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Caddell AJ, Nagpal D, Hegazy AF. Postarrest Care Bundle Improves Quality of Care and Clinical Outcomes in the Normothermia Era. J Intensive Care Med 2024; 39:623-627. [PMID: 38176890 PMCID: PMC11149385 DOI: 10.1177/08850666231223482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
PURPOSE Temperature targets in patients with cardiac arrest and return of spontaneous circulation (ROSC) have changed. Changes to higher temperature targets have been associated with higher breakthrough fevers and mortality. A post-ROSC normothermia bundle was developed to improve compliance with temperature targets. METHODS In August 2021, "ad hoc" normothermia at the discretion of the attending intensivist was initiated. In December 2021, a post-ROSC normothermia protocol was implemented, incorporating a rigorous, stepwise approach to fever prevention (temperature ≥ 37.8). We conducted a before-after cohort study of all adult patients post-ROSC who survived to intensive care unit admission between August 1, 2021, and April 1, 2022. They were divided into "ad hoc" and "protocol" groups. Clinical outcomes compared included fevers, active cooling, and paralytic use. RESULTS Fifty-eight post-ROSC patients were admitted; 24 in the "ad hoc" and 34 in the "protocol" groups. Patient demographics were similar between groups. The "ad hoc" group had more shockable rhythms (67% vs 24%, P = .001) and cardiac catheterizations (42% vs 15%, P = .03). The "protocol" group were significantly less likely to have a fever at 40 h (6% vs 40%, P < .001) and 72 h (14% vs 65%, P ≤ .001). Patients in the normothermia "protocol" used significantly less neuromuscular blocking agents (24% vs 50%, P = .05). The normothermia "protocol" resulted in similar mortality (56% vs 58%, P = 1.0). CONCLUSION Use of a normothermia "protocol" resulted in fewer fevers and less neuromuscular blocker administration compared to "ad hoc" management. A protocolized approach for improved quality of care should be considered in institutions adopting normothermia.
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Affiliation(s)
- Andrew J Caddell
- Cardiology Division, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Dave Nagpal
- Critical Care, Western University, London, Ontario, Canada
| | - Ahmed F Hegazy
- Critical Care, Western University, London, Ontario, Canada
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Liu R, Majumdar T, Gardner MM, Burnett R, Graham K, Beaulieu F, Sutton RM, Nadkarni VM, Berg RA, Morgan RW, Topjian AA, Kirschen MP. Association of Postarrest Hypotension Burden With Unfavorable Neurologic Outcome After Pediatric Cardiac Arrest. Crit Care Med 2024:00003246-990000000-00342. [PMID: 38832829 DOI: 10.1097/ccm.0000000000006339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
OBJECTIVE Quantify hypotension burden using high-resolution continuous arterial blood pressure (ABP) data and determine its association with outcome after pediatric cardiac arrest. DESIGN Retrospective observational study. SETTING Academic PICU. PATIENTS Children 18 years old or younger admitted with in-of-hospital or out-of-hospital cardiac arrest who had invasive ABP monitoring during postcardiac arrest care. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS High-resolution continuous ABP was analyzed up to 24 hours after the return of circulation (ROC). Hypotension burden was the time-normalized integral area between mean arterial pressure (MAP) and fifth percentile MAP for age. The primary outcome was unfavorable neurologic status (pediatric cerebral performance category ≥ 3 with change from baseline) at hospital discharge. Mann-Whitney U tests compared hypotension burden, duration, and magnitude between favorable and unfavorable patients. Multivariable logistic regression determined the association of unfavorable outcomes with hypotension burden, duration, and magnitude at various percentile thresholds from the 5th through 50th percentile for age. Of 140 patients (median age 53 [interquartile range 11-146] mo, 61% male); 63% had unfavorable outcomes. Monitoring duration was 21 (7-24) hours. Using a MAP threshold at the fifth percentile for age, the median hypotension burden was 0.01 (0-0.11) mm Hg-hours per hour, greater for patients with unfavorable compared with favorable outcomes (0 [0-0.02] vs. 0.02 [0-0.27] mm Hg-hr per hour, p < 0.001). Hypotension duration and magnitude were greater for unfavorable compared with favorable patients (0.03 [0-0.77] vs. 0.71 [0-5.01]%, p = 0.003; and 0.16 [0-1.99] vs. 2 [0-4.02] mm Hg, p = 0.001). On logistic regression, a 1-point increase in hypotension burden below the fifth percentile for age (equivalent to 1 mm Hg-hr of burden per hour of recording) was associated with increased odds of unfavorable outcome (adjusted odds ratio [aOR] 14.8; 95% CI, 1.1-200; p = 0.040). At MAP thresholds of 10th-50th percentiles for age, MAP burden below the threshold was greater in unfavorable compared with favorable patients in a dose-dependent manner. CONCLUSIONS High-resolution continuous ABP data can be used to quantify hypotension burden after pediatric cardiac arrest. The burden, duration, and magnitude of hypotension are associated with unfavorable neurologic outcomes.
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Affiliation(s)
- Raymond Liu
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Tanmay Majumdar
- Department of Medicine, Drexel University College of Medicine, Philadelphia, PA
| | - Monique M Gardner
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Ryan Burnett
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Forrest Beaulieu
- Department of Anesthesiology, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Robert M Sutton
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Vinay M Nadkarni
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Robert A Berg
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Ryan W Morgan
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Alexis A Topjian
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Matthew P Kirschen
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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3
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Tejerina Álvarez EE, Lorente Balanza JÁ. Temperature management in acute brain injury: A narrative review. Med Intensiva 2024; 48:341-355. [PMID: 38493062 DOI: 10.1016/j.medine.2024.03.001] [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: 10/31/2023] [Accepted: 02/10/2024] [Indexed: 03/18/2024]
Abstract
Temperature management has been used in patients with acute brain injury resulting from different conditions, such as post-cardiac arrest hypoxic-ischaemic insult, acute ischaemic stroke, and severe traumatic brain injury. However, current evidence offers inconsistent and often contradictory results regarding the clinical benefit of this therapeutic strategy on mortality and functional outcomes. Current guidelines have focused mainly on active prevention and treatment of fever, while therapeutic hypothermia (TH) has fallen into disuse, although doubts persist as to its effectiveness according to the method of application and appropriate patient selection. This narrative review presents the most relevant clinical evidence on the effects of TH in patients with acute neurological damage, and the pathophysiological concepts supporting its use.
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Affiliation(s)
- Eva Esther Tejerina Álvarez
- Servicio de Medicina Intensiva. Hospital Universitario de Getafe, Getafe, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain.
| | - José Ángel Lorente Balanza
- Servicio de Medicina Intensiva. Hospital Universitario de Getafe, Getafe, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain; Departamento de Bioingeniería, Universidad Carlos III de Madrid, Leganés, Madrid, Spain; Departamento de Medicina, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain
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4
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Agarwal A, Baitha U, Ranjan P, Swarnkar NK, Singh GP, Baidya DK, Garg R, Gupta N, Choudhury A, Kumar A, Roy A, Naik N, Khan MA, Wig N. Knowledge and Skills in Cardiopulmonary Resuscitation and Effect of Simulation Training on it among Healthcare Workers in a Tertiary Care Center in India. Indian J Crit Care Med 2024; 28:336-342. [PMID: 38585308 PMCID: PMC10998517 DOI: 10.5005/jp-journals-10071-24670] [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: 10/25/2023] [Accepted: 01/02/2024] [Indexed: 04/09/2024] Open
Abstract
Aim and background High-quality cardiopulmonary resuscitation (CPR) is associated with improved patient outcomes, but healthcare workers (HCWs) may be frequently undertrained. This study aimed to assess baseline knowledge and skills among HCWs about basic and advanced life support and the effect of simulation-based training on it. Methods It was a single-center prospective quasi-interventional study among resident doctors and nurses at a Tertiary Center in New Delhi, India. A questionnaire-based assessment was done to assess baseline knowledge. The participants then underwent simulation-based training followed by questionnaire-based knowledge assessment and skill assessment. A repeat questionnaire-based assessment was done 6 months post-training to assess knowledge retention. Results A total of 82 HCWs (54 doctors and 28 nurses) were enrolled. The participants scored 22.28 ± 6.06 out of 35 (63.65%) in the pre-training knowledge assessment, with low scores in post-cardiac arrest care, advanced life support, and defibrillation. After the training, there was a significant rise in scores to 28.32 ± 4.08 out of 35 (80.9%) (p < 0.01). The retention of knowledge at 6 months was 68.87% (p < 0.01). The participants scored 92.61 ± 4.75% marks in skill assessment with lower scores in chest compressions and team leadership roles. There was a positive correlation (r = 0.35) between knowledge and skills scores (p < 0.01). Conclusion There is a progressive decrease in baseline knowledge of HCWs with the further steps in the adult chain of survival. The simulation training program had a positive impact on the knowledge of HCWs. The training programs should focus on defibrillation, advanced life support, post-cardiac arrest care, and leadership roles. How to cite this article Agarwal A, Baitha U, Ranjan P, Swarnkar NK, Singh GP, Baidya DK, et al. Knowledge and Skills in Cardiopulmonary Resuscitation and Effect of Simulation Training on it among Healthcare Workers in a Tertiary Care Center in India. Indian J Crit Care Med 2024;28(4):336-342.
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Affiliation(s)
- Ayush Agarwal
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Upendra Baitha
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Piyush Ranjan
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Neeraj K Swarnkar
- Department of Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Gyaninder P Singh
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Dalim K Baidya
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Garg
- Department of Onco-Anaesthesiology and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Nishkarsh Gupta
- Department of Onco-Anaesthesiology and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Arindam Choudhury
- Department of Cardiac Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - Arvind Kumar
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ambuj Roy
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - Nitish Naik
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - Maroof Ahmed Khan
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Naveet Wig
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
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Wagner MK, Christensen J, Christensen KA, Dichman C, Gottlieb R, Kolster I, Hansen CM, Hoff H, Hassager C, Folke F, Winkel BG. A multidisciplinary guideline-based approach to improving the sudden cardiac arrest care pathway: The Copenhagen framework. Resusc Plus 2024; 17:100546. [PMID: 38260118 PMCID: PMC10801323 DOI: 10.1016/j.resplu.2023.100546] [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] [Indexed: 01/24/2024] Open
Abstract
Although recommended in the European Resuscitation Council (ERC) and European Society of Intensive Care Medicine (ESICM) Guidelines, a framework for delivering post-cardiac arrest care in a systematic manner in dedicated high-volume cardiac arrest centers is lacking in the existing literature. To our knowledge, the Copenhagen Framework is the only established framework of its kind. The framework comprises management of out-of-hospital cardiac arrest (OHCA) survivors, and follow-up, and rehabilitation. The framework also incorporates research projects on cardiac arrest survivors and their close family members. The overall aim of this paper is to describe a framework made in order to bridge the gaps between international recommendations and delivering high-quality post-resuscitation clinical care, improving the continuity of care for OHCA survivors, access to post-CA rehabilitation, a seamless transition to everyday life, and ultimately patient outcomes in the future.
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Affiliation(s)
| | - Jan Christensen
- Department of Occupational Therapy and Physiotherapy, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Kate Allen Christensen
- Department of Occupational Therapy and Physiotherapy, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Camilla Dichman
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Rikke Gottlieb
- Department of Occupational Therapy and Physiotherapy, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ida Kolster
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Carolina Malta Hansen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
- Department of Cardiology, Herlev and Gentofte University Hospital, Hellerup, Denmark
- Copenhagen Emergency Medical Services, Copenhagen University, Ballerup, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Helle Hoff
- Department of Cardiology, Herlev and Gentofte University Hospital, Hellerup, Denmark
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Fredrik Folke
- Department of Cardiology, Herlev and Gentofte University Hospital, Hellerup, Denmark
- Copenhagen Emergency Medical Services, Copenhagen University, Ballerup, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Bo Gregers Winkel
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
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Nikolovski SS, Lazic AD, Fiser ZZ, Obradovic IA, Tijanic JZ, Raffay V. Recovery and Survival of Patients After Out-of-Hospital Cardiac Arrest: A Literature Review Showcasing the Big Picture of Intensive Care Unit-Related Factors. Cureus 2024; 16:e54827. [PMID: 38529434 PMCID: PMC10962929 DOI: 10.7759/cureus.54827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2024] [Indexed: 03/27/2024] Open
Abstract
As an important public health issue, out-of-hospital cardiac arrest (OHCA) requires several stages of high quality medical care, both on-field and after hospital admission. Post-cardiac arrest shock can lead to severe neurological injury, resulting in poor recovery outcome and increased risk of death. These characteristics make this condition one of the most important issues to deal with in post-OHCA patients hospitalized in intensive care units (ICUs). Also, the majority of initial post-resuscitation survivors have underlying coronary diseases making revascularization procedure another crucial step in early management of these patients. Besides keeping myocardial blood flow at a satisfactory level, other tissues must not be neglected as well, and maintaining mean arterial pressure within optimal range is also preferable. All these procedures can be simplified to a certain level along with using targeted temperature management methods in order to decrease metabolic demands in ICU-hospitalized post-OHCA patients. Additionally, withdrawal of life-sustaining therapy as a controversial ethical topic is under constant re-evaluation due to its possible influence on overall mortality rates in patients initially surviving OHCA. Focusing on all of these important points in process of managing ICU patients is an imperative towards better survival and complete recovery rates.
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Affiliation(s)
- Srdjan S Nikolovski
- Pathology and Laboratory Medicine, Cardiovascular Research Institute, Loyola University Chicago Health Science Campus, Maywood, USA
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Aleksandra D Lazic
- Emergency Center, Clinical Center of Vojvodina, Novi Sad, SRB
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Zoran Z Fiser
- Emergency Medicine, Department of Emergency Medicine, Novi Sad, SRB
| | - Ivana A Obradovic
- Anesthesiology, Resuscitation, and Intensive Care, Sveti Vračevi Hospital, Bijeljina, BIH
| | - Jelena Z Tijanic
- Emergency Medicine, Municipal Institute of Emergency Medicine, Kragujevac, SRB
| | - Violetta Raffay
- School of Medicine, European University Cyprus, Nicosia, CYP
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
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Burns B, Marschner I, Eggins R, Buscher H, Morton RL, Bendall J, Keech A, Dennis M. A randomized trial of expedited intra-arrest transfer versus more extended on-scene resuscitation for refractory out of hospital cardiac arrest: Rationale and design of the EVIDENCE trial. Am Heart J 2024; 267:22-32. [PMID: 37871782 DOI: 10.1016/j.ahj.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/11/2023] [Accepted: 10/19/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND Refractory Out of Hospital Cardiac Arrest (r-OHCA) is common and the benefit versus harm of intra-arrest transport of patients to hospital is not clear. OBJECTIVE To assess the rate of survival to hospital discharge in adult patients with r-OHCA, initial rhythm pulseless ventricular tachycardia (VT)/ventricular fibrillation (VF) or Pulseless Electrical Activity (PEA) treated with 1 of 2 locally accepted standards of care:1 expedited transport from scene; or2 ongoing advanced life support (ALS) resuscitation on-scene. HYPOTHESIS We hypothesize that expedited transport from scene in r-OHCA improves survival with favorable neurological status/outcome. METHODS/DESIGN Phase III, multi-center, partially blinded, prospective, intention-to-treat, safety and efficacy clinical trial with contemporaneous registry of patient ineligible for the clinical trial. Eligible patients for inclusion are adults with witnessed r-OHCA; estimated age 18 to 70, assumed medical cause with immediate bystander cardiopulmonary resuscitation (CPR); initial rhythm of VF/pulseless VT, or PEA; no return of spontaneous circulation following 3 shocks and/or 15 minutes of professional on-scene resuscitation; with mechanical CPR available. Two hundred patients will be randomized in a 1:1 ratio to either expedited transport from scene or ongoing ALS at the scene of cardiac arrest. SETTING Two urban regions in NSW Australia. OUTCOMES Primary: survival to hospital discharge with cerebral performance category (CPC) 1 or 2. Secondary: safety, survival, prognostic factors, use of ECMO supported CPR and functional assessment at hospital discharge and 4 weeks and 6 months, quality of life, healthcare use and cost-effectiveness. CONCLUSIONS The EVIDENCE trial will determine the potential risks and benefits of an expedited transport from scene of cardiac arrest.
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Affiliation(s)
- Brian Burns
- New South Wales Ambulance, Sydney, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Ian Marschner
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; NHMRC Clinical Trials Centre, The University of Sydney, Sydney Australia
| | - Renee Eggins
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; NHMRC Clinical Trials Centre, The University of Sydney, Sydney Australia
| | - Hergen Buscher
- St. Vincent's Hospital, Sydney, Australia; University of New South Wales, Sydney, Australia
| | - Rachael L Morton
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; NHMRC Clinical Trials Centre, The University of Sydney, Sydney Australia
| | | | - Anthony Keech
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Royal Prince Alfred Hospital, Sydney, Australia
| | - Mark Dennis
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Royal Prince Alfred Hospital, Sydney, Australia.
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8
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Ho I, Kuo M, Hsu P, Lee I, Hsu T, Lin Y, Huang C. The impacts of anemia burden on clinical outcomes in patients with out-of-hospital cardiac arrest. Clin Cardiol 2024; 47:e24175. [PMID: 37872851 PMCID: PMC10777437 DOI: 10.1002/clc.24175] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/09/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND Out-of-hospital cardiac arrest (OHCA) has low survival rates, and few patients achieve a desirable neurological outcome. Anemia is common among OHCA patients and has been linked to worse outcomes, but its impact following the return of spontaneous circulation (ROSC) is unclear. This study examines the relationship between anemia burden and clinical outcomes in OHCA patients. HYPOTHESIS Higher anemia burden after ROSC may be related to higher mortality and worse neurologic outcomes. METHODS Patients who experienced OHCA and had ROSC were enrolled retrospectively. Anemia burden was defined as the area under curve from the target hemoglobin level over a 72-h period after OHCA. Hemoglobin level was measured at 12-h intervals. The clinical outcomes of the study included mortality and neurological outcomes at Day 30. RESULTS The study enrolled 258 nontraumatic OHCA patients who achieved ROSC between January 2017 and December 2021. Among the 162 patients who survived more than 72 h, a higher anemia burden, specifically target hemoglobin levels below 7 (hazard ratio [HR]: 1.129, 95% confidence interval [CI]: 1.013-1.259, p = .029), 8 (HR: 1.099, 95% CI: 1.014-1.191, p = .021), and 9 g/dL (HR: 1.066, 95% CI: 1.001-1.134, p = .046) was associated with higher 30-day mortality. Additionally, anemia burden with target hemoglobin levels below 7 (HR: 1.129, 95% CI: 1.016-1.248; p = .024) and 8 g/dL (HR: 1.088; 95% CI: 1.008-1.174, p = .031) was linked to worse neurological outcomes. CONCLUSIONS Anemia burden predicts 30-day mortality and neurological outcomes in OHCA patients who survive more than 72 h. Maintaining higher hemoglobin levels within the first 72 h after ROSC may improve short-term outcomes.
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Affiliation(s)
- I‐Wei Ho
- Division of Cardiology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan
| | - Ming‐Jen Kuo
- Division of Cardiology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan
- School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Pai‐Feng Hsu
- Division of Cardiology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan
- School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Healthcare and Services CenterTaipei Veterans General HospitalTaipeiTaiwan
| | - I‐Hsin Lee
- Department of EmergencyTaipei Veterans General HospitalTaipeiTaiwan
| | - Teh‐Fu Hsu
- Department of EmergencyTaipei Veterans General HospitalTaipeiTaiwan
| | - Yenn‐Jiang Lin
- Division of Cardiology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan
- School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Heart Rhythm CenterTaipei Veterans General HospitalTaipeiTaiwan
| | - Chin‐Chou Huang
- Division of Cardiology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan
- School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Institute of Pharmacology, School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
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9
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Patterson T, Perkins GD, Perkins A, Clayton T, Evans R, Dodd M, Robertson S, Wilson K, Mellett-Smith A, Fothergill RT, McCrone P, Dalby M, MacCarthy P, Firoozi S, Malik I, Rakhit R, Jain A, Nolan JP, Redwood SR. Expedited transfer to a cardiac arrest centre for non-ST-elevation out-of-hospital cardiac arrest (ARREST): a UK prospective, multicentre, parallel, randomised clinical trial. Lancet 2023; 402:1329-1337. [PMID: 37647928 PMCID: PMC10877072 DOI: 10.1016/s0140-6736(23)01351-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 06/23/2023] [Accepted: 06/26/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND The International Liaison Committee on Resuscitation has called for a randomised trial of delivery to a cardiac arrest centre. We aimed to assess whether expedited delivery to a cardiac arrest centre compared with current standard of care following resuscitated cardiac arrest reduces deaths. METHODS ARREST is a prospective, parallel, multicentre, open-label, randomised superiority trial. Patients (aged ≥18 years) with return of spontaneous circulation following out-of-hospital cardiac arrest without ST elevation were randomly assigned (1:1) at the scene of their cardiac arrest by London Ambulance Service staff using a secure online randomisation system to expedited delivery to the cardiac catheter laboratory at one of seven cardiac arrest centres or standard of care with delivery to the geographically closest emergency department at one of 32 hospitals in London, UK. Masking of the ambulance staff who delivered the interventions and those reporting treatment outcomes in hospital was not possible. The primary outcome was all-cause mortality at 30 days, analysed in the intention-to-treat (ITT) population excluding those with unknown mortality status. Safety outcomes were analysed in the ITT population. The trial was prospectively registered with the International Standard Randomised Controlled Trials Registry, 96585404. FINDINGS Between Jan 15, 2018, and Dec 1, 2022, 862 patients were enrolled, of whom 431 (50%) were randomly assigned to a cardiac arrest centre and 431 (50%) to standard care. 20 participants withdrew from the cardiac arrest centre group and 19 from the standard care group, due to lack of consent or unknown mortality status, leaving 411 participants in the cardiac arrest centre group and 412 in the standard care group for the primary analysis. Of 822 participants for whom data were available, 560 (68%) were male and 262 (32%) were female. The primary endpoint of 30-day mortality occurred in 258 (63%) of 411 participants in the cardiac arrest centre group and in 258 (63%) of 412 in the standard care group (unadjusted risk ratio for survival 1·00, 95% CI 0·90-1·11; p=0·96). Eight (2%) of 414 patients in the cardiac arrest centre group and three (1%) of 413 in the standard care group had serious adverse events, none of which were deemed related to the trial intervention. INTERPRETATION In adult patients without ST elevation, transfer to a cardiac arrest centre following resuscitated cardiac arrest in the community did not reduce deaths. FUNDING British Heart Foundation.
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Affiliation(s)
- Tiffany Patterson
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK; Cardiovascular Department, Faculty of Life Sciences and Medicine, King's College London, London, UK.
| | - Gavin D Perkins
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Alexander Perkins
- London School of Hygiene & Tropical Medicine Clinical Trials Unit, London, UK
| | - Tim Clayton
- London School of Hygiene & Tropical Medicine Clinical Trials Unit, London, UK
| | - Richard Evans
- London School of Hygiene & Tropical Medicine Clinical Trials Unit, London, UK
| | - Matthew Dodd
- London School of Hygiene & Tropical Medicine Clinical Trials Unit, London, UK
| | - Steven Robertson
- London School of Hygiene & Tropical Medicine Clinical Trials Unit, London, UK
| | - Karen Wilson
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Rachael T Fothergill
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; Clinical Audit and Research Unit, London Ambulance Service, London, UK; Faculty of Health, Social Care and Education, Kingston University and St George's, University of London, London, UK
| | - Paul McCrone
- Institute for Lifecourse Development, University of Greenwich, London, UK
| | - Miles Dalby
- Department of Cardiology, Brompton and Harefield NHS Foundation Trust, London, UK
| | | | - Sam Firoozi
- Department of Cardiology, St Georges Hospital, London, UK
| | - Iqbal Malik
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK
| | - Roby Rakhit
- Department of Cardiology, Royal Free Hospital Foundation Trust, London, UK
| | - Ajay Jain
- Department of Cardiology, Barts Heart Centre, London, UK
| | - Jerry P Nolan
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; Department of Anaesthesia, Royal United Hospital, Bath, UK
| | - Simon R Redwood
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK; Cardiovascular Department, Faculty of Life Sciences and Medicine, King's College London, London, UK
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Perman SM, Bartos JA, Del Rios M, Donnino MW, Hirsch KG, Jentzer JC, Kudenchuk PJ, Kurz MC, Maciel CB, Menon V, Panchal AR, Rittenberger JC, Berg KM. Temperature Management for Comatose Adult Survivors of Cardiac Arrest: A Science Advisory From the American Heart Association. Circulation 2023; 148:982-988. [PMID: 37584195 DOI: 10.1161/cir.0000000000001164] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
Targeted temperature management has been a cornerstone of post-cardiac arrest care for patients remaining unresponsive after return of spontaneous circulation since the initial trials in 2002 found that mild therapeutic hypothermia improves neurological outcome. The suggested temperature range expanded in 2015 in response to a large trial finding that outcomes were not better with treatment at 33° C compared with 36° C. In 2021, another large trial was published in which outcomes with temperature control at 33° C were not better than those of patients treated with a strategy of strict normothermia. On the basis of these new data, the International Liaison Committee on Resuscitation and other organizations have altered their treatment recommendations for temperature management after cardiac arrest. The new American Heart Association guidelines on this topic will be introduced in a 2023 focused update. To provide guidance to clinicians while this focused update is forthcoming, the American Heart Association's Emergency Cardiovascular Care Committee convened a writing group to review the TTM2 trial (Hypothermia Versus Normothermia After Out-of-Hospital Cardiac Arrest) in the context of other recent evidence and to present an opinion on how this trial may influence clinical practice. This science advisory was informed by review of the TTM2 trial, consideration of other recent influential studies, and discussion between cardiac arrest experts in the fields of cardiology, critical care, emergency medicine, and neurology. Conclusions presented in this advisory statement do not replace current guidelines but are intended to provide an expert opinion on novel literature that will be incorporated into future guidelines and suggest the opportunity for reassessment of current clinical practice.
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11
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Ijuin S, Liu K, Gill D, Kyun Ro S, Vukovic J, Ishihara S, Belohlavek J, Li Bassi G, Suen JY, Fraser JF. Current animal models of extracorporeal cardiopulmonary resuscitation: A scoping review. Resusc Plus 2023; 15:100426. [PMID: 37519410 PMCID: PMC10372365 DOI: 10.1016/j.resplu.2023.100426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/22/2023] [Accepted: 06/29/2023] [Indexed: 08/01/2023] Open
Abstract
Aim Animal models of Extracorporeal Cardiopulmonary Resuscitation (ECPR) focusing on neurological outcomes are required to further the development of this potentially life-saving technology. The aim of this review is to summarize current animal models of ECPR. Methods A comprehensive database search of PubMed, EMBASE, and Web of Science was undertaken. Full-text publications describing animal models of ECPR between January 1, 2000, and June 30, 2022, were identified and included in the review. Data describing the conduct of the animal models of ECPR, measured variables, and outcomes were extracted according to pre-defined definitions. Results The search strategy yielded 805 unique reports of which 37 studies were included in the final analysis. Most studies (95%) described using a pig model of ECPR with the remainder (5%) describing a rat model. The most common method for induction of cardiac arrest was a fatal ventricular arrhythmia through electrical stimulation (70%). 10 studies reported neurological assessment of animals using physical examination, serum biomarkers, or electrophysiological findings, however, only two studies described a multimodal assessment. No studies reported the use of brain imaging as part of the neurological assessment. Return of spontaneous circulation was the most reported primary outcome, and no studies described the neurological status of the animal as the primary outcome. Conclusion Current animal models of ECPR do not describe clinically relevant neurological outcomes after cardiac arrest. Further work is needed to develop models that more accurately mimic clinical scenarios and can test innovations that can be translated to the application of ECPR in clinical medicine.
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Affiliation(s)
- Shinichi Ijuin
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Japan
| | - Keibun Liu
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Denzil Gill
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia
| | - Sun Kyun Ro
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Japan
- Department of Thoracic and Cardiovascular Surgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Jana Vukovic
- School of Biomedical Sciences, University of Queensland, Brisbane, Australia
| | - Satoshi Ishihara
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Japan
| | - Jan Belohlavek
- Second Department of Internal Medicine, Cardiovascular Medicine, General University Hospital and First Medical School, Charles University in Prague, Czech Republic
| | - Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Queensland University of Technology, Brisbane, Australia
| | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia
- Queensland University of Technology, Brisbane, Australia
- St. Andrews War Memorial Hospital, Brisbane, Australia
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12
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Sumner BD, Hahn CW. Prognosis of Cardiac Arrest-Peri-arrest and Post-arrest Considerations. Emerg Med Clin North Am 2023; 41:601-616. [PMID: 37391253 DOI: 10.1016/j.emc.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
There has been only a small improvement in survival and neurologic outcomes in patients with cardiac arrest in recent decades. Type of arrest, length of total arrest time, and location of arrest alter the trajectory of survival and neurologic outcome. In the post-arrest phase, clinical markers such as blood markers, pupillary light response, corneal reflex, myoclonic jerking, somatosensory evoked potential, and electroencephalography testing can be used to help guide neurological prognostication. Most of the testing should be performed 72 hours post-arrest with special considerations for longer observation periods in patients who underwent TTM or who had prolonged sedation and/or neuromuscular blockade.
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Affiliation(s)
- Brian D Sumner
- Institute for Critical Care Medicine, 1468 Madison Avenue, Guggenheim Pavilion 6 East Room 378, New York, NY 10029, USA.
| | - Christopher W Hahn
- Department of Emergency Medicine, Mount Sinai Morningside-West, 1000 10th Avenue, New York, NY 10019, USA
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13
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Hsu TH, Huang WC, Lin KC, Huang CL, Tai HY, Tsai YC, Wu MC, Chang YT. Impact of a targeted temperature management quality improvement project on survival and neurologic outcomes in cardiac arrest patients. J Chin Med Assoc 2023; 86:672-681. [PMID: 37220417 DOI: 10.1097/jcma.0000000000000939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Targeted temperature management (TTM) is recommended for postresuscitation care of patients with sudden cardiac arrest (SCA) and its implementation remains challenging. This study aimed to evaluate the newly designed Quality Improvement Project (QIP) to improve the quality of TTM and outcomes of patients with SCA. METHODS Patients who experienced out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) with return of spontaneous circulation (ROSC) and were treated in our hospital between January 2017 and December 2019 were enrolled retrospectively. All included patients received QIP intervention initiated as follows: (1) Protocols and standard operating procedures were created for TTM; (2) shared decision-making was documented; (3) job training instruction was created; and 4) lean medical management was implemented. RESULTS Among 248 included patients, the postintervention group (n = 104) had shorter duration of ROSC to TTM than the preintervention group (n = 144) (356 vs 540 minutes, p = 0.042); better survival rate (39.4% vs 27.1%, p = 0.04), and neurologic performance (25.0% vs 17.4%, p < 0.001). After propensity score matching (PSM), patients who received TTM (n = 48 ) had better neurologic performance than those without TTM (n = 48) (25.1% vs 18.8%, p < 0.001). OHCA (odds ratio [OR] = 2.705, 95% CI: 1.657-4.416), age >60 (OR = 2.154, 95% CI: 1.428-3.244), female (OR = 1.404, 95% CI: 1.005-1.962), and diabetes mellitus (OR = 1.429, 95% CI: 1.019-2.005) were negative predictors of survival; while TTM (OR = 0.431, 95% CI: 0.266-0.699) and bystander cardiopulmonary resuscitation (CPR) (OR=0.589, 95% CI: 0.35-0.99) were positive predictors. Age >60 (OR= 2.292, 95% CI: 1.58-3.323) and OHCA (OR= 2.928, 95% CI: 1.858-4.616) were negative predictors of favorable neurologic outcomes; while bystander CPR (OR=0.572, 95% CI: 0.355-0.922) and TTM (OR=0.457, 95% CI: 0.296-0.705) were positive predictors. CONCLUSION A new QIP with defined protocols, documented shared decision-making, and medical management guidelines improves TTM execution, duration from ROSC to TTM , survival, and neurologic outcomes of cardiac arrest patients.
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Affiliation(s)
- Thung-Hsien Hsu
- Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Wei-Chun Huang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
- Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan, ROC
| | - Kun-Chang Lin
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Chieh-Ling Huang
- Department of Quality Management Center, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Hsiao-Yun Tai
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yi-Ching Tsai
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Meng-Chen Wu
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Yun-Te Chang
- Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Physical Therapy, Shu-Zen Junior College of Medicine and Management, Kaohsiung, Taiwan, ROC
- Department of Emergency & Critical Care Medicine, Pingtung Veterans General Hospital, Pingtung, Taiwan, ROC
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14
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Jorge-Perez P, Nikolaou N, Donadello K, Khoury A, Behringer W, Hassager C, Boettiger B, Sionis A, Nolan J, Combes A, Quinn T, Price S, Grand J. Management of comatose survivors of out-of-hospital cardiac arrest in Europe: current treatment practice and adherence to guidelines. A joint survey by the Association for Acute CardioVascular Care (ACVC) of the ESC, the European Resuscitation Council (ERC), the European Society for Emergency Medicine (EUSEM), and the European Society of Intensive Care Medicine (ESICM). EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:96-105. [PMID: 36454812 DOI: 10.1093/ehjacc/zuac153] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 10/15/2022] [Accepted: 11/30/2022] [Indexed: 12/03/2022]
Abstract
AIMS International guidelines give recommendations for the management of comatose out-of-hospital cardiac arrest (OHCA) survivors. We aimed to investigate adherence to guidelines and disparities in the treatment of OHCA in hospitals in Europe. METHODS AND RESULTS A web-based, multi-institutional, multinational survey in Europe was conducted using an electronic platform with a predefined questionnaire developed by experts in post-resuscitation care. The survey was disseminated to all members of the societies via email, social media, websites, and newsletters in June 2021. Of 252 answers received, 237 responses from different units were included and 166 (70%) were from cardiac arrest centres. First-line vasopressor used was noradrenaline in 195 (83%) and the first-line inotrope was dobutamine in 148 (64%) of the responses. Echocardiography is available 24/7 in 204 (87%) institutions. Targeted temperature management was used in 160 (75%) institutions for adult comatose survivors of OHCA with an initial shockable rhythm. Invasive or external cooling methods with feedback were used in 72 cardiac arrest centres (44%) and 17 (24%) non-cardiac arrest centres (P < 0.0003). A target temperature between 32 and 34°C was preferred by 46 centres (21%); a target between 34 and 36°C by 103 centres (52%); and <37.5°C by 35 (16%). Multimodal neuroprognostication was poorly implemented and a follow-up at 3 months after discharge was done in 71 (30%) institutions. CONCLUSION Post-resuscitation care is not well established and varies among centres in European hospitals. Cardiac arrest centres have a higher coherence with guidelines compared with respondents from non-cardiac arrest centres. The overall inconsistency in approaches and deviation from recommendations could be a focus for improvement.
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Affiliation(s)
- Pablo Jorge-Perez
- Department of Cardiology, Canary Islands University Hospital, La Laguna, 38320 Santa Cruz de Tenerife, Spain
| | - Nikolaos Nikolaou
- Intensive Cardiac Care Unit, Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Katia Donadello
- Department of Anesthesia and Intensive Care B, Department of Surgery, Dentistry, Gynaecology and Paediatrics, University of Verona, AOUI-University Hospital Integrated Trust of Verona, Policlinico G.B. Rossi, P.le L. Scuro, Verone, Italy
| | - Abdo Khoury
- Department of Emergency Medicine and Critical Care, Besançon University Hospital, Besançon, France.,INSERM CIC 1431, Besançon University Hospital, Besançon, France
| | - Wilhelm Behringer
- Department of Emergency Medicine, Medical University Vienna, Vienna, Austria
| | - Christian Hassager
- Department of Cardiology, University Hospital of Copenhagen, Rigshospitalet, The Heart Center, Copenhagen, Denmark
| | - Bernd Boettiger
- Medical Faculty and University Hospital, University of Cologne, Cologne, Germany.,European Resuscitation Council (ERC), Niel, Belgium.,German Resuscitation Council (GRC), Ulm, Germany
| | - Alessandro Sionis
- Intensive Cardiac Care Unit, Cardiology Department, Hospital de Sant Pau, IIB-Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Jerry Nolan
- Warwick Medical School, University of Warwick, Coventry, UK.,Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
| | - Alain Combes
- Sorbonne Université INSERM Unité Mixte de Recherche (UMRS) 1166, Institute of Cardiometabolism and Nutrition, Paris, France.,Service de Médecine Intensive-Réanimation, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Tom Quinn
- Kingston University and St. Georges, University of London, London, UK
| | - Susanna Price
- Departments of Cardiology and Critical Care, Royal Brompton & Harefield Hospitals, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Johannes Grand
- Department of Cardiology, Amager-Hvidovre Hospital, University Hospital of Copenhagen, Copenhagen, Denmark
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15
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Viana-Tejedor A, Andrea-Riba R, Scardino C, Ariza-Solé A, Bañeras J, García-García C, Jiménez Mena M, Vila M, Martínez-Sellés M, Pastor G, García Acuña JM, Loma-Osorio P, García Rubira JC, Jorge Pérez P, Pastor P, Ferrera C, Noriega FJ, Pérez Macías N, Fernández-Ortiz A, Pérez-Villacastín J. Coronary angiography in patients without ST-segment elevation following out-of-hospital cardiac arrest. COUPE clinical trial. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2023; 76:94-102. [PMID: 35750580 DOI: 10.1016/j.rec.2022.05.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 05/10/2022] [Indexed: 02/01/2023]
Abstract
INTRODUCTION AND OBJECTIVES The role of emergency coronary angiography (CAG) and percutaneous coronary intervention (PCI) following out-of-hospital cardiac arrest (OHCA) in patients without ST-segment elevation myocardial infarction (STEMI) remains unclear. We aimed to assess whether emergency CAG and PCI would improve survival with good neurological outcome in this population. METHODS In this multicenter, randomized, open-label, investigator-initiated clinical trial, we randomly assigned 69 survivors of OHCA without STEMI to undergo immediate CAG or deferred CAG. The primary efficacy endpoint was a composite of in-hospital survival free of severe dependence. The safety endpoint was a composite of major adverse cardiac events including death, reinfarction, bleeding, and ventricular arrhythmias. RESULTS A total of 66 patients were included in the primary analysis (95.7%). In-hospital survival was 62.5% in the immediate CAG group and 58.8% in the delayed CAG group (HR, 0.96; 95%CI, 0.45-2.09; P=.93). In-hospital survival free of severe dependence was 59.4% in the immediate CAG group and 52.9% in the delayed CAG group (HR, 1.29; 95%CI, 0.60-2.73; P=.4986). No differences were found in the secondary endpoints except for the incidence of acute kidney failure, which was more frequent in the immediate CAG group (15.6% vs 0%, P=.002) and infections, which were higher in the delayed CAG group (46.9% vs 73.5%, P=.003). CONCLUSIONS In this underpowered randomized trial involving patients resuscitated after OHCA without STEMI, immediate CAG provided no benefit in terms of survival without neurological impairment compared with delayed CAG. CLINICALTRIALS gov Identifier: NCT02641626.
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Affiliation(s)
- Ana Viana-Tejedor
- Servicio de Cardiología, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria Hospital Clínico San Carlos (IdISSC), Madrid, Spain.
| | - Rut Andrea-Riba
- Instituto Cardiovascular, Hospital Clinic Barcelona, Universidad de Barcelona, Institut D́Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Claudia Scardino
- Servicio de Cardiología. Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain
| | - Albert Ariza-Solé
- Servicio de Cardiología, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Jordi Bañeras
- Servicio de Cardiología, Hospital Universitario Vall d'Hebron, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), España
| | - Cosme García-García
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), España; Servicio de Cardiología, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
| | - Manuel Jiménez Mena
- Servicio de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Monserrat Vila
- Servicio de Cardiología, Fundació Institut de Recerca de l'Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Manuel Martínez-Sellés
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), España; Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Universidad Complutense, Universidad Europea, Madrid, Spain
| | - Gemma Pastor
- Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - José María García Acuña
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), España; Servicio de Cardiología, Hospital Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Pablo Loma-Osorio
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), España; Servicio de Cardiología, Institut d Investigación Biomedica Dr. Josep Trueta de Girona, Girona, Spain
| | | | - Pablo Jorge Pérez
- Servicio de Cardiología, Hospital Universitario de Canarias, Tenerife, Spain
| | - Pablo Pastor
- Servicio de Cardiología, Hospital Universitari Arnau de Vilanova, Lleida - IRBLL, Lleida, Spain
| | - Carlos Ferrera
- Servicio de Cardiología, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Francisco J Noriega
- Servicio de Cardiología, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Natalia Pérez Macías
- Unidades de Investigación Clínica y Ensayos Clínicos (UICEC), Instituto de Investigación Sanitaria Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Antonio Fernández-Ortiz
- Servicio de Cardiología, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Julián Pérez-Villacastín
- Servicio de Cardiología, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria Hospital Clínico San Carlos (IdISSC), Madrid, Spain
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16
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Gutierrez A, Kalra R, Elliott AM, Marquez A, Yannopoulos D, Bartos JA. Acute lung injury and recovery in patients with refractory VT/VF cardiac arrest treated with prolonged CPR and veno-arterial extracorporeal membrane oxygenation. Resuscitation 2023; 182:109651. [PMID: 36442595 DOI: 10.1016/j.resuscitation.2022.11.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 11/19/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022]
Abstract
AIM Describe the lung injury patterns among patients presenting with refractory ventricular tachycardia/ventricular fibrillation out-of-hospital cardiac arrest (VT/VF OHCA) supported with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) facilitated resuscitation. METHODS In this retrospective single-center cohort study including VT/VF OHCA patients supported with VA ECMO, we compared OHCA characteristics, post-arrest computed tomography (CT) scans, ventilator parameters, and other lung-related pathology between survivors, patients who developed brain death, and those with other causes of death. RESULTS Among 138 patients, 48/138 (34.8%) survived, 31/138 (22.4%) developed brain death, and 59/138 (42.7%) died of other causes. Successful extubation was achieved in 39/138 (28%) with a median time to extubation of 8.0 days (6.0, 11.0) in those who survived. Tracheostomy was required in 15/48 (31.3%) survivors. Chest CT obtained on all patients showed lung injury in at least one lung area in 124/135 (91.8%) patients, predominantly in the dependent posterior areas. There was no association between the number of affected areas and survival. Lung compliance was low on admission [26 (19,33) ml/cmH20], improved throughout hospitalization (p = 0.03), and recovered faster in survivors compared to those who died (p < 0.001). VA-ECMO allowed the use of lung-protective ventilation while maintaining normalized PaO2 and PaCO2. Patients treated with V-A ECMO and either IABP or Impella had lower pulmonary compliance and more affected areas on their CT compared to those treated with V-A ECMO alone. CONCLUSIONS Lung injury is common among patients with refractory VT/VF OHCA requiring V-A ECMO, but imaging severity is not associated with survival. Reductions in lung compliance accompany post-arrest lung injury while compliance recovery is associated with survival.
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Affiliation(s)
- Alejandra Gutierrez
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States; Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States.
| | - Rajat Kalra
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States; Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Andrea M Elliott
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States; Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Alexandra Marquez
- Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States; Pediatric Cardiology Critical Care, Children's Hospital, University of Minnesota, United States
| | - Demetris Yannopoulos
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States; Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Jason A Bartos
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States; Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
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Abdulmajeed F, Hamandi M, Malaiyandi D, Shutter L. Neurocritical Care in the General Intensive Care Unit. Crit Care Clin 2023; 39:153-169. [DOI: 10.1016/j.ccc.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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18
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Pre-hospital guidelines for CPR-Induced Consciousness (CPRIC): A scoping review. Resusc Plus 2022; 12:100335. [DOI: 10.1016/j.resplu.2022.100335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 11/10/2022] [Accepted: 11/12/2022] [Indexed: 11/29/2022] Open
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19
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Viana-Tejedor A, Andrea-Riba R, Scardino C, Ariza-Solé A, Bañeras J, García-García C, Jiménez Mena M, Vila M, Martínez-Sellés M, Pastor G, García Acuña JM, Loma-Osorio P, García Rubira JC, Jorge Pérez P, Pastor P, Ferrera C, Noriega FJ, Pérez Macías N, Fernández-Ortiz A, Pérez-Villacastín J. Coronariografía urgente en los pacientes con parada cardiaca extrahospitalaria sin elevación del segmento ST. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Harhash AA, Kluge MA, Muthukrishnan A, Noc M, Radsel P, Jentzer JC, Seder DB, Lee K, Lotun K, Stub D, Hsu CH, Kern KB. Coronary angiographic findings for out-of-hospital cardiac arrest survivors presenting with nonshockable rhythms and no ST elevation post resuscitation. Resuscitation 2022; 178:63-68. [PMID: 35870556 DOI: 10.1016/j.resuscitation.2022.07.023] [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: 03/28/2022] [Revised: 06/27/2022] [Accepted: 07/18/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Recent guidelines suggest that coronary angiography (CAG) should be considered for out-of-hospital cardiac arrest (OHCA) survivors, including those without ST elevation (STE) and without shockable rhythms. However, there is no prospective data to support CAG for survivors with nonshockable rhythms and no STE post resuscitation. METHODS This was a re-analysis of the PEARL study (randomized OHCA survivors without STE to early CAG versus not). Patients were subdivided by initial rhythm as nonshockable (Nsh) vs shockable (Sh). The primary outcome was coronary angiographic evidence of acute culprit lesion, with secondary outcomes being survival to hospital discharge and neurological recovery. RESULTS The PEARL study included 99 patients with OHCA from a presumed cardiac etiology, 24 with nonshockable and 75 with shockable rhythms. There was no difference in the frequency of CAG between the two groups [71% (Nsh) and 75% (Sh); p = 0.79], presence of CAD [81% (Nsh) and 68% (sh); p = 0.37, or culprit lesions identified in each group [50% (Nsh) and 45% (Sh); p = 0.78. Nonshockable patients had worse discharge survival [33% (Nsh) vs 57% (Sh); p = 0.04] and those survived, had worse neurological recovery [30% (Nsh) vs 54% (Sh); p = 0.02] compared to shockable patients. CONCLUSIONS OHCA survivors presenting with nonshockable rhythms and no STE post resuscitation had similar prevalence of culprit coronary lesions to those with shockable rhythms. CAG may be considered in patients with OHCA without STE regardless of initial presenting rhythm. There was no benefit of emergent CAG both in shockable and non-shockable rhythms.
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Affiliation(s)
- A A Harhash
- University of Vermont Medical Center, Burlington, VT, United States
| | - M A Kluge
- University of Vermont Medical Center, Burlington, VT, United States
| | - A Muthukrishnan
- University of Vermont Medical Center, Burlington, VT, United States
| | - M Noc
- Center for Intensive Medicine, University Medical Center Ljubljana, Slovenia
| | - P Radsel
- Center for Intensive Medicine, University Medical Center Ljubljana, Slovenia
| | - J C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - D B Seder
- Department of Critical Care Services, Maine Medical Center, ME, United States
| | - K Lee
- University of Arizona Sarver Heart Center, Tucson, AZ, United States
| | - K Lotun
- University of Arizona Sarver Heart Center, Tucson, AZ, United States
| | - D Stub
- Alfred Hospital & Monash University, Melbourne, Australia
| | - C-H Hsu
- University of Arizona Sarver Heart Center, Tucson, AZ, United States
| | - K B Kern
- University of Arizona Sarver Heart Center, Tucson, AZ, United States.
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Oh TK, Cho M, Song IA. Impact of trained intensivist coverage on survival outcomes after in-hospital cardiopulmonary resuscitation: A nationwide cohort study in South Korea. Resuscitation 2022; 178:69-77. [PMID: 35870558 DOI: 10.1016/j.resuscitation.2022.07.022] [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: 06/10/2022] [Revised: 07/09/2022] [Accepted: 07/15/2022] [Indexed: 10/17/2022]
Abstract
AIM We aimed to investigate whether trained intensivist coverage affects survival outcomes following in-hospital cardiopulmonary resuscitation (ICPR) for in-hospital cardiac arrest (IHCA). METHODS All adult patients who received ICPR for IHCA between January 1, 2016 and December 31, 2019 in South Korea were included. Patients who received ICPR in hospitals with trained intensivist coverage for ICU staffing were defined as the intensivist group, whereas other patients were considered the non-intensivist group. RESULTS In total 68,286 adult patients (36,025 [52.8%] in the intensivist group and 32,261 [47.2%] in the non-intensivist group) were included in the analysis. After propensity score (PS) matching 40,988 patients (20,494 in each group) were included. In logistic regression after PS matching, the intensivist group showed a 17% (odds ratio: 1.17; 95% confidence interval [CI]: 1.12-1.22; P < 0.001) higher live discharge rate after ICPR than the non-intensivist group. In Cox regression after PS matching, the 6-month and the 1-year mortality rates in the intensivist group after ICPR were 11% (hazard ratio [HR]: 0.89; 95% CI: 0.87-0.91; P < 0.001) and 10% (HR: 0.90; 95% CI: 0.88-0.92; P < 0.001) lower than those in the non-intensivist group, respectively. In Kaplan-Meir estimation the median survival time after ICPR in the intensivist group was 12.0 days (95% CI: 11.6-12.4) while that in the non-intensivist group was 8.0 days (95% CI: 7.7-8.3). CONCLUSIONS Trained intensivist coverage in the ICU was associated with improvements in both short and long-term survival outcomes after ICPR for IHCA.
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Affiliation(s)
- Tak Kyu Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, South Korea
| | - Mincheul Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - In-Ae Song
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, South Korea.
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Tsuchida T, Ono K, Maekawa K, Hayamizu M, Hayakawa M. Effect of annual hospital admissions of out-of-hospital cardiac arrest patients on prognosis following cardiac arrest. BMC Emerg Med 2022; 22:121. [PMID: 35794536 PMCID: PMC9261001 DOI: 10.1186/s12873-022-00685-7] [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: 03/13/2022] [Accepted: 06/29/2022] [Indexed: 11/30/2022] Open
Abstract
Background Although the prognosis of patients treated at specialized facilities has improved, the relationship between the number of patients treated at hospitals and prognosis is controversial and lacks constancy in those with out-of-hospital cardiac arrest (OHCA). This study aimed to clarify the effect of annual hospital admissions on the prognosis of adult patients with OHCA by analyzing a large cohort. Methods The effect of annual hospital admissions on patient prognosis was analyzed retrospectively using data from the Japanese Association for Acute Medicine OHCA registry, a nationwide multihospital prospective database. This study analyzed 3632 of 35,754 patients hospitalized for OHCA of cardiac origin at 86 hospitals. The hospitals were divided into tertiles based on the volume of annual admissions. The effect of hospital volume on prognosis was analyzed using logistic regression analysis with multiple imputation. Furthermore, three subgroup analyses were performed for patients with return of spontaneous circulation (ROSC) before arrival at the emergency department, patients admitted to critical care medical centers, and patients admitted to extracorporeal membrane oxygenation-capable hospitals. Results Favorable neurological outcomes 30 days after OHCA for patients overall showed no advantage for medium- and high-volume centers over low-volume centers; Odds ratio (OR) 0.989, (95% Confidence interval [CI] 0.562-1.741), OR 1.504 (95% CI 0.919-2.463), respectively. However, the frequency of favorable neurological outcomes in OHCA patients with ROSC before arrival at the emergency department at high-volume centers was higher than those at low-volume centers (OR 1.955, 95% CI 1.033-3.851). Conclusion Hospital volume did not significantly affect the prognosis of adult patients with OHCA. However, transport to a high-volume hospital may improve the neurological prognosis in OHCA patients with ROSC before arrival at the emergency department. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-022-00685-7.
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Affiliation(s)
- Takumi Tsuchida
- Department of Emergency Medicine, Hokkaido University Hospital, N14W5 Kita-ku, Sapporo, 060-8648, Japan.
| | - Kota Ono
- Ono Biostat Consulting, Narita-higashi, Suginami-ku, Tokyo, 166-0015, Japan
| | - Kunihiko Maekawa
- Department of Emergency Medicine, Hokkaido University Hospital, N14W5 Kita-ku, Sapporo, 060-8648, Japan
| | - Mariko Hayamizu
- Department of Emergency Medicine, Hokkaido University Hospital, N14W5 Kita-ku, Sapporo, 060-8648, Japan
| | - Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, N14W5 Kita-ku, Sapporo, 060-8648, Japan
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Alves N, Mota M, Cunha M, Ribeiro JM. Impact of emergent coronary angiography after out-of-the-hospital cardiac arrest without ST-segment elevation - a systematic review and meta-analysis. Int J Cardiol 2022; 364:1-8. [PMID: 35660557 DOI: 10.1016/j.ijcard.2022.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 05/15/2022] [Accepted: 06/01/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Coronary artery disease is a leading cause of out-of-the-hospital cardiac arrest (OHCA). However, there is no consensus on whether OHCA patients without ST-segment elevation (STE) benefit from emergent (ie < 2 h) coronary angiography (CAG). Our aim was to assess the impact of emergent CAG in no-STE OHCA patients. METHODS We performed a systematic review and meta-analysis by searching the MEDLINE, Cochrane, Scopus, CINAHL and JBI databases for randomized controlled trials (RCTs) comparing emergent CAG versus standard of care (ie CAG >2 h after OHCA or not performed) in no-STE OHCA patients of presumed cardiac aetiology. The primary outcome was short term survival. Secondary outcomes included survival with good neurological outcome, mid-term survival, left ventricle ejection fraction (LVEF), acute kidney injury (AKI) and renal replacement therapy (RRT), ventricular arrhythmias and major bleeding during hospital stay. RESULTS Seven RCTs met the inclusion and exclusion criteria and were included; one was included only in the analysis of mid-term survival and another in the LVEF analysis. Five studies (1278 patients, 643 with early CAG and 635 with no early CAG) were included in the analysis of the primary endpoint. The groups were balanced for all baseline characteristics but previous PCI, which was more frequent in the standard of care groups. There were no significant differences between groups for short-term survival (57 vs 61%; OR0.85, 95% CI0.68-1.07; I2 = 0%). There were also no differences for any of the secondary endpoints. CONCLUSION Routine emergent CAG did not improve survival in comatose survivors of OHCA with shockable rhythm and no-STE.
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Affiliation(s)
- Nuno Alves
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Politécnico de Viseu, Escola Superior de Saúde, Viseu, Portugal; UICISA:E, ESEnfC, Coimbra / SIGMA - Phi Xi Chapter, ESEnfC, Coimbra, Portugal
- CIEC -, UM, Braga, Portugal
| | - Mauro Mota
- Politécnico de Viseu, Escola Superior de Saúde, Viseu, Portugal; Unidade de Investigação em Ciências da Saúde: Enfermagem (UICISA:E)
- Unidade Local de Saúde da Guarda, Portugal
| | - Madelena Cunha
- Politécnico de Viseu, Escola Superior de Saúde, Viseu, Portugal; Serviço de Cardiologia, Centro Hospitalar de Entre o Douro e Vouga, Santa Maria da Feira, Portugal
| | - Joana Maria Ribeiro
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Serviço de Cardiologia, Centro Hospitalar de Entre o Douro e Vouga, Santa Maria da Feira, Portugal.
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Cardiac arrest centres: what, who, when, and where? Curr Opin Crit Care 2022; 28:262-269. [PMID: 35653246 DOI: 10.1097/mcc.0000000000000934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Cardiac arrest centres (CACs) may play a key role in providing postresuscitation care, thereby improving outcomes in out-of-hospital cardiac arrest (OHCA). There is no consensus on CAC definitions or the optimal CAC transport strategy despite advances in research. This review provides an updated overview of CACs, highlighting evidence gaps and future research directions. RECENT FINDINGS CAC definitions vary worldwide but often feature 24/7 percutaneous coronary intervention capability, targeted temperature management, neuroprognostication, intensive care, education, and research within a centralized, high-volume hospital. Significant evidence exists for benefits of CACs related to regionalization. A recent meta-analysis demonstrated clearly improved survival with favourable neurological outcome and survival among patients transported to CACs with conclusions robust to sensitivity analyses. However, scarce data exists regarding 'who', 'when', and 'where' for CAC transport strategies. Evidence for OHCA patients without ST elevation postresuscitation to be transported to CACs remains unclear. Preliminary evidence demonstrated greater benefit from CACs among patients with shockable rhythms. Randomized controlled trials should evaluate specific strategies, such as bypassing nearest hospitals and interhospital transfer. SUMMARY Real-world study designs evaluating CAC transport strategies are needed. OHCA patients with underlying culprit lesions, such as those with ST-elevation myocardial infarction (STEMI) or initial shockable rhythms, will likely benefit the most from CACs.
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Influence of circulatory shock at hospital admission on outcome after out-of-hospital cardiac arrest. Sci Rep 2022; 12:8293. [PMID: 35585159 PMCID: PMC9117194 DOI: 10.1038/s41598-022-12310-5] [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: 09/10/2021] [Accepted: 05/09/2022] [Indexed: 01/27/2023] Open
Abstract
Hypotension after cardiac arrest could aggravate prolonged hypoxic ischemic encephalopathy. The association of circulatory shock at hospital admission with outcome after cardiac arrest has not been well studied. The objective of this study was to investigate the independent association of circulatory shock at hospital admission with neurologic outcome, and to evaluate whether cardiovascular comorbidities interact with circulatory shock. 4004 adult patients with out-of-hospital cardiac arrest enrolled in the International Cardiac Arrest Registry 2006–2017 were included in analysis. Circulatory shock was defined as a systolic blood pressure below 90 mmHg and/or medical or mechanical supportive measures to maintain adequate perfusion during hospital admission. Primary outcome was cerebral performance category (CPC) dichotomized as good, (CPC 1–2) versus poor (CPC 3–5) outcome at hospital discharge. 38% of included patients were in circulatory shock at hospital admission, 32% had good neurologic outcome at hospital discharge. The adjusted odds ratio for good neurologic outcome in patients without preexisting cardiovascular disease with circulatory shock at hospital admission was 0.60 [0.46–0.79]. No significant interaction was detected with preexisting comorbidities in the main analysis. We conclude that circulatory shock at hospital admission after out-of-hospital cardiac arrest is independently associated with poor neurologic outcome.
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Skrifvars MB, Kurola J. The 2022 Finnish Current Care Guidelines for Cardiopulmonary Resuscitation recommend avoiding fever and not mild therapeutic hypothermia in unconscious patients after cardiac arrest. Acta Anaesthesiol Scand 2022; 66:427-429. [PMID: 35090040 DOI: 10.1111/aas.14027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 01/15/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Markus B. Skrifvars
- Department of Emergency Care and Services Helsinki University Hospital and University of Helsinki Helsinki Finland
| | - Jouni Kurola
- Centre for Prehospital Emergency Care Kuopio University Hospital and University of Eastern Finland Kuopio Finland
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Abstract
INTRODUCTION Out-of-hospital cardiac arrest (OHCA) is well studied in high-income countries, and research has encouraged the implementation of policy to increase survival rates. On the other hand, comprehensive research on OHCA in Africa is sparse, despite the higher incidence of risk factors. In this vein, structural barriers to OHCA care in Africa must be fully recognised and understood before similar improvements in outcome may be made. The aim of this study was to describe and summarise the body of literature related to OHCA in Africa. METHODS AND ANALYSIS Using an a priori developed search strategy, electronic searches were performed in Medline via Pubmed, Web of Science, Scopus and Google Scholar databases to identify articles published in English between 2000 and 2020 relevant to OHCA in Africa. Titles, abstract and full text were reviewed by two reviewers, with discrepancies handled by an independent reviewer. A summary of the main themes contained in the literature was developed using descriptive analysis on eligible articles. RESULTS A total of 1200 articles were identified. In the screening process, 785 articles were excluded based on title, and a further 127 were excluded following abstract review. During full-text review to determine eligibility, 80 articles were excluded and one was added following references review. A total of 19 articles met the inclusion criteria. During analysis, the following three themes were found: epidemiology and underlying causes for OHCA, first aid training and bystander action, and Emergency Medical Services (EMS) resuscitation and training. CONCLUSIONS In order to begin addressing OHCA in Africa, representative research with standardised reporting that complies to data standards is required to understand the full, context-specific picture. Policies and research may then target underlying conditions, improvements in bystander and EMS training, and system improvements that are contextually relevant and ultimately result in better outcomes for OHCA victims.
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Affiliation(s)
- Juliette Thibodeau
- University of Chicago Biological Sciences Division, Chicago, Illinois, USA
| | - Kalin Werner
- Division of Emergency Medicine, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Lee A Wallis
- Division of Emergency Medicine, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Willem Stassen
- Division of Emergency Medicine, University of Cape Town, Rondebosch, Western Cape, South Africa
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Choi ES, Park GH, Kim DS, Shin HS, Park SY, Kim M, Hong JM. A novel global ischemia-reperfusion rat model with asymmetric brain damage simulating post-cardiac arrest brain injury. J Neurosci Methods 2022; 372:109554. [DOI: 10.1016/j.jneumeth.2022.109554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 02/21/2022] [Accepted: 02/28/2022] [Indexed: 11/29/2022]
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Kjaergaard J, Schmidt H, Møller JE, Hassager C. The “Blood pressure and oxygenation targets in post resuscitation care, a randomized clinical trial”: design and statistical analysis plan. Trials 2022; 23:177. [PMID: 35209951 PMCID: PMC8867659 DOI: 10.1186/s13063-022-06101-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 02/10/2022] [Indexed: 12/27/2022] Open
Abstract
Background Comatose patients admitted after resuscitation from cardiac arrest have a significant risk of poor outcome due to hypoxic brain injury. While numerous studies have investigated and challenged the target temperature as the efficacious part of the guideline endorsed Targeted Temperature Management (TTM) protocols, our knowledge and how the remaining parts of the TTM are optimized remain sparse. The present randomized trial investigated two aspects of the TTM protocol: target blood pressure during the ICU stay and oxygenation during mechanical ventilation. Furthermore, the efficacy of device-based post-TTM fever management is addressed. Methods Investigator-initiated, dual-center, randomized clinical trial in comatose OHCA patients admitted to an intensive cardiac care unit. Patients are eligible for inclusion if unconscious, older than 18 years of age, and have return of spontaneous circulation for more than 20 min. Intervention: allocation 1:1:1:1 into a group defined by (a) blood pressure targets in double-blind intervention targeting a mean arterial blood pressure of 63 or 77 mmHg and (b) restrictive (9–10 kPa) or liberal (13–14 kPa) of arterial oxygen concentration during mechanical ventilation. As a subordinate intervention, device-based active fever management is discontinued after 36 h or 72. Patients will otherwise receive protocolized standard of care according to international guidelines, including targeted temperature management at 36 °C for 24 h, sedation with fentanyl and propofol, and multimodal neuro-prognostication. Primary endpoint: Discharge from hospital in poor neurological status (Cerebral Performance category 3 or 4) or death, whichever comes first. Secondary outcomes: Time to initiation of renal replacement therapy or death, neuron-specific enolase (NSE) level at 48 h, MOCA score at day 90, Modified Ranking Scale (mRS) and CPC at 3 months, NT-pro-BNP at 90 days, eGFR and LVEF at 90 days, daily cumulated vasopressor requirement during ICU stay, and need for a combination of vasopressors and inotropic agents or mechanical circulatory support. Discussion We hypothesize that low or high target blood pressure and restrictive and liberal oxygen administration will have an impact on mortality by reducing the risk and degree of hypoxic brain injury. This will be assessment neurological outcome and biochemical and neuropsychological testing after 90 days. Trial registration ClinicalTrials.gov NCT03141099. Registered on May 2017 (retrospectively registered)
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Verghese D, Harsha Patlolla S, Cheungpasitporn W, Doshi R, Miller VM, Jentzer JC, Jaffe AS, Holmes DR, Vallabhajosyula S. Sex Disparities in Management and Outcomes of Cardiac Arrest Complicating Acute Myocardial Infarction in the United States. Resuscitation 2022; 172:92-100. [DOI: 10.1016/j.resuscitation.2022.01.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/16/2022] [Accepted: 01/24/2022] [Indexed: 02/08/2023]
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Yeo JW, Ng ZHC, Goh AXC, Gao JF, Liu N, Lam SWS, Chia YW, Perkins GD, Ong MEH, Ho AFW. Impact of Cardiac Arrest Centers on the Survival of Patients With Nontraumatic Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2021; 11:e023806. [PMID: 34927456 PMCID: PMC9075197 DOI: 10.1161/jaha.121.023806] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background The role of cardiac arrest centers (CACs) in out‐of‐hospital cardiac arrest care systems is continuously evolving. Interpretation of existing literature is limited by heterogeneity in CAC characteristics and types of patients transported to CACs. This study assesses the impact of CACs on survival in out‐of‐hospital cardiac arrest according to varying definitions of CAC and prespecified subgroups. Methods and Results Electronic databases were searched from inception to March 9, 2021 for relevant studies. Centers were considered CACs if self‐declared by study authors and capable of relevant interventions. Main outcomes were survival and neurologically favorable survival at hospital discharge or 30 days. Meta‐analyses were performed for adjusted odds ratio (aOR) and crude odds ratios. Thirty‐six studies were analyzed. Survival with favorable neurological outcome significantly improved with treatment at CACs (aOR, 1.85 [95% CI, 1.52–2.26]), even when including high‐volume centers (aOR, 1.50 [95% CI, 1.18–1.91]) or including improved‐care centers (aOR, 2.13 [95% CI, 1.75–2.59]) as CACs. Survival significantly increased with treatment at CACs (aOR, 1.92 [95% CI, 1.59–2.32]), even when including high‐volume centers (aOR, 1.74 [95% CI, 1.38–2.18]) or when including improved‐care centers (aOR, 1.97 [95% CI, 1.71–2.26]) as CACs. The treatment effect was more pronounced among patients with shockable rhythm (P=0.006) and without prehospital return of spontaneous circulation (P=0.005). Conclusions were robust to sensitivity analyses, with no publication bias detected. Conclusions Care at CACs was associated with improved survival and neurological outcomes for patients with nontraumatic out‐of‐hospital cardiac arrest regardless of varying CAC definitions. Patients with shockable rhythms and those without prehospital return of spontaneous circulation benefited more from CACs. Evidence for bypassing hospitals or interhospital transfer remains inconclusive.
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Affiliation(s)
- Jun Wei Yeo
- Yong Loo Lin School of Medicine National University of Singapore Singapore
| | - Zi Hui Celeste Ng
- Yong Loo Lin School of Medicine National University of Singapore Singapore
| | | | | | - Nan Liu
- Centre for Quantitative Medicine Duke-NUS Medical SchoolNational University of Singapore Singapore
| | - Shao Wei Sean Lam
- Health Services Research Centre SingHealth Duke-NUS Academic Medical Centre Singapore
| | - Yew Woon Chia
- Department of Cardiology Tan Tock Seng Hospital Singapore
| | - Gavin D Perkins
- Warwick Medical School University of Warwick Coventry United Kingdom
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine Singapore General Hospital Singapore.,Health Services & Systems Research Duke-NUS Medical School Singapore
| | - Andrew Fu Wah Ho
- Department of Emergency Medicine Singapore General Hospital Singapore.,Pre-Hospital and Emergency Research Centre Health Services and Systems Research Duke-NUS Medical School Singapore
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Jacobs AK, Ali MJ, Best PJ, Bieniarz MC, Bufalino VJ, French WJ, Henry TD, Hollowell L, Jauch EC, Kurz MC, Levy M, Patel P, Spier T, Stone RH, Tataris KL, Thomas RJ, Zègre-Hemsey JK. Systems of Care for ST-Segment-Elevation Myocardial Infarction: A Policy Statement From the American Heart Association. Circulation 2021; 144:e310-e327. [PMID: 34641735 DOI: 10.1161/cir.0000000000001025] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The introduction of Mission: Lifeline significantly increased timely access to percutaneous coronary intervention for patients with ST-segment-elevation myocardial infarction (STEMI). In the years since, morbidity and mortality rates have declined, and research has led to significant developments that have broadened our concept of the STEMI system of care. However, significant barriers and opportunities remain. From community education to 9-1-1 activation and emergency medical services triage and from emergency department and interfacility transfer protocols to postacute care, each critical juncture presents unique challenges for the optimal care of patients with STEMI. This policy statement sets forth recommendations for how the ideal STEMI system of care should be designed and implemented to ensure that patients with STEMI receive the best evidence-based care at each stage in their illness.
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Elliott A, Dahyia G, Kalra R, Alexy T, Bartos J, Kosmopoulos M, Yannopoulos D. Extracorporeal Life Support for Cardiac Arrest and Cardiogenic Shock. US CARDIOLOGY REVIEW 2021. [DOI: 10.15420/usc.2021.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The rising incidence and recognition of cardiogenic shock has led to an increase in the use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). As clinical experience with this therapy has increased, there has also been a rapid growth in the body of observational and randomized data describing the clinical and logistical considerations required to institute a VA-ECMO program with successful clinical outcomes. The aim of this review is to summarize this contemporary data in the context of four key themes that pertain to VA-ECMO programs: the principles of patient selection; basic hemodynamic and technical principles underlying VA-ECMO; contraindications to VA-ECMO therapy; and common complications and intensive care considerations that are encountered in the setting of VA-ECMO therapy.
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Affiliation(s)
- Andrea Elliott
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Garima Dahyia
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Rajat Kalra
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Tamas Alexy
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Jason Bartos
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Marinos Kosmopoulos
- Department of Medicine, Division of Cardiology, Center for Resuscitation Medicine, University of Minnesota, Minneapolis, MN
| | - Demetri Yannopoulos
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
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Harhash AA, May T, Hsu CH, Seder DB, Dankiewicz J, Agarwal S, Patel N, McPherson J, Riker R, Soreide E, Hirsch KG, Stammet P, Dupont A, Forsberg S, Rubertsson S, Friberg H, Nielsen N, Mooney MR, Kern KB. Incidence of cardiac interventions and associated cardiac arrest outcomes in patients with nonshockable initial rhythms and no ST elevation post resuscitation. Resuscitation 2021; 167:188-197. [PMID: 34437992 DOI: 10.1016/j.resuscitation.2021.08.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 08/02/2021] [Accepted: 08/12/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Out of Hospital Cardiac arrest (OHCA) survivors with ST elevation (STE) with or without shockable rhythms often benefit from coronary angiography (CAG) and, if indicated, percutaneous coronary intervention (PCI). However, the benefits of CAG and PCI in OHCA survivors with nonshockable rhythms (PEA/asystole) and no STE are debated. METHODS Using the International Cardiac Arrest Registry (INTCAR 2.0), representing 44 centers in the US and Europe, comatose OHCA survivors with known presenting rhythms and post resuscitation ECGs were identified. Survival to hospital discharge, neurological recovery on discharge, and impact of CAG with or without PCI on such outcome were assessed and compared with other groups (shockable rhythms with or without STE). RESULTS Total of 2113 OHCA survivors were identified and described as; nonshockable/no STE (Nsh-NST) (n = 940, 44.5%), shockable/no STE (Sh-NST) (n = 716, 33.9%), nonshockable/STE (Nsh-ST) (n = 110, 5.2%), and shockable/STE (Sh-ST) (n = 347, 16.4%). Of Nsh-NST, 13.7% (129) were previously healthy before CA and only 17.3% (161) underwent CAG; of those, 30.4% (52) underwent PCI. A total of 18.6% (174) Nsh-NST patients survived to hospital discharge, with 57.5% (100) of such survivors having good neurological recovery (cerebral performance category 1 or 2) on discharge. Coronary angiography was associated with improved odds for survival and neurological recovery among all groups, including those with NSh-NST. CONCLUSIONS Nonshockable initial rhythms with no ST elevation post resuscitation was the most common presentation after OHCA. Although most of these patients did not undergo coronary angiography, among those who did, 1 in 4 patients had a culprit lesion and underwent revascularization. Invasive CAG should be at least considered for all OHCA survivors, including those with nonshockable rhythms and no ST elevation post resuscitation. BRIEF ABSTRACT Out of hospital cardiac arrest (OHCA) survivors with ST elevation and/or shockable rhythms benefit from coronary angiography and revascularization. Nonshockable cardiac arrest survivors with no ST elevation have the worst prognosis and rarely undergo coronary angiography. Nonshockable rhythms with no ST elevation was the most common presentation after OHCA and among a small subgroup underwent coronary angiography, 1 in 4 patients with had culprit lesion and underwent revascularization. Coronary angiography was associated with high prevalence of acute culprit coronary lesions and should be considered for those with a probably cardiac cause for their arres.
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Affiliation(s)
- Ahmed A Harhash
- University of Arizona Sarver Heart Center, Tucson, AZ, United States; University of Vermont Medical Center, Burlington, VT, United States
| | - Teresa May
- Maine Medical Center, Portland, ME, United States
| | - Chiu-Hsieh Hsu
- University of Arizona College of Public Health, Tucson, AZ, United States
| | | | | | | | - Nainesh Patel
- Lehigh Valley Heart Institute, Allentown, PA, United States
| | - John McPherson
- Vanderbilt University Medical Center, Nashville, TN, United States
| | | | | | | | | | | | | | | | | | - Niklas Nielsen
- Lund University, Helsingborg Hospital, Helsingborg, Sweden
| | | | - Karl B Kern
- University of Arizona Sarver Heart Center, Tucson, AZ, United States.
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Harhash AA, May TL, Hsu CH, Agarwal S, Seder DB, Mooney MR, Patel N, McPherson J, McMullan P, Riker R, Soreide E, Hirsch KG, Stammet P, Dupont A, Rubertsson S, Friberg H, Nielsen N, Rab T, Kern KB. Risk Stratification Among Survivors of Cardiac Arrest Considered for Coronary Angiography. J Am Coll Cardiol 2021; 77:360-371. [PMID: 33509392 DOI: 10.1016/j.jacc.2020.11.043] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 11/12/2020] [Accepted: 11/16/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND The American College of Cardiology Interventional Council published consensus-based recommendations to help identify resuscitated cardiac arrest patients with unfavorable clinical features in whom invasive procedures are unlikely to improve survival. OBJECTIVES This study sought to identify how many unfavorable features are required before prognosis is significantly worsened and which features are most impactful in predicting prognosis. METHODS Using the INTCAR (International Cardiac Arrest Registry), the impact of each proposed "unfavorable feature" on survival to hospital discharge was individually analyzed. Logistic regression was performed to assess the association of such unfavorable features with poor outcomes. RESULTS Seven unfavorable features (of 10 total) were captured in 2,508 patients successfully resuscitated after cardiac arrest (ongoing cardiopulmonary resuscitation and noncardiac etiology were exclusion criteria in our registry). Chronic kidney disease was used in lieu of end-stage renal disease. In total, 39% survived to hospital discharge. The odds ratio (OR) of survival to hospital discharge for each unfavorable feature was as follows: age >85 years OR: 0.30 (95% CI: 0.15 to 0.61), time-to-ROSC >30 min OR: 0.30 (95% CI: 0.23 to 0.39), nonshockable rhythm OR: 0.39 (95% CI: 0.29 to 0.54), no bystander cardiopulmonary resuscitation OR: 0.49 (95% CI: 0.38 to 0.64), lactate >7 mmol/l OR: 0.50 (95% CI: 0.40 to 0.63), unwitnessed arrest OR: 0.58 (95% CI: 0.44 to 0.78), pH <7.2 OR: 0.78 (95% CI: 0.63 to 0.98), and chronic kidney disease OR: 0.96 (95% CI: 0.70 to 1.33). The presence of any 3 or more unfavorable features predicted <40% survival. Presence of the 3 strongest risk factors (age >85 years, time-to-ROSC >30 min, and non-ventricular tachycardia/ventricular fibrillation) together or ≥6 unfavorable features predicted a ≤10% chance of survival to discharge. CONCLUSIONS Patients successfully resuscitated from cardiac arrest with 6 or more unfavorable features have a poor long-term prognosis. Delaying or even forgoing invasive procedures in such patients is reasonable.
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Affiliation(s)
- Ahmed A Harhash
- University of Arizona Sarver Heart Center, Tucson, Arizona, USA; University of Vermont, Burlington, Vermont, USA
| | | | - Chiu-Hsieh Hsu
- University of Arizona College of Public Health, Tucson, Arizona, USA
| | | | | | | | - Nainesh Patel
- Lehigh Valley Medical Center, Lehigh, Pennsylvania, USA
| | - John McPherson
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | | | | | | | | | | | | | | | - Tanveer Rab
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Karl B Kern
- University of Arizona Sarver Heart Center, Tucson, Arizona, USA.
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Kwon WY, Jung YS, Suh GJ, Kim T, Kwak H, Kim T, Kim JY, Lee MS, Kim KS, Shin J, Lee HJ, You KM. Regional cerebral oxygen saturation in cardiac arrest survivors undergoing targeted temperature management 36℃ versus 33℃: A randomized clinical trial. Resuscitation 2021; 167:362-371. [PMID: 34331985 DOI: 10.1016/j.resuscitation.2021.07.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/16/2021] [Accepted: 07/21/2021] [Indexed: 11/18/2022]
Abstract
AIM of study To investigate whether regional cerebral oxygen saturation (rSO2) differs in out-of-hospital cardiac arrest (OHCA) survivors undergoing targeted temperature management (TTM) 36℃ versus 33℃. METHODS A randomized clinical trial was conducted at intensive care units in two referral hospitals. Fifty-seven comatose OHCA survivors were randomized into either a 36℃ or 33℃ group. Patients were cooled and maintained at an oesophageal temperature of either 36℃ or 33℃ for 24 hours, rewarmed at a rate of 0.25℃/hour, and maintained at < 37.5℃ until 72 hours. During 72 hours of TTM, rSO2 was continuously monitored on the left forehead using near-infrared spectroscopy (INVOSTM 5100C). The rSO2 level at 72 hours was compared between the two groups. Next, serial rSO2 levels for 72 hours were compared using mixed effects regression. The association between rSO2 levels and 6-month neurological outcomes was also evaluated. RESULTS There were no significant differences in the rSO2 level at 72 hours between the 36℃ and 33℃ groups (p = 0.372). Furthermore, serial rSO2 levels for 72 hours of TTM were not different between the two groups (p = 0.733). However, low rSO2 levels, particularly at 24 hours of TTM, were significantly associated with poor 6-month neurological outcomes (odds ratio = 0.899, 95% confidence interval: 0.831 - 0.974). The area under the receiver operating characteristic curve of the rSO2 level at 24 hours for poor neurological outcomes was 0.800. CONCLUSIONS Regardless of target temperatures, low rSO2 levels during TTM were significantly associated with poor 6-month neurological outcomes in OHCA survivors.
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Affiliation(s)
- Woon Yong Kwon
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul 03080, Republic of Korea; Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Yoon Sun Jung
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Gil Joon Suh
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul 03080, Republic of Korea; Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea.
| | - Taekyun Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Hyeongkyu Kwak
- Department of Emergency Medicine, Uijeongbu Eulji University Hospital/Eulji University School of Medicine, Uijeongbu-si, Gyeonggi-do, Republic of Korea
| | - Taekwon Kim
- Department of Emergency Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Jeong Yeon Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Min Sung Lee
- Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Kyung Su Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Jonghwan Shin
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul 03080, Republic of Korea; Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul 07061, Republic of Korea
| | - Hui Jai Lee
- Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul 07061, Republic of Korea
| | - Kyung Min You
- Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul 07061, Republic of Korea
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Møller S, Wissenberg M, Søndergaard K, Kragholm K, Folke F, Hansen CM, Ringgren KB, Andersen J, Lippert F, Møller AL, Køber L, Gerds TA, Torp-Pedersen C. Long-term outcomes after out-of-hospital cardiac arrest in relation to socioeconomic status. Resuscitation 2021; 167:336-344. [PMID: 34302925 DOI: 10.1016/j.resuscitation.2021.07.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 07/05/2021] [Accepted: 07/14/2021] [Indexed: 01/15/2023]
Abstract
AIMS This study aimed to examine whether socioeconomic differences exist in long-term outcomes after out-of-hospital cardiac arrest (OHCA). METHODS We included 2309 30-day OHCA survivors ≥ 30 years of age from the Danish Cardiac Arrest Registry, 2001-2014, divided in tertiles of household income (low, medium, high). Absolute probabilities were estimated using logistic regression for 1-year outcomes and cause-specific Cox regression for 5-year outcomes. Differences between income-groups were standardized with respect to age, sex, education and comorbidities. RESULTS High-income compared to low-income patients had highest 1-year (96.4% vs. 84.2%) and 5-year (87.6% vs. 64.1%) survival, and lowest 1-year (11.3% vs. 7.4%) and 5-year (13.7% vs. 8.6%) risk of anoxic brain damage/nursing home admission. The corresponding standardized probability differences were 8.2% (95%CI 4.7-11.6%) and 13.9% (95%CI 8.2-19.7%) for 1- and 5-year survival, respectively; and -4.5% (95%CI -8.2 to -1.2%) and -5.1% (95%CI -9.3 to -0.9%) for 1- and 5-year risk of anoxic brain damage/nursing home admission, respectively. Among 831 patients < 66 years working prior to OHCA, 72.1% returned to work within 1 year and 80.8% within 5 years. High-income compared to low-income patients had the highest chance of 1-year (76.4% vs. 58.8%) and 5-year (85.3% vs. 70.6%) return to work with the corresponding absolute probability difference of 18.0% (95%CI 3.8-32.7%) for 1-year and 9.4% (95%CI -3.4 to 22.3%) for 5-year. CONCLUSION Patients of high socioeconomic status had higher probability of long-term survival and return to work, and lower risk of anoxic brain damage/nursing home admission after OHCA compared to patients of low socioeconomic status.
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Affiliation(s)
- Sidsel Møller
- Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark.
| | - Mads Wissenberg
- Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark; Emergency Medical Services Copenhagen, University of Copenhagen, Denmark
| | - Kathrine Søndergaard
- Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark
| | - Kristian Kragholm
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Fredrik Folke
- Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark; Emergency Medical Services Copenhagen, University of Copenhagen, Denmark
| | - Carolina Malta Hansen
- Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark; Emergency Medical Services Copenhagen, University of Copenhagen, Denmark
| | | | - Julie Andersen
- Danish Heart Foundation, Department of Research, Copenhagen, Denmark
| | - Freddy Lippert
- Emergency Medical Services Copenhagen, University of Copenhagen, Denmark
| | | | - Lars Køber
- The Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Alexander Gerds
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Dalton HJ, Berg RA, Nadkarni VM, Kochanek PM, Tisherman SA, Thiagarajan R, Alexander P, Bartlett RH. Cardiopulmonary Resuscitation and Rescue Therapies. Crit Care Med 2021; 49:1375-1388. [PMID: 34259654 DOI: 10.1097/ccm.0000000000005106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The history of cardiopulmonary resuscitation and the Society of Critical Care Medicine have much in common, as many of the founders of the Society of Critical Care Medicine focused on understanding and improving outcomes from cardiac arrest. We review the history, the current, and future state of cardiopulmonary resuscitation.
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Affiliation(s)
- Heidi J Dalton
- Heart and Vascular Institute and Department of Pediatrics, INOVA Fairfax Medical Center, Falls Church, VA. Department of Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA. Department of Anesthesiology/Critical Care Medicine, Peter Safer Resuscitation Center, Pittsburgh, PA. Department of Surgery, R Adams Cowley Shock Trauma Center, Baltimore, MD. Department of Cardiology, Division of Cardiovascular Critical Care, Boston Children's Hospital, Boston, MA. Department of Surgery, University of Michigan, Ann Arbor, MI
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Otaki Y, Watanabe T, Goto J, Wanezaki M, Kato S, Tamura H, Nishiyama S, Arimoto T, Takahashi H, Watanabe M. Association between thrombolysis in myocardial infarction grade and clinical outcome after emergent percutaneous coronary intervention in patients with acute myocardial infarction who have suffered out-of-hospital cardiac arrest: the Yamagata AMI registry. Heart Vessels 2021; 37:40-49. [PMID: 34228158 DOI: 10.1007/s00380-021-01903-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/02/2021] [Indexed: 11/30/2022]
Abstract
Despite improvements in the survival rate of acute myocardial infarction (AMI), out-of-hospital cardiac arrest (OHCA) due to AMI is still a devastating condition. Thrombolysis in myocardial infarction (TIMI) grade is used to classify coronary reperfusion after percutaneous coronary intervention (PCI), but it remains unclear whether TIMI grade after emergent PCI is associated with short-term mortality in patients with AMI who have suffered OHCA. We analyzed data collected from 2012 to 2017 and recorded in the Yamagata AMI registry, which is a multicenter surveillance conducted in all institutions in Yamagata prefecture. Among 3332 patients with AMI, 254 had suffered OHCA. There were 564 deaths during the 30 days after the onset of AMI. The survival rate was lower in patients who had suffered OHCA than in those who had not (40% vs. 87%; P < 0.0001). Patients with AMI who had suffered OHCA were divided into three groups based on TIMI grade (TIMI III group, n = 70; TIMI ≤ II group, n = 21; and no coronary angiography [non-CAG] group, n = 163). The survival rates in the TIMI III, TIMI ≤ II, and non-CAG groups were 87%, 38%, and 5%, respectively. Kaplan-Meier analysis demonstrated that the survival rate was highest in the TIMI III group. Multivariate Cox proportional hazard regression analysis demonstrated that TIMI III was closely associated with survival after adjustment for confounding factors. Achieving TIMI grade III during emergent PCI is crucial to improve survival in patients with AMI who have suffered OHCA.
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Affiliation(s)
- Yoichiro Otaki
- Department of Advanced Cardiovascular Therapeutics, Yamagata University School of Medicine, Yamagata, Japan
| | - Tetsu Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, 2-2-2 Iida-Nishi, Yamagata, 990-9585, Japan.
| | - Jun Goto
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, 2-2-2 Iida-Nishi, Yamagata, 990-9585, Japan
| | - Masahiro Wanezaki
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, 2-2-2 Iida-Nishi, Yamagata, 990-9585, Japan
| | - Shigehiko Kato
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, 2-2-2 Iida-Nishi, Yamagata, 990-9585, Japan
| | - Harutoshi Tamura
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, 2-2-2 Iida-Nishi, Yamagata, 990-9585, Japan
| | - Satoshi Nishiyama
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, 2-2-2 Iida-Nishi, Yamagata, 990-9585, Japan
| | - Takanori Arimoto
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, 2-2-2 Iida-Nishi, Yamagata, 990-9585, Japan
| | - Hiroki Takahashi
- Department of Advanced Cardiovascular Therapeutics, Yamagata University School of Medicine, Yamagata, Japan
| | - Masafumi Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, 2-2-2 Iida-Nishi, Yamagata, 990-9585, Japan
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Qafiti FN, Rubay D, Shin R, Lottenberg L, Borrego R. Therapeutic Hypothermia With Progesterone Improves Neurologic Outcomes in Ventricular Fibrillation Cardiac Arrest After Electric Shock. Cureus 2021; 13:e15749. [PMID: 34290928 PMCID: PMC8289402 DOI: 10.7759/cureus.15749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2021] [Indexed: 11/24/2022] Open
Abstract
Trauma by electricity imposes mechanical, electrical, and thermal forces on the human body. Often, the delicate cardiac electrophysiology is disrupted causing dysrhythmia and subsequent cardiac arrest. Anoxic brain injury (ABI) is the most severe consequence and the main cause of mortality following cardiac arrest. Establishing a working protocol to treat patients who are at risk for ABI after suffering a cardiac arrest is of paramount importance. There has yet to be sufficient exploration of combination therapy of therapeutic hypothermia (TH) and progesterone as a neuroprotective strategy in patients who have suffered cardiac arrest after electric shock. The protocol required TH initiation upon transfer to the ICU with a target core body temperature of 33°C for 18 hours. This was achieved through a combination of cooling blankets, ice packs, chilled IV fluids, nasogastric lavage with iced saline, and intravascular cooling devices. Progesterone therapy at 80-100 mg intramuscularly every 12 hours for 72 hours was initiated shortly after admission to the ICU. We present a case series of three patients (mean age = 29.3 years, mean presenting Glasgow Coma Score = 3) who suffered ventricular fibrillation (VF) cardiac arrest from non-lightning electric shock, and who had considerably improved outcomes following the TH-progesterone combination therapy protocol. The average length of stay was 13.7 days. The cases presented suggest that there may be a role for neuroprotective combination therapy in post-resuscitation care of VF cardiac arrest. While TH is well documented as a neuroprotective measure, progesterone administration is a safe therapy with promising, albeit currently inconclusive, neuroprotective effect. Future protocols involving TH and progesterone combination therapy in these patients should be further explored.
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Affiliation(s)
- Fred N Qafiti
- General Surgery, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
| | - David Rubay
- Trauma and Surgical Critical Care, University of Florida College of Medicine, Gainesville, USA
| | - Rebecca Shin
- Surgery, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
| | - Lawrence Lottenberg
- Surgery, St. Mary's Medical Center, Florida Atlantic University, West Palm Beach, USA
| | - Robert Borrego
- Surgery, St. Mary's Medical Center, West Palm Beach, USA
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. Postreanimationsbehandlung. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00892-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Kovács E, Gyarmathy VA, Pilecky D, Fekete-Győr A, Szakál-Tóth Z, Gellér L, Hauser B, Gál J, Merkely B, Zima E. An Interaction Effect Analysis of Thermodilution-Guided Hemodynamic Optimization, Patient Condition, and Mortality after Successful Cardiopulmonary Resuscitation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18105223. [PMID: 34068997 PMCID: PMC8156244 DOI: 10.3390/ijerph18105223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/19/2021] [Accepted: 05/08/2021] [Indexed: 01/03/2023]
Abstract
Proper hemodynamic management is necessary among post-cardiac arrest patients to improve survival. We aimed to investigate the effects of PiCCO™-guided (pulse index contour cardiac output) hemodynamic management on mortality in post-resuscitation therapy. In this longitudinal analysis of 63 comatose patients after successful cardiopulmonary resuscitation cooled to 32–34 °C, 33 patients received PiCCO™, and 30 were not monitored with PiCCO™. Primary and secondary outcomes were 30 day and 1 year mortality. Kaplan–Meier curves and log-rank tests were used to assess differences in mortality among the groups. Interaction effects to disentangle the relationship between patient’s condition, PiCCO™ application, and mortality were assessed by means of Chi-square tests and logistic regression models. A 30 day mortality was significantly higher among PiCCO™ patients, while 1 year mortality was marginally higher. More severe patient condition per se was not the cause of higher mortality rate in the PiCCO™ group. Patients in better health conditions (without ST-elevation myocardial infarction, without cardiogenic shock, without intra-aortic balloon pump device, or without stroke in prior history) had worse outcomes with PiCCO™-guided therapy. Catecholamine administration worsened both 30 day and 1 year mortality among all patients. Our analysis showed that there was a complex interaction relationship between PiCCO™-guided therapy, patients’ condition, and 30 day mortality for most conditions.
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Affiliation(s)
- Enikő Kovács
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, H-1428 Budapest, Hungary; (B.H.); (J.G.)
- Correspondence:
| | - Valéria Anna Gyarmathy
- Medical Department, EpiConsult Biomedical Consulting and Medical Communication Agency, Dover, DE 19901, USA;
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Dávid Pilecky
- Department of Internal Medicine III, Klinikum Passau, 94032 Passau, Germany;
| | | | - Zsófia Szakál-Tóth
- Heart and Vascular Center, Semmelweis University, H-1428 Budapest, Hungary; (Z.S.-T.); (L.G.); (B.M.); (E.Z.)
| | - László Gellér
- Heart and Vascular Center, Semmelweis University, H-1428 Budapest, Hungary; (Z.S.-T.); (L.G.); (B.M.); (E.Z.)
| | - Balázs Hauser
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, H-1428 Budapest, Hungary; (B.H.); (J.G.)
| | - János Gál
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, H-1428 Budapest, Hungary; (B.H.); (J.G.)
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, H-1428 Budapest, Hungary; (Z.S.-T.); (L.G.); (B.M.); (E.Z.)
| | - Endre Zima
- Heart and Vascular Center, Semmelweis University, H-1428 Budapest, Hungary; (Z.S.-T.); (L.G.); (B.M.); (E.Z.)
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43
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Kim YM, Jeung KW, Kim WY, Park YS, Oh JS, You YH, Lee DH, Chae MK, Jeong YJ, Kim MC, Ha EJ, Hwang KJ, Kim WS, Lee JM, Cha KC, Chung SP, Park JD, Kim HS, Lee MJ, Na SH, Kim ARE, Hwang SO. 2020 Korean Guidelines for Cardiopulmonary Resuscitation. Part 5. Post-cardiac arrest care. Clin Exp Emerg Med 2021; 8:S41-S64. [PMID: 34034449 PMCID: PMC8171174 DOI: 10.15441/ceem.21.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 03/07/2021] [Accepted: 03/19/2021] [Indexed: 12/20/2022] Open
Affiliation(s)
- Young-Min Kim
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Kyung Woon Jeung
- Department of Emergency Medicine, Chonnam National University College of Medicine, Gwangju, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, Ulsan University College of Medicine, Seoul, Korea
| | - Yoo Seok Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Joo Suk Oh
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Yeon Ho You
- Department of Emergency Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Dong Hoon Lee
- Department of Emergency Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Minjung Kathy Chae
- Department of Emergency Medicine, Ajou University College of Medicine, Suwon, Korea
| | - Yoo Jin Jeong
- Department of Emergency Medicine, Chonnam National University College of Medicine, Gwangju, Korea
| | - Min Chul Kim
- Department of Internal Medicine, Chonnam National University College of Medicine, Gwangju, Korea
| | - Eun Jin Ha
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyoung Jin Hwang
- Department of Neurology, Kyung Hee University College of Medicine, Seoul, Korea
| | - Won-Seok Kim
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jae Myung Lee
- Department of General Surgery, Korea University College of Medicine, Seoul, Korea
| | - Kyoung-Chul Cha
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - June Dong Park
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Mi Jin Lee
- Department of Emergency Medicine, Kyoungbook University College of Medicine, Daegu, Korea
| | - Sang-Hoon Na
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Ai-Rhan Ellen Kim
- Department of Pediatrics, Ulsan University College of Medicine, Seoul, Korea
| | - Sung Oh Hwang
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - on behalf of the Steering Committee of 2020 Korean Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Chonnam National University College of Medicine, Gwangju, Korea
- Department of Emergency Medicine, Asan Medical Center, Ulsan University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Chungnam National University College of Medicine, Daejeon, Korea
- Department of Emergency Medicine, Chung-Ang University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Ajou University College of Medicine, Suwon, Korea
- Department of Internal Medicine, Chonnam National University College of Medicine, Gwangju, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Neurology, Kyung Hee University College of Medicine, Seoul, Korea
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Department of General Surgery, Korea University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Kyoungbook University College of Medicine, Daegu, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Pediatrics, Ulsan University College of Medicine, Seoul, Korea
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44
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care. Intensive Care Med 2021; 47:369-421. [PMID: 33765189 PMCID: PMC7993077 DOI: 10.1007/s00134-021-06368-4] [Citation(s) in RCA: 417] [Impact Index Per Article: 139.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/08/2021] [Indexed: 12/13/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation and organ donation.
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Affiliation(s)
- Jerry P. Nolan
- University of Warwick, Warwick Medical School, Coventry, CV4 7AL UK
- Royal United Hospital, Bath, BA1 3NG UK
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
- Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W. Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC), Université Catholique de Louvain, Brussels, Belgium
- Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Division of Health Sciences, Warwick Medical School, University of Warwick, Room A108, Coventry, CV4 7AL UK
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Véronique R. M. Moulaert
- Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Markus B. Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB UK
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45
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Mariero Olasveengen T, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care. Resuscitation 2021; 161:220-269. [PMID: 33773827 DOI: 10.1016/j.resuscitation.2021.02.012] [Citation(s) in RCA: 338] [Impact Index Per Article: 112.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation, and organ donation.
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Affiliation(s)
- Jerry P Nolan
- University of Warwick, Warwick Medical School, Coventry CV4 7AL, UK; Royal United Hospital, Bath, BA1 3NG, UK.
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy; Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W Böttiger
- University Hospital of Cologne, Kerpener Straße 62, D-50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC) Université Catholique de Louvain, Brussels, Belgium; Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Room A108, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Gisela Lilja
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden
| | - Véronique R M Moulaert
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB, UK
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46
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Care Does Not Stop Following ROSC: A Quality Improvement Approach to Postcardiac Arrest Care. Pediatr Qual Saf 2021; 6:e392. [PMID: 33718747 PMCID: PMC7952102 DOI: 10.1097/pq9.0000000000000392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 10/04/2020] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is available in the text. Pediatric cardiac arrests carry significant morbidity and mortality. With increasing rates of return of spontaneous circulation, it is vital to optimize recovery conditions to decrease morbidity.
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47
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Broch O, Hummitzsch L, Renner J, Meybohm P, Albrecht M, Rosenthal P, Rosenthal AC, Steinfath M, Bein B, Gruenewald M. Feasibility and beneficial effects of an early goal directed therapy after cardiac arrest: evaluation by conductance method. Sci Rep 2021; 11:5326. [PMID: 33674623 PMCID: PMC7935910 DOI: 10.1038/s41598-021-83925-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 02/09/2021] [Indexed: 11/09/2022] Open
Abstract
Although beneficial effects of an early goal directed therapy (EGDT) after cardiac arrest and successful return of spontaneous circulation (ROSC) have been described, clinical implementation in this period seems rather difficult. The aim of the present study was to investigate the feasibility and the impact of EGDT on myocardial damage and function after cardiac resuscitation. A translational pig model which has been carefully adapted to the clinical setting was employed. After 8 min of cardiac arrest and successful ROSC, pigs were randomized to receive either EGDT (EGDT group) or therapy by random computer-controlled hemodynamic thresholds (noEGDT group). Therapeutic algorithms included blood gas analysis, conductance catheter method, thermodilution cardiac output and transesophageal echocardiography. Twenty-one animals achieved successful ROSC of which 13 pigs survived the whole experimental period and could be included into final analysis. cTnT and LDH concentrations were lower in the EGDT group without reaching statistical significance. Comparison of lactate concentrations between 1 and 8 h after ROSC exhibited a decrease to nearly baseline levels within the EGDT group (1 h vs 8 h: 7.9 vs. 1.7 mmol/l, P < 0.01), while in the noEGDT group lactate concentrations did not significantly decrease. The EGDT group revealed a higher initial need for fluids (P < 0.05) and less epinephrine administration (P < 0.05) post ROSC. Conductance method determined significant higher values for preload recruitable stroke work, ejection fraction and maximum rate of pressure change in the ventricle for the EGDT group. EGDT after cardiac arrest is associated with a significant decrease of lactate levels to nearly baseline and is able to improve systolic myocardial function. Although the results of our study suggest that implementation of an EGDT algorithm for post cardiac arrest care seems feasible, the impact and implementation of EGDT algorithms after cardiac arrest need to be further investigated.
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Affiliation(s)
- Ole Broch
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany.,Department of Anesthesiology and Intensive Care Medicine, Elbe Hospital Stade, Stade, Germany
| | - Lars Hummitzsch
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany. .,Christian-Albrechts-University Kiel, Kiel, Germany.
| | - Jochen Renner
- Department of Anesthesiology and Intensive Care Medicine, Städtisches Krankenhaus Kiel, Kiel, Germany
| | - Patrick Meybohm
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Martin Albrecht
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany.,Christian-Albrechts-University Kiel, Kiel, Germany
| | | | | | - Markus Steinfath
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany.,Christian-Albrechts-University Kiel, Kiel, Germany
| | - Berthold Bein
- Department of Anesthesiology and Intensive Care Medicine, Asklepios Hospital St. Georg, Hamburg, Germany
| | - Matthias Gruenewald
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany.,Christian-Albrechts-University Kiel, Kiel, Germany
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48
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Karasek J, Seiner J, Renza M, Salanda F, Moudry M, Strycek M, Lejsek J, Polasek R, Ostadal P. Bypassing out-of-hospital cardiac arrest patients to a regional cardiac center: Impact on hemodynamic parameters and outcomes. Am J Emerg Med 2021; 44:95-99. [PMID: 33582615 DOI: 10.1016/j.ajem.2021.01.080] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Current guidelines recommend systematic care for patients who experience out-of-hospital cardiac arrest (OHCA) and the development of cardiac arrest centers (CACs). However, data regarding prolonged transport time of these often hemodynamically unstable patients are limited. METHODS Data from a prospective OHCA registry of a regional CAC collected between 2013 and 2017, when all OHCA patients from the district were required to be transferred directly to the CAC, were analyzed. Patients were divided into two subgroups: CAC, when the CAC was the nearest hospital; and bypass, when OHCA occurred in a region of another local hospital but the subject was transferred directly to the CAC (7 hospitals in the district). Data included transport time, baseline characteristics, hemodynamic and laboratory parameters on admission (systolic blood pressure, lactate, pH, oxygen saturation, body temperature, and initial doses of vasopressors and inotropes), and final outcomes (30-day in-hospital mortality, intensive care unit stay, days on artificial ventilation, and cerebral performance capacity at 1 year). RESULTS A total of 258 subjects experienced OHCA in the study period; however, 27 were excluded due to insufficient data and 17 for secondary transfer to CAC. As such, 214 patients were analyzed, 111 in the CAC group and 103 in the bypass group. The median transport time was significantly longer for the bypass group than the CAC group (40.5 min [IQR 28.3-55.0 min] versus 20.0 min [IQR 13.0-34.0], respectively; p˂0.0001). There were no differences in 30-day in-hospital mortality, 1-year neurological outcome, or median length of mechanical ventilation. There were no differences in baseline characteristics, initial hemodynamic parameters on admission, catecholamine dosage(s). CONCLUSION Individuals who experienced OHCA and taken to a CAC incurred significantly prolonged transport times; however, hemodynamic parameters and/or outcomes were not affected. These findings shows the safety of bypassing local hospitals for a CAC.
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Affiliation(s)
- Jiri Karasek
- Hospital Liberec, Cardiology, Liberec, Czech Republic; Third Medical Faculty, Charles University, Prague, Czech Republic.
| | - Jiri Seiner
- Hospital Liberec, Cardiology, Liberec, Czech Republic
| | - Metodej Renza
- Third Medical Faculty, Charles University, Prague, Czech Republic
| | | | - Martin Moudry
- Third Medical Faculty, Charles University, Prague, Czech Republic
| | - Matej Strycek
- Hospital Liberec, Cardiology, Liberec, Czech Republic
| | - Jan Lejsek
- EMS Region Liberec, Liberec, Czech Republic
| | | | - Petr Ostadal
- Hospital Na Homolce, Cardiology, Prague, Czech Republic
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49
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Abstract
Cardiac arrest is a catastrophic event with high morbidity and mortality. Despite advances over time in cardiac arrest management and postresuscitation care, the neurologic consequences of cardiac arrest are frequently devastating to patients and their families. Targeted temperature management is an intervention aimed at limiting postanoxic injury and improving neurologic outcomes following cardiac arrest. Recovery of neurologic function governs long-term outcome after cardiac arrest and prognosticating on the potential for recovery is a heavy burden for physicians. An early and accurate estimate of the potential for recovery can establish realistic expectations and avoid futile care in those destined for a poor outcome. This chapter reviews the epidemiology, pathophysiology, therapeutic interventions, prognostication, and neurologic sequelae of cardiac arrest.
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Affiliation(s)
- Rick Gill
- Department of Neurology, Loyola University Chicago, Chicago, Stritch School of Medicine, Maywood, IL, United States
| | - Michael Teitcher
- Department of Neurology, Loyola University Chicago, Chicago, Stritch School of Medicine, Maywood, IL, United States
| | - Sean Ruland
- Department of Neurology, Loyola University Chicago, Chicago, Stritch School of Medicine, Maywood, IL, United States.
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50
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Kim SH, Park KN, Youn CS, Chae MK, Kim WY, Lee BK, Lee DH, Jang TC, Lee JH, Choi YH, You JS, Cho IS, Kim SJ, Lee JS, Kim YH, Sim MS, Shin J, Park YS, Lee YH, Moon H, Jeong WJ, Oh JS, Choi SP, Cha KC. Outcome and status of postcardiac arrest care in Korea: results from the Korean Hypothermia Network prospective registry. Clin Exp Emerg Med 2020; 7:250-258. [PMID: 33440102 PMCID: PMC7808836 DOI: 10.15441/ceem.20.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 06/25/2020] [Indexed: 12/13/2022] Open
Abstract
Objective High-quality intensive care, including targeted temperature management (TTM) for patients with postcardiac arrest syndrome, is a key element for improving outcomes after out-of-hospital cardiac arrest (OHCA). We aimed to assess the status of postcardiac arrest syndrome care, including TTM and 6-month survival with neurologically favorable outcomes, after adult OHCA patients were treated with TTM, using data from the Korean Hypothermia Network prospective registry. Methods We used the Korean Hypothermia Network prospective registry, a web-based multicenter registry that includes data from 22 participating hospitals throughout the Republic of Korea. Adult comatose OHCA survivors treated with TTM between October 2015 and December 2018 were included. The primary outcome was neurological outcome at 6 months. Results Of the 1,354 registered OHCA survivors treated with TTM, 550 (40.6%) survived 6 months, and 413 (30.5%) had good neurological outcomes. We identified 839 (62.0%) patients with preClinsumed cardiac etiology. A total of 937 (69.2%) collapses were witnessed, shockable rhythms were demonstrated in 482 (35.6%) patients, and 421 (31.1%) patients arrived at the emergency department with prehospital return of spontaneous circulation. The most common target temperature was 33°C, and the most common target duration was 24 hours. Conclusion The survival and good neurologic outcome rates of this prospective registry show great improvements compared with those of an earlier registry. While the optimal target temperature and duration are still unknown, the most common target temperature was 33°C, and the most common target duration was 24 hours.
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Affiliation(s)
- Soo Hyun Kim
- Department of Emergency Medicine, Eunpyeong St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Kyu Nam Park
- Department of Emergency Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Chun Song Youn
- Department of Emergency Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Minjung Kathy Chae
- Department of Emergency Medicine, Ajou University Medical Center, Suwon, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Dong Hoon Lee
- Department of Emergency Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Tae Chang Jang
- Department of Emergency Medicine, Daegu Catholic University Medical Center, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Jae Hoon Lee
- Department of Emergency Medicine, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Yoon Hee Choi
- Department of Emergency Medicine, Ewha Womans University Mokdong Hospital, Ewha Womans School of Medicine, Seoul, Korea
| | - Je Sung You
- Department of Emergency Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - In Soo Cho
- Department of Emergency Medicine, Hanil General Hospital, Seoul, Korea
| | - Su Jin Kim
- Department of Emergency Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jong-Seok Lee
- Department of Emergency Medicine, Kyung Hee University Medical Center, Kyung Hee University School of Medicine, Seoul, Korea
| | - Yong Hwan Kim
- Department of Emergency Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Min Seob Sim
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jonghwan Shin
- Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Yoo Seok Park
- Department of Emergency Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Hwan Lee
- Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - HyungJun Moon
- Department of Emergency Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Won Jung Jeong
- Department of Emergency Medicine, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Joo Suk Oh
- Department of Emergency Medicine, Uijeongbu St. Mary's Hospital, The Catholic University of Korea College of Medicine, Uijeongbu, Korea
| | - Seung Pill Choi
- Department of Emergency Medicine, Eunpyeong St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea.,Department of Emergency Medicine, Yeouido St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Kyoung-Chul Cha
- Department of Emergency Medicine, Wonju Severance Christian Hospital, Yonsei University College of Medicine, Wonju, Korea
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