "targeted temperature management" in 2011, which in turn was replaced by the term "temperature control" in 2022 because of new evidence of the similar effects of target normothermia and 33 °C. However, there is no clear consensus on the efficacy of therapeutic hypothermia. In this article, we provide an overview of the recent evidence from basic and clinical research related to therapeutic hypothermia and re-evaluate its application as a post-ROSC neuroprotective intervention in clinical settings.
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Affiliation(s)
- Peijuan Li
- Department of Emergency, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China; Dalian Medical University, Dalian, Liaoning, China
| | - Zhangping Sun
- Department of Emergency, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China; Dalian Medical University, Dalian, Liaoning, China
| | - Tian Tian
- Department of Emergency, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China; Dalian Medical University, Dalian, Liaoning, China
| | - Dongping Yu
- Department of Emergency, Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Hui Tian
- Department of Emergency, Dalian Municipal Central Hospital, Dalian, Liaoning, China
| | - Ping Gong
- Department of Emergency, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China; Department of Emergency, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China.
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Hubar I, Fischer M, Monaco T, Gräsner JT, Westenfeld R, Bernhard M. Development of the epidemiology and outcomes of out-of-hospital cardiac arrest using data from the German Resuscitation Register over a 15-year period (EpiCPR study). Resuscitation 2023; 182:109648. [PMID: 36423737 DOI: 10.1016/j.resuscitation.2022.11.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 10/22/2022] [Accepted: 11/10/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Sudden cardiac arrest is a relevant problem with a significant number of deaths in Europe. AIM Using data from the German Resuscitation Register (GRR), we examined changes in epidemiology and therapeutic interventions over a 15-year period in order to identify key factors contributing to favourable outcome in out-of-hospital cardiac arrest (OHCA) patients. METHODS GRR data were analysed in 5-year periods (2006-2010 vs 2011-2015 vs 2016-2020) representing changes in the European Resuscitation Council (ERC) guidelines. Group comparison of OHCA patients was made for epidemiological and resuscitation-associated factors. Endpoints included 30-day survival and hospital discharge with a good neurological outcome (CPC 1,2). Matched-pair analysis compared outcomes, and multivariate binary logistic regression analysis identified variables with effects on survival. RESULTS A total of 42,997 GRR patients were studied (2006-2010: n = 3,471, 2011-2015: n = 16,122, 2016-2020: n = 23,404). Proportion of patients over 80 years, use of intraosseous (IO) access and supraglottic airway devices, rate of bystander CPR, and the proportion of telephone CPR increased over the study period. The 30-day survival, and hospital discharge rates with CPC1/2 were unchanged. After adjusting cohorts using matched pairs, a higher CPC1,2 rate was observed (8.8 vs 10.2%, p < 0.03). Logistic regression analysis showed that IO and SAD had an unfavourable impact on outcome. CONCLUSION Despite a significant increase in bystander and telephone CPR rates, no improvement in 30-day survival and hospital discharge rate with CPC1,2 was observed. Initial rhythm (VF/VT), cardiac and hypoxic cause of CA, bystander CPR and IV access were identified as factors associated with a favourable neurological outcome.
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Affiliation(s)
- Iryna Hubar
- Emergency Department, University Hospital of Duesseldorf, Medical Faculty, Moorenstrasse 5, 40225 Duesseldorf, Germany
| | - Matthias Fischer
- Department of Anesthesiology and Intensive Care, ALB FILS Kliniken, Eichertstraße 3, 73035 Göppingen, Germany
| | - Tobias Monaco
- Emergency Department, University Hospital of Duesseldorf, Medical Faculty, Moorenstrasse 5, 40225 Duesseldorf, Germany
| | - Jan-Thorsten Gräsner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Medical Faculty, Arnold-Heller-Straße 3, 24105 Kiel, Germany
| | - Ralf Westenfeld
- Department of Cardiology, Pulmonology and Vascular Medicine, University Hospital of Duesseldorf, Medical Faculty, Moorenstrasse 5, 40225 Düsseldorf, Germany
| | - Michael Bernhard
- Emergency Department, University Hospital of Duesseldorf, Medical Faculty, Moorenstrasse 5, 40225 Duesseldorf, Germany.
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Bakhsh A, Alotaibi H, Alothman S, Alothman A, Alothman R, Alsulami A, Alamoudi M, Alothman A, Al-Shareef A. Opinions and attitudes toward targeted temperature management in the emergency department and intensive care unit in a developing country: a survey study. World J Emerg Med 2023; 14:138-142. [PMID: 36911059 PMCID: PMC9999127 DOI: 10.5847/wjem.j.1920-8642.2023.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/17/2022] [Indexed: 02/18/2023] Open
Affiliation(s)
- Abdullah Bakhsh
- Department of Emergency Medicine, the King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Hadeel Alotaibi
- Faculty of Medicine, the King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Sara Alothman
- Faculty of Medicine, the King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | | | - Rahaf Alothman
- Faculty of Medicine, the King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | | | - Malak Alamoudi
- Faculty of Medicine, the King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Ali Alothman
- Department of Anesthesia, Intensive Care Unit, the King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Ali Al-Shareef
- Department of Emergency Medicine, the King Abdulaziz University, Jeddah 21589, Saudi Arabia.,College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, College of Medicine, Jeddah 21589, Saudi Arabia.,King Abdulaziz Medical City, Jeddah 21589, Saudi Arabia.,King Abdullah International Medical Research Center, Jeddah 21589, Saudi Arabia
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Lazzarin T, Tonon CR, Martins D, Fávero EL, Baumgratz TD, Pereira FWL, Pinheiro VR, Ballarin RS, Queiroz DAR, Azevedo PS, Polegato BF, Okoshi MP, Zornoff L, Rupp de Paiva SA, Minicucci MF. Post-Cardiac Arrest: Mechanisms, Management, and Future Perspectives. J Clin Med 2022; 12:259. [PMID: 36615059 PMCID: PMC9820907 DOI: 10.3390/jcm12010259] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 12/22/2022] [Accepted: 12/23/2022] [Indexed: 12/31/2022] Open
Abstract
Cardiac arrest is an important public health issue, with a survival rate of approximately 15 to 22%. A great proportion of these deaths occur after resuscitation due to post-cardiac arrest syndrome, which is characterized by the ischemia-reperfusion injury that affects the role body. Understanding physiopathology is mandatory to discover new treatment strategies and obtain better results. Besides improvements in cardiopulmonary resuscitation maneuvers, the great increase in survival rates observed in recent decades is due to new approaches to post-cardiac arrest care. In this review, we will discuss physiopathology, etiologies, and post-resuscitation care, emphasizing targeted temperature management, early coronary angiography, and rehabilitation.
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Affiliation(s)
- Taline Lazzarin
- Internal Medicine Department, Botucatu Medical School, Universidade Estadual Paulista (UNESP), Botucatu 18607-741, Brazil
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Byrne C, Barcella CA, Krogager ML, Pareek M, Ringgren KB, Andersen MP, Mills EHA, Wissenberg M, Folke F, Gislason G, Køber L, Lippert F, Kjærgaard J, Hassager C, Torp-Pedersen C, Kragholm K, Lip GYH. External validation of the simple NULL-PLEASE clinical score in predicting outcomes of out-of-hospital cardiac arrest in the Danish population - A nationwide registry-based study. Resuscitation 2022; 180:128-136. [PMID: 36007857 DOI: 10.1016/j.resuscitation.2022.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 08/11/2022] [Accepted: 08/11/2022] [Indexed: 11/23/2022]
Abstract
AIM The NULL-PLEASE score (Nonshockable rhythm, Unwitnessed arrest, Long no-flow or Long low-flow period, blood pH < 7.2, Lactate > 7.0 mmol/L, End-stage renal disease on dialysis, Age ≥85 years, Still resuscitation, and Extracardiac cause) may identify patients with out-of-hospital cardiac arrest (OHCA) unlikely to survive. We aimed to validate the NULL-PLEASE score in a nationwide setting. METHODS We used Danish nationwide registry data from 2001 to 2019 and identified OHCA survivors with return of spontaneous circulation (ROSC) or ongoing cardiopulmonary resuscitation at hospital arrival. The primary outcome was 1-day mortality. Secondary outcomes were 30-day mortality and the combined outcome of 1-year mortality or anoxic brain damage. The risks of outcomes were estimated using logistic regression with a NULL-PLEASE score of 0 as reference (range 0-14). The predictive ability of the score was examined using the area under the receiver operating characteristics (AUCROC) curve. RESULTS A total of 3,881 patients were included in the analyses. One-day mortality was 35%, 30-day mortality was 61%, and 68% experienced the combined outcome. For a NULL-PLEASE score ≥9 (n = 244) the absolute risks were: 1-day mortality: 80.7% (95% confidence interval [CI]: 75.8-85.7%); 30-day mortality: 98.0% (95% CI: 96.2-99.7%); and the combined outcome: 98.4% (95% CI: 96.8-100.0%). Corresponding AUCROC values were 0.800 (95% CI: 0.786-0.814) for 1-day mortality, 0.827 (95% CI: 0.814-0.840) for 30-day mortality, and 0.828 (95% CI: 0.815-0.841) for the combined outcome. CONCLUSIONS In a nationwide OHCA-cohort, AUCROC values for the predictive ability of NULL-PLEASE were high for all outcomes. However, some survived even with high NULL-PLEASE scores.
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Affiliation(s)
- Christina Byrne
- Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark; Department of Cardiology, Gentofte University Hospital, Hellerup, Denmark.
| | - Carlo A Barcella
- Department of Cardiology, Gentofte University Hospital, Hellerup, Denmark; Department of Internal Medicine, Nykøbing Falster Hospital, Nykøbing Falster, Denmark
| | | | - Manan Pareek
- Department of Cardiology, Gentofte University Hospital, Hellerup, Denmark
| | | | | | | | - Mads Wissenberg
- Department of Cardiology, Gentofte University Hospital, Hellerup, Denmark
| | - Fredrik Folke
- Department of Cardiology, Gentofte University Hospital, Hellerup, Denmark; Copenhagen EMS Services, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Gentofte University Hospital, Hellerup, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Jesper Kjærgaard
- Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Kristian Kragholm
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Zhu YB, Yao Y, Ren Y, Feng JZ, Huang HB. Targeted Temperature Management for Cardiac Arrest Due to Non-shockable Rhythm: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Front Med (Lausanne) 2022; 9:910560. [PMID: 35721063 PMCID: PMC9203727 DOI: 10.3389/fmed.2022.910560] [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: 04/01/2022] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
Background Targeted temperature management (TTM) is recommended in adult patients following cardiac arrest (CA) with any rhythm. However, as to non-shockable (NSR) CA, high-quality evidence of TTM supporting its practices remains uncertain. Thus, we aimed to conduct a systematic review and meta-analysis with randomized controlled trials (RCTs) to explore the efficacy and safety of TTM in this population. Methods We searched PubMed, Embase, and Cochrane library databases for potential trials from inception through Aug 25, 2021. RCTs evaluating TTM for CA adults due to NSR were included, regardless of the timing of cooling initiation. Outcome measurements were mortality and good neurological function. We used the Cochrane bias tools to evaluate the quality of the included studies. Heterogeneity, subgroup analyses, and sensitivity analysis were investigated to test the robustness of the primary outcomes. Results A total of 14 RCTs with 4,009 adults were eligible for the final analysis. All trials had a low to moderate risk of bias. Of the included trials, six compared NSR patients with or without TTM, while eight compared pre-hospital to in-hospital TTM. Pooled data showed that TTM was not associated with improved mortality (Risk ratio [RR] 1.00; 95% CI, 0.944–1.05; P = 0.89, I2 = 0%) and good neurological outcome (RR 1.18; 95% CI 0.90–1.55; P = 0.22, I2 = 8%). Similarly, use of pre-hospital TTM resulted in neither an improved mortality (RR 0.99, 95% CI 0.97–1.03; I2 = 0%, P = 0.32) nor favorable neurological outcome (RR 1.13, 95% CI 0.93–1.38; I2 = 0%, P = 0.22). These results were further confirmed in the sensitivity analyses and subgroup analyses. Conclusions Our results showed that using the TTM strategy did not significantly affect the mortality and neurologic outcomes in CA survival presenting initial NSR.
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Affiliation(s)
- Yi-Bing Zhu
- Department of Emergency, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yan Yao
- Department of Critical Care Medicine, School of Clinical Medicine, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Yu Ren
- Department of Critical Care Medicine, School of Clinical Medicine, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Jing-Zhi Feng
- Department of Critical Care Medicine, School of Clinical Medicine, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Hui-Bin Huang
- Department of Critical Care Medicine, School of Clinical Medicine, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
- *Correspondence: Hui-Bin Huang
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20
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Scholte NTB, van Wees C, Rietdijk WJR, van der Graaf M, Jewbali LSD, van der Jagt M, van den Berg RCM, Lenzen MJ, den Uil CA. Clinical Outcomes with Targeted Temperature Management (TTM) in Comatose Out-of-Hospital Cardiac Arrest Patients-A Retrospective Cohort Study. J Clin Med 2022; 11:jcm11071786. [PMID: 35407394 PMCID: PMC8999846 DOI: 10.3390/jcm11071786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 03/22/2022] [Accepted: 03/23/2022] [Indexed: 01/23/2023] Open
Abstract
Purpose: we evaluated the effects of the shift of a targeted temperature management (TTM) strategy from 33 °C to 36 °C in comatose out-of-hospital cardiac arrest (OHCA) patients admitted to the Intensive Care Unit (ICU). Methods: we performed a retrospective study of all comatose (GCS < 8) OHCA patients treated with TTM from 2010 to 2018 (n = 798) from a single-center academic hospital. We analyzed 90-day mortality, and neurological outcome (CPC score) at ICU discharge and ICU length of stay, as primary and secondary outcomes, respectively. Results: we included 798 OHCA patients (583 in the TTM33 group and 215 in the TTM36 group). We found no association between the TTM strategy (TTM33 and TTM36) and 90-day mortality (hazard ratio (HR)] 0.877, 95% CI 0.677−1.135, with TTM36 as reference). Also, no association was found between TTM strategy and favorable neurological outcome at ICU discharge (odds ratio (OR) 1.330, 95% CI 0.941−1.879). Patients in the TTM33 group had on average a longer ICU LOS (beta 1.180, 95% CI 0.222−2.138). Conclusion: no differences in clinical outcomes—both 90-day mortality and favorable neurological outcome at ICU discharge—were found between targeted temperature at 33 °C and 36 °C. These results may help to corroborate previous trial findings and assist in implementation of TTM.
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Affiliation(s)
- Niels T. B. Scholte
- Department of Cardiology, Erasmus MC—University Medical Center, 3015 GD Rotterdam, The Netherlands; (C.v.W.); (M.v.d.G.); (L.S.D.J.); (M.J.L.)
- Correspondence:
| | - Christiaan van Wees
- Department of Cardiology, Erasmus MC—University Medical Center, 3015 GD Rotterdam, The Netherlands; (C.v.W.); (M.v.d.G.); (L.S.D.J.); (M.J.L.)
- Department of Intensive Care, Erasmus MC—University Medical Center, 3015 GD Rotterdam, The Netherlands;
| | - Wim J. R. Rietdijk
- Department of Hospital Pharmacy, Erasmus MC—University Medical Center, 3015 GD Rotterdam, The Netherlands;
| | - Marisa van der Graaf
- Department of Cardiology, Erasmus MC—University Medical Center, 3015 GD Rotterdam, The Netherlands; (C.v.W.); (M.v.d.G.); (L.S.D.J.); (M.J.L.)
| | - Lucia S. D. Jewbali
- Department of Cardiology, Erasmus MC—University Medical Center, 3015 GD Rotterdam, The Netherlands; (C.v.W.); (M.v.d.G.); (L.S.D.J.); (M.J.L.)
- Department of Intensive Care, Erasmus MC—University Medical Center, 3015 GD Rotterdam, The Netherlands;
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus MC—University Medical Center, 3015 GD Rotterdam, The Netherlands;
| | | | - Mattie J. Lenzen
- Department of Cardiology, Erasmus MC—University Medical Center, 3015 GD Rotterdam, The Netherlands; (C.v.W.); (M.v.d.G.); (L.S.D.J.); (M.J.L.)
| | - Corstiaan A. den Uil
- Department of Intensive Care, Maasstad Hospital, 3079 DZ Rotterdam, The Netherlands;
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Shaheen FAM, Meunier A, Altowaijri A, Faadhel TA, Al-Abdulkarim H, AlGabash A, Floros L. Cost Consequence Analysis of the Management of Hyperkalemia by Patiromer and Optimization of Renin-Angiotensin-Aldosterone System Inhibitors Therapy in Chronic Kidney Disease Patients in Saudi Arabia. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2022; 33:S39-S52. [PMID: 37102523 DOI: 10.4103/1319-2442.374381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023] Open
Abstract
Renin-angiotensin-aldosterone system inhibitors (RAASi) have been shown to improve outcomes in chronic kidney disease (CKD) patients but are associated with an increased risk of hyperkalemia in this vulnerable population. Hyperkalemia often leads to patients' downtitrating or discontinuing RAASi which can result in sub-optimal health outcomes. The objective is to evaluate the cost and health benefits of maintaining normokalemia using patiromer, an oral potassium binder while optimizing RAASi therapy in CKD patients in the Kingdom of Saudi Arabia. The medium-to long-term costs and health outcomes of patients with CKD stage 3-4 and raised serum potassium levels (≥5.5 mmol/L) at baseline were estimated, from a Saudi Arabia payer perspective, using a Markov state-transition model simulating the natural progression of CKD depending on patients' serum potassium level and usage of RAASi at different dosages. The analysis demonstrated that appropriate management of hyperkalemia, enabling optimization of RAASi, leads to cost and health benefits. The cost of patiromer is offset by 68% due to a reduction in management costs associated with CKD progression, hyperkalemia-related hospitalization, and cardiovascular (CV) events. Over a 10-year time horizon, a pool of 300 patients treated with patiromer experience increased life-expectancy [+3.78 life-years (LYs)] and slower disease progression, with decreased time spent in end-stage renal disease (-9.59 LYs). Patiromer may deliver value to both CKD patients and payers in Saudi Arabia, leading to better health outcomes for the former and reduced cost of management of CKD progression and CV events at low additional costs for the latter.
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Affiliation(s)
| | | | | | - Talal Al Faadhel
- Division of Nephrology, King Saud University, Riyadh, Saudi Arabia
| | - Hana Al-Abdulkarim
- Drug Policy and Economics Center, National Guard Health Affairs, Riyadh, Saudi Arabia
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22
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Shrestha DB, Sedhai YR, Budhathoki P, Gaire S, Adhikari A, Poudel A, Aryal BB, Yadullahi Mir WA, Dahal K, Kashiouris MG. Hypothermia versus normothermia after out-of-hospital cardiac arrest: A systematic review and meta-analysis of randomized controlled trials. Ann Med Surg (Lond) 2022; 74:103327. [PMID: 35145684 PMCID: PMC8818536 DOI: 10.1016/j.amsu.2022.103327] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 01/23/2022] [Accepted: 01/25/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The current guidelines recommend targeted temperature management (TTM) as part of the post-resuscitation care for comatose patients following out-of-hospital cardiac arrest. These recommendations are based on the weak evidence of benefit seen in the early clinical trials. Recent large multicentered trials have failed to show a meaningful clinical benefit of hypothermia, unlike the earlier studies. Thus, to fully appraise the available data, we sought to perform this systematic review and meta-analysis of randomized controlled trials. METHODS We searched four databases for randomized controlled trials comparing therapeutic hypothermia (32-34 °C) with normothermia (≥36 °C with control of fever) in adult patients resuscitated after out-of-hospital cardiac arrest. Independent reviewers did the title and abstract screening, full-text screening, and extraction. The primary outcome was mortality six months after cardiac arrest, and secondary outcomes were neurological outcomes and adverse effects. RELEVANCE FOR PATIENTS Six randomized controlled trials were included in this review. There was no significant difference between the hypothermia and normothermia groups in mortality till 6 months follow up after out-of-hospital cardiac arrest (OR 0.88, 95% CI 0.67-1.16; n = 3243; I2 = 51%), or favorable neurological outcome (OR 1.31, 95% CI 0.93-1.84; n = 3091; I2 = 68%). Rates of arrhythmias were notably higher in the hypothermia group than the normothermia group (OR 1.43, 95% CI 1.20-1.71; n = 3029; I2 = 4%). However, odds for development of pneumonia showed no significant differences across two groups (OR 1.13, 95% CI 0.98-1.31; n = 3056; I2 = 22%). Therefore, targeted hypothermia with a target temperature of 32-34 °C does not provide mortality benefit or better neurological outcome in patients resuscitated after the out-of-hospital cardiac arrest when compared with normothermia.
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Key Words
- AHA, American Heart Association
- CI, Confidence interval
- ESC, European resuscitation council
- IHCA, In-hospital cardiac arrest
- Induced Hypothermia
- OHCA, Out-of-hospital cardiac arrest
- OR, Odds ratio
- Out-of-hospital cardiac arrest
- PRISMA, Preferred Reporting Items for Systematic Review and Meta-Analysis
- RCTs, Randomized controlled trials
- ROSC, Return of spontaneous circulation
- TH, Therapeutic hypothermia
- TTM, Targeted temperature management
- Temperature
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Affiliation(s)
| | - Yub Raj Sedhai
- Department of Internal Medicine, Division of Hospital Medicine, Virginia Commonwealth University, School of Medicine, Richmond, VA, USA
| | - Pravash Budhathoki
- Department of Internal Medicine, Bronxcare Health System, Bronx, NY, USA
| | - Suman Gaire
- Department of Emergency Medicine, Palpa Hospital, Palpa, Nepal
| | - Anurag Adhikari
- Department of Emergency Medicine, Nepal National Hospital, Kathmandu, Nepal
| | - Ayusha Poudel
- Department of Emergency Medicine, Alka Hospital, Kathmandu, Nepal
| | | | | | - Khagendra Dahal
- Department of Internal Medicine, Division of Cardiology, Creighton University School of Medicine, Omaha, NE, USA
| | - Markos G. Kashiouris
- Department of Internal Medicine, Division of Pulmonary Disease and Critical Care Medicine, VCU School of Medicine, Richmond, VA, USA
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23
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Byrne C, Pareek M, Krogager ML, Ringgren KB, Wissenberg M, Folke F, Lippert F, Gislason G, Køber L, Søgaard P, Lip GYH, Torp-Pedersen C, Kragholm K. Increased 5-year risk of stroke, atrial fibrillation, acute coronary syndrome, and heart failure in out-of-hospital cardiac arrest survivors compared with population controls: A nationwide registry-based study. Resuscitation 2021; 169:53-59. [PMID: 34695442 DOI: 10.1016/j.resuscitation.2021.10.024] [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: 08/08/2021] [Revised: 09/30/2021] [Accepted: 10/15/2021] [Indexed: 01/18/2023]
Abstract
AIM Long-term risks of stroke, atrial fibrillation, or flutter (AF), acute coronary syndrome (ACS), and heart failure (HF) among survivors of out-of-hospital cardiac arrest (OHCA) are unknown. We aimed to examine 5-year risks of these outcomes among 30-day survivors of OHCA. METHODS Thirty-day survivors of OHCA without a prior (or within 30 days after cardiac arrest) history of stroke, AF, ACS, or HF and population controls without a prior history of these conditions were identified using Danish nationwide registries. Five-year risks of stroke, AF, ACS, and HF standardized to the distributions of age, sex, and comorbidities among OHCA survivors and controls were obtained using multivariable regression. RESULTS Of 4,362 30-day OHCA-survivors, 1,051 were stroke-, AF-, ACS-, and HF-naïve and matched with controls using age, sex, and time of OHCA event. Absolute five-year risks for OHCA survivors vs. controls were for stroke: 6.3% [95% confidence interval (CI) 4.1-8.5] vs. 2.0% [1.6-2.5], AF: 7.9% [5.7-10.2] vs. 2.6% [2.1-3.1], ACS: 5.0% [3.2-6.8] vs. 1.5% [1.1-1.9], and HF: 12.7% [10.1-15.4] vs. 1.2% [0.9-1.6], respectively. Corresponding relative risks were 3.18 [95% CI 1.76-4.61] for stroke, 3.03 [1.93-4.14] for AF, 3.23 [1.69-4.77] for ACS, and 10.40 [6.57-14.13] for HF. CONCLUSION When compared with population controls, OHCA survivors had significantly increased five-year risks of incident stroke, AF, ACS, and HF.
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Affiliation(s)
- Christina Byrne
- Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark.
| | - Manan Pareek
- Department of Cardiology, North Zealand Hospital, Hillerød, Denmark
| | | | | | - Mads Wissenberg
- Department of Cardiology, Herlev Gentofte University Hospital, Denmark
| | - Fredrik Folke
- Department of Cardiology, Herlev Gentofte University Hospital, Denmark; Copenhagen Emergency Medical Services, University of Copenhagen, Denmark
| | - Freddy Lippert
- Copenhagen Emergency Medical Services, University of Copenhagen, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Herlev Gentofte University Hospital, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Peter Søgaard
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom, and Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - Kristian Kragholm
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
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24
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Granfeldt A, Holmberg MJ, Nolan JP, Soar J, Andersen LW. Targeted temperature management in adult cardiac arrest: Systematic review and meta-analysis. Resuscitation 2021; 167:160-172. [PMID: 34474143 DOI: 10.1016/j.resuscitation.2021.08.040] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 08/22/2021] [Indexed: 02/04/2023]
Abstract
AIM To perform a systematic review and meta-analysis on targeted temperature management in adult cardiac arrest patients. METHODS PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched on June 17, 2021 for clinical trials. The population included adult patients with cardiac arrest. The review included all aspects of targeted temperature management including timing, temperature, duration, method of induction and maintenance, and rewarming. Two investigators reviewed trials for relevance, extracted data, and assessed risk of bias. Data were pooled using random-effects models. Certainty of evidence was evaluated using GRADE. RESULTS The systematic search identified 32 trials. Risk of bias was assessed as intermediate for most of the outcomes. For targeted temperature management with a target of 32-34 °C vs. normothermia (which often required active cooling), 9 trials were identified, with six trials included in meta-analyses. Targeted temperature management with a target of 32-34 °C did not result in an improvement in survival (risk ratio: 1.08 [95%CI: 0.89, 1.30]) or favorable neurologic outcome (risk ratio: 1.21 [95%CI: 0.91, 1.61]) at 90 to 180 days after the cardiac arrest (low certainty of evidence). Three trials assessed different hypothermic temperature targets and found no difference in outcomes (low certainty of evidence). Ten trials were identified comparing prehospital cooling vs. no prehospital cooling with no improvement in survival (risk ratio: 1.01 [95%CI: 0.92, 1.11]) or favorable neurologic outcome (risk ratio: 1.00 [95%CI: 0.90, 1.11]) at hospital discharge (moderate certainty of evidence). CONCLUSIONS Among adult patients with cardiac arrest, the use of targeted temperature management at 32-34 °C, when compared to normothermia, did not result in improved outcomes in this meta-analysis. There was no effect of initiating targeted temperature management prior to hospital arrival. These findings warrant an update of international cardiac arrest guidelines.
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Affiliation(s)
- Asger Granfeldt
- Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Mathias J Holmberg
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark; Department of Cardiology, Viborg Regional Hospital, Viborg, Denmark
| | - Jerry P Nolan
- University of Warwick, Warwick Medical School, Coventry, United Kingdom; Royal United Hospital, Bath, United Kingdom
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
| | - Lars W Andersen
- Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark; Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark; Prehospital Emergency Medical Services, Central Denmark Region, Denmark.
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25
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Liu YY, Wang YP, Zu LY, Zheng K, Ma QB, Zheng YA, Gao W. Comparison of intraosseous access and central venous catheterization in Chinese adult emergency patients: A prospective, multicenter, and randomized study. World J Emerg Med 2021; 12:105-110. [PMID: 33728002 DOI: 10.5847/wjem.j.1920-8642.2021.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND It is challenging to establish peripheral intravenous access in adult critically patients. This study aims to compare the success rate of the first attempt, procedure time, operator satisfaction with the used devices, pain score, and complications between intraosseous (IO) access and central venous catheterization (CVC) in critically ill Chinese patients. METHODS In this prospective clustered randomized controlled trial, eight hospitals were randomly divided into either the IO group or the CVC group. Patients who needed emergency vascular access were included. From April 1, 2017 to December 31, 2018, each center included 12 patients. We recorded the data mentioned above. RESULTS A total of 96 patients were enrolled in the study. There were no statistically significant differences between the two groups regarding sex, age, body mass index, or operator satisfaction with the used devices. The success rates of the first attempt and the procedure time were statistically significant between the IO group and the CVC group (91.7% vs. 50.0%, P<0.001; 52.0 seconds vs. 900.0 seconds, P<0.001). During the study, 32 patients were conscious. There was no statistically significant difference between the two groups regarding the pain score associated with insertion. There were statistically significant differences between the two groups regarding the pain score associated with IO or CVC infusion (1.5 vs. 0.0, P=0.044). Complications were not observed in the two groups. CONCLUSIONS IO access is a safe, rapid, and effective technique for gaining vascular access in critically ill adults with inaccessible peripheral veins in the emergency departments.
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Affiliation(s)
- Yan-Yan Liu
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital; NHC Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides; Key Laboratory of Molecular Cardiovascular Sciences, Ministry of Education; Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing 100191, China
| | - Yu-Peng Wang
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital; NHC Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides; Key Laboratory of Molecular Cardiovascular Sciences, Ministry of Education; Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing 100191, China
| | - Ling-Yun Zu
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital; NHC Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides; Key Laboratory of Molecular Cardiovascular Sciences, Ministry of Education; Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing 100191, China
| | - Kang Zheng
- Department of Emergency Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Qing-Bian Ma
- Department of Emergency Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Ya-An Zheng
- Department of Emergency Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Wei Gao
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital; NHC Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides; Key Laboratory of Molecular Cardiovascular Sciences, Ministry of Education; Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing 100191, China
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26
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Lind PC, Johannsen CM, Vammen L, Magnussen A, Andersen LW, Granfeldt A. Translation from animal studies of novel pharmacological therapies to clinical trials in cardiac arrest: A systematic review. Resuscitation 2020; 158:258-269. [PMID: 33147523 DOI: 10.1016/j.resuscitation.2020.10.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 10/09/2020] [Accepted: 10/15/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND There is a lack of new promising therapies to improve the dismal outcomes from cardiac arrest. The objectives of this study were: (1) To identify novel pharmacological therapies investigated in experimental animal studies and (2) to identify pharmacological therapies translated from experimental animal studies to clinical trials. METHODS PubMed was searched to first identify relevant experimental cardiac arrest animal models published within the last 20 years. Based on this, a list of interventions was created and a second search was performed to identify clinical trials testing one of these interventions. Data extraction was performed using standardised data extraction forms. RESULTS We identified 415 animal studies testing 190 different pharmacological interventions. The most commonly tested interventions were classified as vasopressors, anaesthetics/gases, or interventions aimed at molecular targets. We found 43 clinical trials testing 26 different interventions identified in the animal studies. Of these, 13 trials reported positive findings and 30 trials reported neutral findings with regards to the primary endpoint. No study showed harm of the intervention. Some interventions tested in human clinical trials, had previously been tested in animal studies without a positive effect on outcomes. A large number of animal studies was performed after publication of a clinical trial. CONCLUSION Numerous different pharmacological interventions have been tested in experimental animal models. Despite this only a limited number of these interventions have advanced to clinical trials, however several of the clinical trials tested interventions that were first tested in experimental animal models.
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Affiliation(s)
- Peter Carøe Lind
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Lauge Vammen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Intensive Care and Anesthesiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Lars W Andersen
- Department of Intensive Care and Anesthesiology, Aarhus University Hospital, Aarhus, Denmark; Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark; Prehospital Emergency Medical Services, Central Denmark Region, Denmark
| | - Asger Granfeldt
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Intensive Care and Anesthesiology, Aarhus University Hospital, Aarhus, Denmark; Department of Anesthesiology and Intensive Care Medicine, Randers Regional Hospital, Randers, Denmark.
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Miller L, Gozalo‐Marcilla M, Culshaw G, Panti A. Successful transcutaneous pacing following ventricular standstill during anaesthetic induction in a dog with third‐degree atrioventricular block. VETERINARY RECORD CASE REPORTS 2020. [DOI: 10.1136/vetreccr-2020-001146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Lucy Miller
- Royal Dick School of Veterinary Studies and The Roslin InstituteThe University of EdinburghRoslin, MidlothianUK
| | - Miguel Gozalo‐Marcilla
- Royal Dick School of Veterinary Studies and The Roslin InstituteThe University of EdinburghRoslin, MidlothianUK
| | - Geoff Culshaw
- Royal Dick School of Veterinary Studies and The Roslin InstituteThe University of EdinburghRoslin, MidlothianUK
| | - Ambra Panti
- Royal Dick School of Veterinary Studies and The Roslin InstituteThe University of EdinburghRoslin, MidlothianUK
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Kim OH, Go SJ, Kwon OS, Park CY, Yu B, Chang SW, Jung PY, Lee GJ. Part 2. Clinical Practice Guideline for Trauma Team Composition and Trauma Cardiopulmonary Resuscitation from the Korean Society of Traumatology. JOURNAL OF TRAUMA AND INJURY 2020. [DOI: 10.20408/jti.2020.0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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The current temperature: A survey of post-resuscitation care across Australian and New Zealand intensive care units. Resusc Plus 2020; 1-2:100002. [PMID: 34223289 PMCID: PMC8244479 DOI: 10.1016/j.resplu.2020.100002] [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: 03/11/2020] [Revised: 04/16/2020] [Accepted: 04/18/2020] [Indexed: 11/22/2022] Open
Abstract
Aim Targeted temperature management (TTM) in post-resuscitation care has changed dramatically over the last two decades. However, uptake across Australian and New Zealand (NZ) intensive care units (ICUs) is unclear. We aimed to describe post-resuscitation care in our region, with a focus on TTM, and to gain insights into clinician's opinions about the level of evidence supporting TTM. Methods In December 2017, we sent an online survey to 163 ICU medical directors in Australia (n = 141) and NZ (n = 22). Results Sixty-one ICU medical directors responded (50 from Australia and 11 from NZ). Two respondents were excluded from analysis as their Private ICUs did not admit post-arrest patients. The majority of remaining respondents stated their ICU followed a post-resuscitation care clinical guideline (n = 41/59, 70%). TTM was used in 57 (of 59, 97%) ICUs, of these only 64% had a specific TTM clinical guideline/policy and there was variation in the types of patients treated, temperatures targeted (range = 33-37.5 °C), methods for cooling and duration of cooling (range = 12-72 h). The majority of respondents stated that their ICU (n = 45/57, 88%) changed TTM practice following the TTM trial: with 28% targeting temperatures >36 °C, and 23 (of 46, 50%) respondents expressed concerns with current level of evidence for TTM. Only 38% of post-resuscitation guidelines included prognostication procedures, few ICUs reported the use of electrophysiological tests. Conclusions In Australian and New Zealand ICUs there is widespread variation in post-resuscitation care, including TTM practice and prognostication. There also seems to be concerns with current TTM evidence and recommendations.
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Herrera-Perez D, Fox-Lee R, Bien J, Prasad V. Frequency of Medical Reversal Among Published Randomized Controlled Trials Assessing Cardiopulmonary Resuscitation (CPR). Mayo Clin Proc 2020; 95:889-910. [PMID: 32370852 DOI: 10.1016/j.mayocp.2020.01.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 01/31/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To characterize what proportion of all randomized controlled trials (RCTs) among patients experiencing cardiac arrest find that an established practice is ineffective or harmful, that is, a medical reversal. METHODS We reviewed a database of all published RCTs of cardiac arrest patient populations between 1995 and 2014. Articles were classified on the basis of whether they tested a new or existing therapy and whether results were positive or negative. A reversal was defined as a negative RCT of an established practice. Further review and categorization were performed to confirm that reversals were supported by subsequent systematic review, as well as to identify the type of medical practice studied in each reversal. This study was conducted from October 2017 to June 17, 2019. RESULTS We reviewed 92 original articles, 76 of which could be conclusively categorized. Of these, 18 (24%) articles examined a new medical practice, whereas 58 (76%) tested an established practice. A total of 18 (24%) studies had positive findings, whereas 58 (76%) reached a negative conclusion. Of the 58 articles testing existing standard of care, 44 (76%) reversed that practice, whereas 14 (24%) reaffirmed it. CONCLUSION Reversal of cardiopulmonary resuscitation practices is widespread. This investigation sheds new light on low-value practices and patterns of medical research and suggests that novel resuscitation practices have low pretest probability and should be empirically tested with rigorous trials before implementation.
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Affiliation(s)
- Diana Herrera-Perez
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland
| | - Ryan Fox-Lee
- School of Medicine, Oregon Health and Science University, Portland
| | - Jeffrey Bien
- School of Medicine, Oregon Health and Science University, Portland
| | - Vinay Prasad
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland; Center for Health Care Ethics, Oregon Health and Science University, Portland.
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Automated external defibrillator use and outcomes after out-of-hospital cardiac arrest: an Israeli cohort study. Coron Artery Dis 2020; 31:289-292. [DOI: 10.1097/mca.0000000000000807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Chan WH, Cheng CP, Chiu YL, Hsu YC, Hu MH, Huang GS. Two head positions for orotracheal intubation with the trachway videolight intubating stylet with manual in-line stabilization: A randomized controlled trial. Medicine (Baltimore) 2020; 99:e19645. [PMID: 32332608 PMCID: PMC7220508 DOI: 10.1097/md.0000000000019645] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 02/25/2020] [Accepted: 02/25/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The Trachway Videolight Intubating Stylet is a video-assisted system with a rigid but malleable intubating stylet that facilitates endotracheal intubation. Minimizing cervical spine movement with manual in-line stabilization is essential for patients with cervical spine injuries such as multiple trauma. However, the intubation time of the Trachway Videolight Intubating Stylet and complications associated with intubation in patients with manual in-line stabilization in the neutral-head and head-lift positions remain unclear. METHODS Patients (20-80 years old) who were scheduled to undergo surgery that required general anesthesia with tracheal intubation were randomly allocated to either a neutral-head (n = 62) or a head-lift position (n = 62) group. Manual in-line stabilization was performed to limit cervical spine mobility. We aimed to evaluate orotracheal intubation time and success rate in these 2 positions with the Trachway Videolight Intubating Stylet. RESULTS Intubation was faster in the head-lift than in the neutral-head position (20 ± 10 and 25 ± 13 seconds, respectively, P = .000); intubation was equally successful in the 2 positions (96.8% vs 96.8%). Responses to intubation did not differ between positions (heart rate, P = .142; visual analog scale scores for throat soreness, P = .54). The only significant predictor of intubation time was the body mass index in the head-lift position group (P = .005). CONCLUSIONS Intubation using the Trachway Videolight Intubating Stylet with manual in-line stabilization is faster in the head-lift position, and therefore preferable. However, if the head-lift position is not suitable, the neutral-head position is a sensible alternative, with comparable intubation success rate, heart rate change, and postoperative throat soreness.
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Affiliation(s)
- Wei-Hung Chan
- Department of Anesthesiology, Tri-Service General Hospital
| | - Chiao-Pei Cheng
- Department of Anesthesiology, Tri-Service General Hospital
- Graduate Institute of Medical Sciences
| | - Yu-Lung Chiu
- Graduate Institute of Medical Sciences
- School of Public Health, National Defense Medical Center, Taipei
| | - Yung-Chi Hsu
- Department of Anesthesiology, Tri-Service General Hospital
| | - Mei-Hua Hu
- Division of Pediatric General Medicine, Chang Gung Memorial Hospital, LinKou Branch
- Graduate Institute of Clinical Medical Sciences, College of Medicine
- School of Traditional Chinese Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Go-Shine Huang
- Department of Anesthesiology, Tri-Service General Hospital
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Kim JG, Shin H, Choi HY, Kim W, Kim J, Moon S, Kim B, Ahn C, Lee J. Prognostic factors for neurological outcomes in Korean targeted temperature management recipients with return of spontaneous circulation after out-of-hospital cardiac arrests: A nationwide observational study. Medicine (Baltimore) 2020; 99:e19581. [PMID: 32282707 PMCID: PMC7440340 DOI: 10.1097/md.0000000000019581] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Targeted temperature management (TTM) is recommended for comatose patients after out-of-hospital cardiac arrests (OHCAs). Even after successful TTM, several factors could influence the neuroprotective effect of TTM. The aim of this study is to identify prognostic factors associated with good neurological outcomes in TTM recipients.This study used nationwide data during 2012 to 2016 to investigate prognostic factors associated with good neurological outcomes in patients who received TTM after the return of spontaneous circulation (ROSC). Multivariate logistic regression analysis was conducted to analyse the factors that may affect the neurological outcomes in the TTM recipients.The study included 1578 eligible patients, comprising 767 with good and 811 with poor neurological outcomes. Multivariable analyses showed that OHCA in public places (OR, 1.599; 95% CI, 1.100-2.323, P = .014), initial shockable rhythms (OR, 1.721; 95% CI, 1.191-2.486, P = .004), pre-hospital ROSCs (OR, 6.748; 95% CI, 4.703-9.682, P < .001), bystander cardiopulmonary resuscitation (CPR) (OR, 1.715; 95% CI, 1.200-2.450, P = .003), and primary coronary interventions (PCIs) (OR, 2.488; 95% CI, 1.639-3.778, P < .001) were statistically significantly associated with good neurological outcomes. Whereas, increase of age (OR, 0.962; 95% CI, 0.950-0.974, P < .001) and conventional cooling (OR, 0.478; 95% CI, 0.255-0.895, P = .021) were statistically significantly associated with poor neurological outcome.This study suggests that being younger, experiencing OHCA in public places, having initial shockable rhythm, pre-hospital ROSC, and bystander CPR, implementing PCIs and applying intravascular or surface cooling devices compared to conventional cooling method could predict good neurological outcomes in post-cardiac arrest patients who received TTM.
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Affiliation(s)
- Jae Guk Kim
- Department of Emergency Medicine, Hallym University College of Medicine
- Department of Emergency Medicine, Graduate School of Medicine, Kangwon National University, Chuncheon
| | - Hyungoo Shin
- Department of Emergency Medicine, Hanyang University College of Medicine, Hanyang University Guri Hospital, Guri
| | - Hyun Young Choi
- Department of Emergency Medicine, Hallym University College of Medicine
| | - Wonhee Kim
- Department of Emergency Medicine, Hallym University College of Medicine
| | - Jihoon Kim
- Department of Thoracic and Cardiovascular Surgery, Hallym University College of Medicine, Chuncheon
| | - Shinje Moon
- Department of Internal Medicine, Hallym University College of Medicine
| | - Bongyoung Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul
| | - Chiwon Ahn
- Department of Emergency Medicine, Armed Force Yangju Hospital, Yangju
| | - Juncheol Lee
- Department of Emergency Medicine, Armed Force Capital Hospital, Seongnam, Republic of Korea
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Baert V, Vilhelm C, Escutnaire J, Nave S, Hugenschmitt D, Chouihed T, Tazarourte K, Javaudin F, Wiel E, El Khoury C, Hubert H. Intraosseous Versus Peripheral Intravenous Access During Out-of-Hospital Cardiac Arrest: a Comparison of 30-Day Survival and Neurological Outcome in the French National Registry. Cardiovasc Drugs Ther 2020; 34:189-197. [DOI: 10.1007/s10557-020-06952-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Intravenous vs. intraosseous administration of drugs during cardiac arrest: A systematic review. Resuscitation 2020; 149:150-157. [PMID: 32142750 DOI: 10.1016/j.resuscitation.2020.02.025] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 02/12/2020] [Accepted: 02/19/2020] [Indexed: 01/22/2023]
Abstract
AIM To perform a systematic review of the literature on intravenous (IV) vs. intraosseous (IO) administration of drugs during cardiac arrest in order to inform an update of international guidelines. METHODS The review was performed according to PRISMA guidelines and registered on PROSPERO. Medline, Embase and Evidence-Based Medicine Reviews were searched on December 17, 2019 for studies comparing IV to IO administration of drugs. The population included neonatal, paediatric, and adult patients with cardiac arrest. Two investigators reviewed each search for study relevance, extracted data, and assessed the risk of bias of individual studies. Meta-analyses were performed for studies without a critical risk of bias. Certainty of evidence was evaluated using GRADE. RESULTS We included six observational studies comparing IV to IO administration of drugs and two randomized trials assessing the effect of specific drugs in subgroups related to IV vs. IO administration. All studies included adult out-of-hospital cardiac arrest patients. No studies were identified in neonatal or paediatric patients. The risk of bias for the observational studies was overall assessed as critical or serious, with confounding and selection bias being the primary sources of bias. The meta-analyses excluding studies with a critical risk of bias favoured IV access for all outcomes. Using GRADE, the certainty of evidence was judged at very low. Subgroup analyses of the two randomized trials demonstrated no statistically significant interactions between the route of access and study drugs on outcomes. However, these trials were underpowered to assess such interactions. CONCLUSIONS We identified a limited number of studies comparing IV vs. IO administration of drugs during cardiac arrest. Pooled results from four observational studies favoured IV access with very low certainty of evidence. From the subgroup analyses of two randomized clinical trials, there was no statistically significant interaction between the route of access and study drug on outcomes.
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Kim JG, Ahn C, Shin H, Kim W, Lim TH, Jang BH, Cho Y, Choi KS, Lee J, Na MK. Efficacy of the cooling method for targeted temperature management in post-cardiac arrest patients: A systematic review and meta-analysis. Resuscitation 2020; 148:14-24. [DOI: 10.1016/j.resuscitation.2019.12.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 11/06/2019] [Accepted: 12/03/2019] [Indexed: 12/14/2022]
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Al-Mulhim MA, Alshahrani MS, Asonto LP, Abdulhady A, Almutairi TM, Hajji M, Alrubaish MA, Almulhim KN, Al-Sulaiman MH, Al-Qahtani LB. Impact of epinephrine administration frequency in out-of-hospital cardiac arrest patients: a retrospective analysis in a tertiary hospital setting. J Int Med Res 2019; 47:4272-4283. [PMID: 31311363 PMCID: PMC6753528 DOI: 10.1177/0300060519860952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Introduction Epinephrine is recommended for patients with out-of-hospital cardiac arrest
(OHCA). However, whether epinephrine improves or adversely affects OHCA
outcomes is controversial. Objectives This study aims to determine whether the frequency of epinephrine
administration impacts OHCA patient survival. Methods We conducted a retrospective analysis of OHCA cases registered in the
Emergency Department at King Fahd University Hospital, Saudi Arabia between
2005 and 2015. The primary outcomes were mortality and survival rates until
discharge. The impact of epinephrine administration timing and frequency on
patient survival was analyzed. Results Data from 300 OHCA cases were analyzed. Among them, 66.3% were men, and the
overall mean age of 50.4 ± 20.6 years. The overall survival rate until
hospital discharge was 12%. There was no statistically significant
difference between in gender, age, or time interval to the first epinephrine
dose in the survival and non-survival groups. Only the number of epinephrine
doses was related to the survival outcome. Conclusion Non-survivors received significantly more epinephrine doses compared with
survivors. However, a causal relationship between OHCA patient survival and
epinephrine dose and time cannot be confirmed. Further studies are needed to
investigate whether the long-term outcomes in OHCA patients are influenced
by the timing and frequency of epinephrine administration.
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Affiliation(s)
- Mohammed A Al-Mulhim
- College of Medicine, Imam Abdulrahman Bin Faisal University, Kingdom of Saudi Arabia
| | - Mohammed S Alshahrani
- College of Medicine, Imam Abdulrahman Bin Faisal University, Kingdom of Saudi Arabia
| | - Laila Perlas Asonto
- College of Medicine, Imam Abdulrahman Bin Faisal University, Kingdom of Saudi Arabia
| | - Ahmad Abdulhady
- College of Medicine, Imam Abdulrahman Bin Faisal University, Kingdom of Saudi Arabia
| | - Talal M Almutairi
- College of Medicine, Imam Abdulrahman Bin Faisal University, Kingdom of Saudi Arabia
| | | | - Mohammed A Alrubaish
- College of Medicine, Imam Abdulrahman Bin Faisal University, Kingdom of Saudi Arabia
| | - Khalid N Almulhim
- College of Medicine, King Faisal University, Al-Ahsa, Kingdom of Saudi Arabia
| | | | - Layla B Al-Qahtani
- Children's Specialist Hospital, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
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Humaloja J, Litonius E, Efendijev I, Folger D, Raj R, Pekkarinen PT, Skrifvars MB. Early hyperoxemia is not associated with cardiac arrest outcome. Resuscitation 2019; 140:185-193. [PMID: 31039393 DOI: 10.1016/j.resuscitation.2019.04.035] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 04/14/2019] [Accepted: 04/22/2019] [Indexed: 01/20/2023]
Abstract
AIM Studies suggest that hyperoxemia increases short-term mortality after cardiopulmonary resuscitation (CPR), but the effect of hyperoxemia on long-term outcomes is unclear. We determined the prevalence of early hyperoxemia after CPR and its association with long-term neurological outcome and mortality. METHODS We analysed data from adult cardiac arrest patients treated after CPR in tertiary ICUs during 2005-2013. We retrieved data from the resuscitation and the first arterial blood sample collected after return of spontaneous circulation (ROSC) (severe hyperoxemia defined as PaO2 > 40 kPa and moderate as PaO2 16-40 kPa). We inspected two outcomes, neurological performance at one year after resuscitation according to the Cerebral Performance Category and one-year mortality. We used logistic regression to test associations between hyperoxemia and the outcome and interaction analyses to test the effect of hyperoxemia exposure on the outcomes in smaller subgroups. RESULTS Of 1110 patients 11% had severe hyperoxemia, prevalence was 10% for out-of-hospital arrests, 13% for in-hospital arrests and 9% for in-ICU arrests. In total 585(53%) patients had an unfavourable neurological outcome. Compared to normoxemia, severe (Odds ratio [OR] 0.81, 95% confidence interval [CI] 0.50-1.30) and moderate hyperoxemia (OR 0.94 95%CI 0.69-1.27) did not associate with neurological outcome. Additionally, hyperoxemia had no association with mortality. In subgroup analyses there were no significant associations between severe hyperoxemia and outcomes regardless of cardiac arrest location, initial rhythm or time-to-ROSC. CONCLUSION We found no association between early post-arrest hyperoxemia and unfavourable outcome. Subgroup analysis found no differential effect depending on arrest location, initial rhythm or time-to-ROSC.
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Affiliation(s)
- Jaana Humaloja
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Finland.
| | - Erik Litonius
- Division of Intensive Care Medicine, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Finland
| | - Ilmar Efendijev
- Division of Intensive Care Medicine, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Finland
| | - Daniel Folger
- Division of Intensive Care Medicine, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Finland
| | - Rahul Raj
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Finland
| | - Pirkka T Pekkarinen
- Division of Intensive Care Medicine, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Finland
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Finland; Division of Intensive Care Medicine, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Finland
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Andrews PJ, Sinclair HL, Rodríguez A, Harris B, Rhodes J, Watson H, Murray G. Therapeutic hypothermia to reduce intracranial pressure after traumatic brain injury: the Eurotherm3235 RCT. Health Technol Assess 2019; 22:1-134. [PMID: 30168413 DOI: 10.3310/hta22450] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major cause of disability and death in young adults worldwide. It results in around 1 million hospital admissions annually in the European Union (EU), causes a majority of the 50,000 deaths from road traffic accidents and leaves a further ≈10,000 people severely disabled. OBJECTIVE The Eurotherm3235 Trial was a pragmatic trial examining the effectiveness of hypothermia (32-35 °C) to reduce raised intracranial pressure (ICP) following severe TBI and reduce morbidity and mortality 6 months after TBI. DESIGN An international, multicentre, randomised controlled trial. SETTING Specialist neurological critical care units. PARTICIPANTS We included adult participants following TBI. Eligible patients had ICP monitoring in place with an ICP of > 20 mmHg despite first-line treatments. Participants were randomised to receive standard care with the addition of hypothermia (32-35 °C) or standard care alone. Online randomisation and the use of an electronic case report form (CRF) ensured concealment of random treatment allocation. It was not possible to blind local investigators to allocation as it was obvious which participants were receiving hypothermia. We collected information on how well the participant had recovered 6 months after injury. This information was provided either by the participant themself (if they were able) and/or a person close to them by completing the Glasgow Outcome Scale - Extended (GOSE) questionnaire. Telephone follow-up was carried out by a blinded independent clinician. INTERVENTIONS The primary intervention to reduce ICP in the hypothermia group after randomisation was induction of hypothermia. Core temperature was initially reduced to 35 °C and decreased incrementally to a lower limit of 32 °C if necessary to maintain ICP at < 20 mmHg. Rewarming began after 48 hours if ICP remained controlled. Participants in the standard-care group received usual care at that centre, but without hypothermia. MAIN OUTCOME MEASURES The primary outcome measure was the GOSE [range 1 (dead) to 8 (upper good recovery)] at 6 months after the injury as assessed by an independent collaborator, blind to the intervention. A priori subgroup analysis tested the relationship between minimisation factors including being aged < 45 years, having a post-resuscitation Glasgow Coma Scale (GCS) motor score of < 2 on admission, having a time from injury of < 12 hours and patient outcome. RESULTS We enrolled 387 patients from 47 centres in 18 countries. The trial was closed to recruitment following concerns raised by the Data and Safety Monitoring Committee in October 2014. On an intention-to-treat basis, 195 participants were randomised to hypothermia treatment and 192 to standard care. Regarding participant outcome, there was a higher mortality rate and poorer functional recovery at 6 months in the hypothermia group. The adjusted common odds ratio (OR) for the primary statistical analysis of the GOSE was 1.54 [95% confidence interval (CI) 1.03 to 2.31]; when the GOSE was dichotomised the OR was 1.74 (95% CI 1.09 to 2.77). Both results favoured standard care alone. In this pragmatic study, we did not collect data on adverse events. Data on serious adverse events (SAEs) were collected but were subject to reporting bias, with most SAEs being reported in the hypothermia group. CONCLUSIONS In participants following TBI and with an ICP of > 20 mmHg, titrated therapeutic hypothermia successfully reduced ICP but led to a higher mortality rate and worse functional outcome. LIMITATIONS Inability to blind treatment allocation as it was obvious which participants were randomised to the hypothermia group; there was biased recording of SAEs in the hypothermia group. We now believe that more adequately powered clinical trials of common therapies used to reduce ICP, such as hypertonic therapy, barbiturates and hyperventilation, are required to assess their potential benefits and risks to patients. TRIAL REGISTRATION Current Controlled Trials ISRCTN34555414. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 45. See the NIHR Journals Library website for further project information. The European Society of Intensive Care Medicine supported the pilot phase of this trial.
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Affiliation(s)
- Peter Jd Andrews
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - H Louise Sinclair
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Aryelly Rodríguez
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Bridget Harris
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | | | | | - Gordon Murray
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
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Olsen JA, Brunborg C, Steinberg M, Persse D, Sterz F, Lozano M, Westfall M, van Grunsven PM, Lerner EB, Wik L. Survival to hospital discharge with biphasic fixed 360 joules versus 200 escalating to 360 joules defibrillation strategies in out-of-hospital cardiac arrest of presumed cardiac etiology. Resuscitation 2019; 136:112-118. [PMID: 30708074 DOI: 10.1016/j.resuscitation.2019.01.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 01/02/2019] [Accepted: 01/18/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Guidelines recommend constant or escalating energy levels for shocks after the initial defibrillation attempt. Studies comparing survival to hospital discharge with escalating vs fixed high energy level shocks are lacking. We compared survival to hospital discharge for 200 J escalating to 360 J vs fixed 360 J in patients with initial ventricular fibrillation/pulseless ventricular tachycardia in a post-hoc analysis of the Circulation Improving Resuscitation Care trial database. METHODS AND RESULTS Pre-shock rhythm, rhythm 5 s after shock, shock energy levels, termination of ventricular fibrillation/pulseless ventricular tachycardia (TOF), and survival to hospital discharge were recorded. Association between defibrillation strategy and survival to hospital discharge was investigated with multivariable logistic regression. The escalating energy group included 260 patients and 883 shocks vs 478 patients and 1736 shocks in the fixed-high energy group. There was no difference in survival to hospital discharge between escalating (70/255 patients, 28%) and fixed energy group (132/478 patients, 28%) (unadjusted OR 1.00, 95% CI 0.72-1.42 and adjusted OR 0.81, 95% CI 0.54-1.22, p = 0.32). First shock TOF was 86% in the escalating group compared to 83% in the fixed-high group, p = 0.27. CONCLUSION There was no difference in survival to hospital discharge or the frequency of TOF between escalating energy and fixed-high energy group. ClinicalTrials.gov Identifier: NCT00597207.
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Affiliation(s)
- Jan-Aage Olsen
- Norwegian National Advisory Unit on Prehospital Emergency Medicine, Oslo University Hospital, Oslo, Norway; Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Cathrine Brunborg
- Department of Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
| | - Mikkel Steinberg
- Norwegian National Advisory Unit on Prehospital Emergency Medicine, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - David Persse
- Houston Fire Department and the Baylor College of Medicine, Houston, TX, United States
| | - Fritz Sterz
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Michael Lozano
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, United States
| | - Mark Westfall
- Gold Cross Ambulance Service, Appleton Neenah-Menasha and Grand Chute Fire Departments, WI, United States; Theda Clark Regional Medical Center, Neenah, WI, United States
| | | | - E Brooke Lerner
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Lars Wik
- Norwegian National Advisory Unit on Prehospital Emergency Medicine, Oslo University Hospital, Oslo, Norway.
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Mcgloughlin SA, Udy A, O'Donoghue S, Bandeshe H, Gowardman JR. Therapeutic Hypothermia following Out-Of-Hospital Cardiac Arrest (Ohca): An Audit of Compliance at a Large Australian Hospital. Anaesth Intensive Care 2019; 40:844-9. [DOI: 10.1177/0310057x1204000512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- S. A. Mcgloughlin
- Department of Intensive Care, Royal Brisbane Hospital, Herston, Queensland, Australia
| | - A. Udy
- Department of Intensive Care, Royal Brisbane Hospital, Herston, Queensland, Australia
| | - S. O'Donoghue
- Department of Intensive Care, Royal Brisbane Hospital, Herston, Queensland, Australia
| | - H. Bandeshe
- Department of Intensive Care, Royal Brisbane Hospital, Herston, Queensland, Australia
| | - J. R. Gowardman
- Department of Intensive Care, Royal Brisbane Hospital, Herston, Queensland, Australia
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Abstract
Recognizing and acting early on airway compromise reduces morbidity and mortality in patients with airway obstruction. Causes include foreign bodies, toxic/hot fumes, difficult intubation, laryngeal spasm, and tumors. Before definitive control of the airway is possible, provide 100% oxygen with a tightly fitting mask to optimize body oxygen stores. Pulse oximetry is a poor indicator of airway compromise; a decreasing arterial hemoglobin oxygen saturation is a late sign of impending hypoxemia. Basic airway maneuvers improve the patency of an obstructed airway. Getting help from an anesthetist early is a priority.
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Benthem Y, van de Pol EMR, Draaisma JMT, Donders R, van Goor H, Tan ECTH. Professionalizing peer instructor skills in basic life support training for medical students: A randomized controlled trial. HONG KONG J EMERG ME 2018. [DOI: 10.1177/1024907918806644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: The Radboud university medical center designed an obligatory basic life support and first-aid course for first-year medical students. Objectives: We evaluated the value of an additional train-the-trainer course following European Resuscitation Council guidelines, which focuses on practical basic life support training and providing feedback, in comparison with standard in-service instructor training. Methods: This study was a prospective randomized controlled trial. A total of 10 intervention instructors, 14 control instructors, and 337 first-year medical students participated in the study. Students, blinded for the type of instructor, completed questionnaires evaluating the quality of the basic life support training (theoretical and practical) and provided feedback. The secondary endpoint was the basic life support examination to assess whether the instructors’ training influenced the quality of the participants’ basic life support. Results: The response rate of the questionnaire was 82% on average. No differences were found between intervention and control group concerning theoretical basic life support training. The intervention instructors scored significantly higher on practical basic life support training according to student evaluations ( p < 0.001). The pass rate on basic life support examinations did not differ significantly ( p = 0.669). Appreciation of given feedback was independent of instructors’ educational training. Conclusion: This study is the first to establish that the 12-h train-the-trainer course following European Resuscitation Council guidelines improves students’ appreciation of practical basic life support training. The additional course did not influence appreciation of theoretical basic life support training or perceived feedback.
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Affiliation(s)
- Yvet Benthem
- Department of Surgery, Radboud university medical center, Nijmegen, The Netherlands
| | - Eva MR van de Pol
- Department of Surgery, Radboud university medical center, Nijmegen, The Netherlands
| | - Jos MTh Draaisma
- Department of Paediatrics, Radboud university medical center, Nijmegen, The Netherlands
| | - Rogier Donders
- Department for Health Evidence, Radboud university medical center, Nijmegen, The Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud university medical center, Nijmegen, The Netherlands
| | - Edward CTH Tan
- Department of Surgery, Radboud university medical center, Nijmegen, The Netherlands
- Department of Emergency Medicine, Radboud university medical center, Nijmegen, The Netherlands
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44
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Khoshnood A. High time to omit oxygen therapy in ST elevation myocardial infarction. BMC Emerg Med 2018; 18:35. [PMID: 30342466 PMCID: PMC6196022 DOI: 10.1186/s12873-018-0187-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 10/11/2018] [Indexed: 12/23/2022] Open
Abstract
Supplemental oxygen (O2) therapy in patients with chest pain has been a cornerstone in the treatment of suspected myocardial infarction (MI). Recent randomized controlled trials have, however, shown that supplemental O2 therapy has no positive nor negative effects on cardiovascular functions, mortality, morbidity or pain in normoxic patients with suspected MI and foremost patients with ST Elevation Myocardial Infarction (STEMI). O2 therapy in normoxic STEMI patients should therefore be omitted. More studies are needed in discussing hemodynamically unstable STEMI patients, as well as patients with non-STEMI, unstable angina and other emergency conditions.
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Affiliation(s)
- Ardavan Khoshnood
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden.
- Department of Emergency and Internal Medicine, Skåne University Hospital Lund, Lund, Sweden.
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45
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Lim K, Yang JH, Hahn JY, Choi SH, Gwon HC, Park SJ, Song YB. Impact of Natural Mild Hypothermia in the Early Phase of ST-Elevation Myocardial Infarction: Cardiac Magnetic Resonance Imaging Study. J Cardiovasc Imaging 2018; 26:175-185. [PMID: 30310885 PMCID: PMC6160816 DOI: 10.4250/jcvi.2018.26.e21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 09/18/2018] [Accepted: 09/19/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Mild hypothermia (32-35°C) during acute myocardial ischemia has been considered cardioprotective in animal studies. We sought to determine the association of between natural mild hypothermia and myocardial salvage as assessed by cardiac magnetic resonance imaging (CMR) in ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI). METHODS In 291 patients with STEMI, CMR was performed a median of 3 days after the index event. Body temperature was collected for 24 hours after PCI. Fifty-one patients (17.5%) had natural mild hypothermia (less than 35°C) during the day after PCI, and 240 (82.5%) did not. RESULTS The primary endpoint, the myocardial salvage index, was significantly higher in the natural mild hypothermia group than in the normothermia group (median [IQR], 50 [37-64] vs. 43 [30-56], p = 0.013). The myocardial area at risk between the 2 groups did not differ (39 [22-51] vs. 35 [24-44], p = 0.361), nor did the infarct size (16 [10-28] vs. 20 [12-27], p = 0.301), presence of microvascular obstruction (57% vs. 60%, p=0.641), or hemorrhagic infarction (43% vs. 46%, p = 0.760). A multivariable linear regression showed a significant association between the lowest body temperature and myocardial salvage index (β = -0.191, p = 0.001). CONCLUSIONS In patients with STEMI undergoing primary PCI, natural mild hypothermia within 24 hours is associated with greater salvaged myocardium.
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Affiliation(s)
- Kyunghee Lim
- Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Hyuk Choi
- Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung-Ji Park
- Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Bin Song
- Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Changes in automated external defibrillator use and survival after out-of-hospital cardiac arrest in the Nijmegen area. Neth Heart J 2018; 26:600-605. [PMID: 30280320 PMCID: PMC6288040 DOI: 10.1007/s12471-018-1162-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Purpose Out-of-hospital cardiac arrests (OHCAs) are a major healthcare problem. Over the years, several initiatives have contributed to more lay volunteers providing cardiopulmonary resuscitation (CPR) and increased use of automated external defibrillators (AEDs) in the Netherlands. As part of a quality and outcomes program, we registered bystander CPR, AED use and outcome in the Nijmegen area. Methods Prospective resuscitation registry with a study cohort of non-traumatic OHCA cases from 2013–2016 and historical controls from 2008–2011. In line with previous reports, we studied patients transported to the hospital (Radboudumc, Nijmegen, the Netherlands) and excluded arrests witnessed by the emergency medical service (EMS). Primary outcomes were return of spontaneous circulation (ROSC) and survival to discharge. Results In the study cohort (n = 349) the AED was attached more often than in the historical cohort (n = 180): 46% vs. 23% and the proportion of bystander CPR was higher: 78% vs. 63% (both p < 0.001). A higher proportion of patients received an AED shock (39% vs. 15%, p < 0.001) and the number of required shocks by the EMS was lower (2 vs. 4, p = 0.004). Survival to discharge was higher (47% vs. 33%, p = 0.002) without differences in ROSC. The survival benefit was restricted to patients with a shockable initial rhythm. In both cohorts, bystander CPR and AED use were independently associated with survival. Conclusion In patients admitted after OHCA, survival to discharge has markedly improved to 40–50%, comparable with other Dutch registries. As increased bystander CPR and the doubled use of AEDs seem to have contributed, all civilian-based resuscitation initiatives should be encouraged.
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47
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Larribau R, Deham H, Niquille M, Sarasin FP. Improvement of out-of-hospital cardiac arrest survival rate after implementation of the 2010 resuscitation guidelines. PLoS One 2018; 13:e0204169. [PMID: 30248116 PMCID: PMC6152955 DOI: 10.1371/journal.pone.0204169] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 09/03/2018] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The implementation of cardiopulmonary resuscitation guidelines, updated every five years, appears to improve patient survival rates after Out-Of-Hospital Cardiac Arrest (OHCA). The aim of this study is: 1) to measure the level of improvement in the prognosis of OHCA patient survival rates for the years 2009 and 2010 and the following two years 2011 and 2012; and 2) correlate the improvement in prognosis with the updated 2010 Advanced Cardiovascular Life Support (ACLS) Guidelines. METHOD We performed a retrospective observational study based on Geneva's OHCA register that includes data from January 1, 2009 to December 31, 2012. We compared the evolution of prognostic factors that influenced survival at hospital discharge between the periods before and after the implementation of the 2010 guidelines. We then compared the survival rates between each period. Finally, we adjusted the effects on survival in the second period to prognostic factors not linked with the care provided by Emergency Medical Services (EMS) teams, using a multivariable logistic regression model. Changes in advanced resuscitation treatment provided by EMS personnel were also examined. RESULTS 795 OHCA were resuscitated between 1st January, 2009 and 31st December, 2012. The prognosis of patient survival at the time of hospital discharge rose from 10.33% in 2009-2010 to 17.01% in 2011-2012 (p = 0.007). After making adjustments for the effect of improved survival rates on the second period with factors not related to care provided by EMS teams, the odds ratio (OR) remains comparable (OR = 1.87, 95% CI [1.08-3.22]). Measured changes in treatment provided by EMS personnel were minor. CONCLUSIONS Survival rate for OHCA patients improved significantly in 2011-2012. This study suggests that it was probably the improvement in the quality of care provided during CPR and post-cardiac arrest care that have contributed to the increase in survival rates at the time of hospital discharge.
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Affiliation(s)
- Robert Larribau
- Division of Emergency Medicine, Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Hélène Deham
- Division of Emergency Medicine, Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Marc Niquille
- Division of Emergency Medicine, Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - François Pierre Sarasin
- Division of Emergency Medicine, Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
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48
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Yuan W, Wu JY, Zhao YZ, Li J, Li JB, Li ZH, Li CS. Effects of Mild Hypothermia on Cardiac and Neurological Function in Piglets Under Pathological and Physiological Stress Conditions. Ther Hypothermia Temp Manag 2018; 9:136-145. [PMID: 30239278 DOI: 10.1089/ther.2018.0026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
To investigate the different effects of mild hypothermia on pathological and physiological stress conditions in piglets, 30 pigs were randomized into four groups: cardiac arrest and mild hypothermia (CA-MH group), cardiac arrest and normothermia (CA-NH group), non-CA-MH (NCA-MH group), and a sham operation. The same hypothermia intervention was implemented in both CA-MH and NCA-MH groups. The CA-NH group did not undergo therapeutic hypothermia after resuscitation. The hemodynamic parameters were recorded. Cerebral metabolism variables and neurotransmitters in the extracellular fluid were collected through microdialysis tubes. The serum of venous blood was used to detect levels of inflammatory factors. The cerebral function was evaluated. At 24 and 72 hours after resuscitation, the cerebral performance category and neurological deficit score in the CA-NH group had higher values. Heart rate and cardiac output (CO) in the CA-MH group during cooling were lower than that of the CA-NH group, but CO was higher after rewarming. Glucose was higher during cooling, and extracellular lactate and lactate/pyruvate ratio in the CA-MH group were lower than that of the CA-NH group. Noradrenaline and 5-hydroxytryptamine in the CA-MH and NCA-MH groups were lower than that of the CA-NH group and sham group during cooling, respectively. Inflammatory factor levels, including interleukin (IL)-1β, IL-2, IL-4, IL-6, IL-8, and tumor necrosis factor-α, in the CA-MH group were lower than that of the CA-NH group at cooling for 12 hours. These values in the NCA-MH group were higher than that of the sham group. Under a light and an electron microscope, the worse pathological results of heart and brain were observed in the two cardiac arrest groups. Mild hypothermia can provide limited organ protection in the specific pathological condition caused by ischemia-reperfusion, but it may produce a negative effect in a normal physiological state.
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Affiliation(s)
- Wei Yuan
- 1 Department of Emergency, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.,2 Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing, China
| | - Jun-Yuan Wu
- 1 Department of Emergency, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.,2 Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing, China
| | - Yong-Zhen Zhao
- 1 Department of Emergency, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.,2 Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing, China
| | - Jie Li
- 3 Department of Emergency, Beijing Fu-Xing Hospital, Capital Medical University, Beijing, China
| | - Jie-Bin Li
- 4 Department of Emergency, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Zhen-Hua Li
- 5 Department of Emergency, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Chun-Sheng Li
- 1 Department of Emergency, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.,2 Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing, China
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49
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Abstract
BACKGROUND Mechanical chest compression devices have been proposed to improve the effectiveness of cardiopulmonary resuscitation (CPR). OBJECTIVES To assess the effectiveness of resuscitation strategies using mechanical chest compressions versus resuscitation strategies using standard manual chest compressions with respect to neurologically intact survival in patients who suffer cardiac arrest. SEARCH METHODS On 19 August 2017 we searched the Cochrane Central Register of Controlled Studies (CENTRAL), MEDLINE, Embase, Science Citation Index-Expanded (SCI-EXPANDED) and Conference Proceedings Citation Index-Science databases. Biotechnology and Bioengineering Abstracts and Science Citation abstracts had been searched up to November 2009 for prior versions of this review. We also searched two clinical trials registries for any ongoing trials not captured by our search of databases containing published works: Clinicaltrials.gov (August 2017) and the World Health Organization International Clinical Trials Registry Platform portal (January 2018). We applied no language restrictions. We contacted experts in the field of mechanical chest compression devices and manufacturers. SELECTION CRITERIA We included randomised controlled trials (RCTs), cluster-RCTs and quasi-randomised studies comparing mechanical chest compressions versus manual chest compressions during CPR for patients with cardiac arrest. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included five new studies in this update. In total, we included 11 trials in the review, including data from 12,944 adult participants, who suffered either out-of-hospital cardiac arrest (OHCA) or in-hospital cardiac arrest (IHCA). We excluded studies explicitly including patients with cardiac arrest caused by trauma, drowning, hypothermia and toxic substances. These conditions are routinely excluded from cardiac arrest intervention studies because they have a different underlying pathophysiology, require a variety of interventions specific to the underlying condition and are known to have a prognosis different from that of cardiac arrest with no obvious cause. The exclusions were meant to reduce heterogeneity in the population while maintaining generalisability to most patients with sudden cardiac death.The overall quality of evidence for the outcomes of included studies was moderate to low due to considerable risk of bias. Three studies (N = 7587) reported on the designated primary outcome of survival to hospital discharge with good neurologic function (defined as a Cerebral Performance Category (CPC) score of one or two), which had moderate quality evidence. One study showed no difference with mechanical chest compressions (risk ratio (RR) 1.07, 95% confidence interval (CI) 0.82 to 1.39), one study demonstrated equivalence (RR 0.79, 95% CI 0.60 to 1.04), and one study demonstrated reduced survival (RR 0.41, CI 0.21 to 0.79). Two other secondary outcomes, survival to hospital admission (N = 7224) and survival to hospital discharge (N = 8067), also had moderate quality level of evidence. No studies reported a difference in survival to hospital admission. For survival to hospital discharge, two studies showed benefit, four studies showed no difference, and one study showed harm associated with mechanical compressions. No studies demonstrated a difference in adverse events or injury patterns between comparison groups but the quality of data was low. Marked clinical and statistical heterogeneity between studies precluded any pooled estimates of effect. AUTHORS' CONCLUSIONS The evidence does not suggest that CPR protocols involving mechanical chest compression devices are superior to conventional therapy involving manual chest compressions only. We conclude on the balance of evidence that mechanical chest compression devices used by trained individuals are a reasonable alternative to manual chest compressions in settings where consistent, high-quality manual chest compressions are not possible or dangerous for the provider (eg, limited rescuers available, prolonged CPR, during hypothermic cardiac arrest, in a moving ambulance, in the angiography suite, during preparation for extracorporeal CPR [ECPR], etc.). Systems choosing to incorporate mechanical chest compression devices should be closely monitored because some data identified in this review suggested harm. Special attention should be paid to minimising time without compressions and delays to defibrillation during device deployment.
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Affiliation(s)
- Peter L Wang
- Queen's UniversityDepartment of MedicineKingstonCanada
- Queen's UniversitySchool of Medicine, Faculty of Health SciencesKingstonCanada
| | - Steven C Brooks
- Queen's UniversityDepartment of Emergency MedicineKingstonONCanada
- University of TorontoRescu, Li Ka Shing Knowledge Institute, Division of Emergency Medicine, Department of MedicineTorontoCanada
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50
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Lampe JW, Yin T, Bratinov G, Kaufman CL, Berg RA, Venema A, Becker LB. Effect of compression waveform and resuscitation duration on blood flow and pressure in swine: One waveform does not optimally serve. Resuscitation 2018; 131:55-62. [PMID: 30092277 DOI: 10.1016/j.resuscitation.2018.08.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 07/02/2018] [Accepted: 08/03/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Chest compression (CC) research primarily focuses on finding the 'optimum' compression waveform using a variety of compression efficacy metrics. Blood flow is rarely measured systematically with high fidelity. Using a programmable mechanical chest compression device, we studied the effect of inter-compression pauses in a swine model of cardiac arrest, testing the hypothesis that a single 'optimal' CC waveform exists based on measurements of resulting blood flow. METHODS Hemodynamics were studied in 9 domestic swine (∼30 kg) using multiple flow probes and standard physiological monitoring. After 10 min of ventricular fibrillation, five mechanical chest compression waveforms (5.1 cm, varying inter-compression pauses) were delivered for 2 min each in a semi-random pattern, totaling 50 compression minutes. Linear Mixed Models were used to estimate the effect of compression waveform on hemodynamics. RESULTS Blood flow and pressure decayed significantly with time in both arteries and veins. No waveform maximized blood flow in all vessels simultaneously and the waveform generating maximal blood flow in a specific vessel changed over time in all vessels. A flow mismatch between paired arteries and veins, e.g. abdominal aorta and inferior vena cava, also developed over time. The waveform with the slowest rate and shortest duty cycle had the smallest mismatch between flows after about 30 min of CPR. CONCLUSIONS This data challenges the concept of a single optimal CC waveform. Time dependent physiological response to compressions and no single compression waveform optimizing flow in all vessels indicate that current descriptions of CPR don't reflect patient physiology.
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Affiliation(s)
- Joshua W Lampe
- The Feinstein Institute for Medical Research, Department of Emergency Medicine, Northwell Health, Manhasset, NY, United States; ZOLL Medical Corporation, Chelmsford, MA, United States.
| | - Tai Yin
- The Feinstein Institute for Medical Research, Department of Emergency Medicine, Northwell Health, Manhasset, NY, United States.
| | - George Bratinov
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, United States.
| | | | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, United States.
| | - Alyssa Venema
- Dept. of Trauma Surgery & Resuscitation, DSATC, Radboud Universitair Medisch Centrum Geert Grooteplein 10, 6525 GA, Nijmegen, NL, The Netherlands.
| | - Lance B Becker
- The Feinstein Institute for Medical Research, Department of Emergency Medicine, Northwell Health, Manhasset, NY, United States.
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