1
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Oberdier MT, Li J, Ambinder DI, Suzuki M, Tumarkin E, Fink S, Neri L, Zhu X, Justice CN, Vanden Hoek TL, Halperin HR. Survival and Neurologic Outcomes From Pharmacologic Peptide Administration During Cardiopulmonary Resuscitation of Pulseless Electrical Activity. J Am Heart Assoc 2024; 13:e9757. [PMID: 38934857 PMCID: PMC11255698 DOI: 10.1161/jaha.123.033371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 05/08/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Outcomes from cardiopulmonary resuscitation (CPR) following sudden cardiac arrest are suboptimal. Postresuscitation targeted temperature management has been shown to have benefit in subjects with sudden cardiac arrest due to ventricular fibrillation, but there are few data for outcomes from sudden cardiac arrest due to pulseless electrical activity. In addition, intra-CPR cooling is more effective than postresuscitation cooling. Physical cooling is associated with increased protein kinase B activity. Therefore, our group developed a novel peptide, TAT-PHLPP9c, which regulates protein kinase B. We hypothesized that when given during CPR, TAT-PHLPP9c would improve survival and neurologic outcomes following pulseless electrical activity arrest. METHODS AND RESULTS In 24 female pigs, pulseless electrical activity was induced by inflating balloon catheters in the right coronary and left anterior descending arteries for ≈7 minutes. Advanced life support was initiated. In 12 control animals, epinephrine was given after 1 and 3 minutes. In 12 peptide-treated animals, 7.5 mg/kg TAT-PHLPP9c was also administered at 1 and 3 minutes of CPR. The balloons were removed after 2 minutes of support. Animals were recovered and neurologically scored 24 hours after return of spontaneous circulation. Return of spontaneous circulation was more common in the peptide group, but this difference was not significant (8/12 control versus 12/12 peptide; P=0.093), while fully intact neurologic survival was significantly more common in the peptide group (0/12 control versus 11/12 peptide; P<0.00001). TAT-PHLPP9c significantly increased myocardial nicotinamide adenine dinucleotide levels. CONCLUSIONS TAT-PHLPP9c resulted in improved survival with full neurologic function after sudden cardiac arrest in a swine model of pulseless electrical activity, and the peptide shows potential as an intra-CPR pharmacologic agent.
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Affiliation(s)
| | - Jing Li
- University of Illinois – ChicagoChicagoIL
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2
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Belur AD, Sedhai YR, Truesdell AG, Khanna AK, Mishkin JD, Belford PM, Zhao DX, Vallabhajosyula S. Targeted Temperature Management in Cardiac Arrest: An Updated Narrative Review. Cardiol Ther 2023; 12:65-84. [PMID: 36527676 PMCID: PMC9986171 DOI: 10.1007/s40119-022-00292-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022] Open
Abstract
The established benefits of cooling along with development of sophisticated methods to safely and precisely induce, maintain, monitor, and reverse hypothermia have led to the development of targeted temperature management (TTM). Early trials in human subjects showed that hypothermia conferred better neurological outcomes when compared to normothermia among survivors of cardiac arrest, leading to guidelines recommending targeted hypothermia in this patient population. Multiple studies have sought to explore and compare the benefit of hypothermia in various subgroups of patients, such as survivors of out-of-hospital cardiac arrest versus in-hospital cardiac arrest, and survivors of an initial shockable versus non-shockable rhythm. Larger and more recent trials have shown no statistically significant difference in neurological outcomes between patients with targeted hypothermia and targeted normothermia; further, aggressive cooling is associated with a higher incidence of multiple systemic complications. Based on this data, temporal trends have leaned towards using a lenient temperature target in more recent times. Current guidelines recommend selecting and maintaining a constant target temperature between 32 and 36 °C for those patients in whom TTM is used (strong recommendation, moderate-quality evidence), as soon as possible after return of spontaneous circulation is achieved and airway, breathing (including mechanical ventilation), and circulation are stabilized. The comparative benefit of lower (32-34 °C) versus higher (36 °C) temperatures remains unknown, and further research may help elucidate this. Any survivor of cardiac arrest who is comatose (defined as unarousable unresponsiveness to external stimuli) should be considered as a candidate for TTM regardless of the initial presenting rhythm, and the decision to opt for targeted hypothermia versus targeted normothermia should be made on a case-by-case basis.
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Affiliation(s)
- Agastya D Belur
- Division of Cardiology, Department of Medicine, University of Louisville, Louisville, KY, USA
| | - Yub Raj Sedhai
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Kentucky College of Medicine, Bowling Green, KY, USA
| | | | - Ashish K Khanna
- Section of Critical Care Medicine, Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, USA.,Outcomes Research Consortium, Cleveland, OH, USA.,Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA
| | - Joseph D Mishkin
- Section of Advanced Heart Failure and Transplant Cardiology, Atrium Health Sanger Heart and Vascular Institute, Charlotte, NC, USA
| | - P Matthew Belford
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest School of Medicine, 306 Westwood Avenue, Suite 401, High Point, Winston-Salem, NC, 27262, USA
| | - David X Zhao
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest School of Medicine, 306 Westwood Avenue, Suite 401, High Point, Winston-Salem, NC, 27262, USA
| | - Saraschandra Vallabhajosyula
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA. .,Section of Cardiovascular Medicine, Department of Medicine, Wake Forest School of Medicine, 306 Westwood Avenue, Suite 401, High Point, Winston-Salem, NC, 27262, USA. .,Department of Implementation Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA.
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3
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Targeted Temperature Management After Out-of-Hospital Cardiac Arrest: Integrating Evidence Into Real World Practice. Can J Cardiol 2023; 39:385-393. [PMID: 36610519 DOI: 10.1016/j.cjca.2022.12.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/27/2022] [Accepted: 12/27/2022] [Indexed: 01/06/2023] Open
Abstract
Targeted temperature management (TTM) after out-of-hospital cardiac arrest (OHCA) has been a focus of debate in an attempt to improve post-arrest outcomes. Contemporary trials examining the role of TTM after cardiac arrest suggest that targeting normothermia should be the standard of care for initially comatose survivors of cardiac arrest. Differences in patient populations have been demonstrated across trials, and important subgroups may be under-represented in clinical trials compared with real-world registries. In this review, we aimed to describe the populations represented in international OHCA registries and to propose a pathway to integrate clinical trial evidence into practice. The patient case mix among registries including survivors to hospital admission was similar to the pivotal trials (shockable rhythm, witnessed arrest), suggesting reasonable external validity. Therefore, for the majority of OHCA, targeted normothermia should be the strategy of choice. There remains conflicting evidence for patients with a nonshockable rhythm, with no clear evidence-based justification for mild hypothermia over targeted normothermia.
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4
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Robba C, Badenes R, Battaglini D, Ball L, Brunetti I, Jakobsen JC, Lilja G, Friberg H, Wendel-Garcia PD, Young PJ, Eastwood G, Chew MS, Unden J, Thomas M, Joannidis M, Nichol A, Lundin A, Hollenberg J, Hammond N, Saxena M, Annborn M, Solar M, Taccone FS, Dankiewicz J, Nielsen N, Pelosi P. Ventilatory settings in the initial 72 h and their association with outcome in out-of-hospital cardiac arrest patients: a preplanned secondary analysis of the targeted hypothermia versus targeted normothermia after out-of-hospital cardiac arrest (TTM2) trial. Intensive Care Med 2022; 48:1024-1038. [PMID: 35780195 PMCID: PMC9304050 DOI: 10.1007/s00134-022-06756-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 05/24/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE The optimal ventilatory settings in patients after cardiac arrest and their association with outcome remain unclear. The aim of this study was to describe the ventilatory settings applied in the first 72 h of mechanical ventilation in patients after out-of-hospital cardiac arrest and their association with 6-month outcomes. METHODS Preplanned sub-analysis of the Target Temperature Management-2 trial. Clinical outcomes were mortality and functional status (assessed by the Modified Rankin Scale) 6 months after randomization. RESULTS A total of 1848 patients were included (mean age 64 [Standard Deviation, SD = 14] years). At 6 months, 950 (51%) patients were alive and 898 (49%) were dead. Median tidal volume (VT) was 7 (Interquartile range, IQR = 6.2-8.5) mL per Predicted Body Weight (PBW), positive end expiratory pressure (PEEP) was 7 (IQR = 5-9) cmH20, plateau pressure was 20 cmH20 (IQR = 17-23), driving pressure was 12 cmH20 (IQR = 10-15), mechanical power 16.2 J/min (IQR = 12.1-21.8), ventilatory ratio was 1.27 (IQR = 1.04-1.6), and respiratory rate was 17 breaths/minute (IQR = 14-20). Median partial pressure of oxygen was 87 mmHg (IQR = 75-105), and partial pressure of carbon dioxide was 40.5 mmHg (IQR = 36-45.7). Respiratory rate, driving pressure, and mechanical power were independently associated with 6-month mortality (omnibus p-values for their non-linear trajectories: p < 0.0001, p = 0.026, and p = 0.029, respectively). Respiratory rate and driving pressure were also independently associated with poor neurological outcome (odds ratio, OR = 1.035, 95% confidence interval, CI = 1.003-1.068, p = 0.030, and OR = 1.005, 95% CI = 1.001-1.036, p = 0.048). A composite formula calculated as [(4*driving pressure) + respiratory rate] was independently associated with mortality and poor neurological outcome. CONCLUSIONS Protective ventilation strategies are commonly applied in patients after cardiac arrest. Ventilator settings in the first 72 h after hospital admission, in particular driving pressure and respiratory rate, may influence 6-month outcomes.
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Affiliation(s)
- Chiara Robba
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy. .,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Viale Benedetto XV 16, Genoa, Italy.
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clínic Universitari de Valencia, Valencia, Spain.,Department of Surgery, University of Valencia, Valencia, Spain
| | - Denise Battaglini
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Lorenzo Ball
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Viale Benedetto XV 16, Genoa, Italy
| | - Iole Brunetti
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.,Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Getingevägen 4, 222 41, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences Lund, Anesthesia and Intensive Care, Lund University, Lund, Sweden
| | - Pedro D Wendel-Garcia
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Paul J Young
- Medical Research Institute of New Zealand, Private Bag 7902, Wellington, 6242, New Zealand.,Intensive Care Unit, Wellington Regional Hospital, Wellington, New Zealand.,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Department of Critical Care, University of Melbourne, Parkville, VIC, Australia
| | - Glenn Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Johan Unden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.,Department of Operation and Intensive Care, Lund University, Hallands Hospital Halmstad, Halland, Sweden
| | - Matthew Thomas
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | | | - Andreas Lundin
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 423 45, Gothenburg, Sweden
| | - Jacob Hollenberg
- Department of Medicine, Centre for Resuscitation Science, Karolinska Institutet, Södersjukhuset Sjukhusbacken 10, Solna, 118 83, Stockholm, Sweden
| | - Naomi Hammond
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Critical Care Division, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, Australia
| | - Manoj Saxena
- Intensive Care Unit, St George Hospital, Sydney, Australia
| | - Martin Annborn
- Department of Clinical Medicine, Anaesthesiology and Intensive Care, Lund University, Lund, Sweden
| | - Miroslav Solar
- Department of Internal Medicine, Faculty of Medicine in Hradec Králové, Charles University, Hradec Králové, Czech Republic.,Department of Internal Medicine-Cardioangiology, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Fabio S Taccone
- Department of Intensive Care Medicine, Université Libre de Bruxelles, Hopital Erasme, Brussels, Belgium
| | - Josef Dankiewicz
- Department of Clinical Sciences Lund, Cardiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care and Clinical Sciences Helsingborg, Helsingborg Hospital, Lund University, Lund, Sweden
| | - Paolo Pelosi
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Viale Benedetto XV 16, Genoa, Italy
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5
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Robba C, Nielsen N, Dankiewicz J, Badenes R, Battaglini D, Ball L, Brunetti I, Pedro David WG, Young P, Eastwood G, Chew MS, Jakobsen J, Unden J, Thomas M, Joannidis M, Nichol A, Lundin A, Hollenberg J, Lilja G, Hammond NE, Saxena M, Martin A, Solar M, Taccone FS, Friberg HA, Pelosi P. Ventilation management and outcomes in out-of-hospital cardiac arrest: a protocol for a preplanned secondary analysis of the TTM2 trial. BMJ Open 2022; 12:e058001. [PMID: 35241476 PMCID: PMC8896064 DOI: 10.1136/bmjopen-2021-058001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Mechanical ventilation is a fundamental component in the management of patients post cardiac arrest. However, the ventilator settings and the gas-exchange targets used after cardiac arrest may not be optimal to minimise post-anoxic secondary brain injury. Therefore, questions remain regarding the best ventilator management in such patients. METHODS AND ANALYSIS This is a preplanned analysis of the international randomised controlled trial, targeted hypothermia versus targeted normothermia after out-of-hospital cardiac arrest (OHCA)-target temperature management 2 (TTM2). The primary objective is to describe ventilatory settings and gas exchange in patients who required invasive mechanical ventilation and included in the TTM2 trial. Secondary objectives include evaluating the association of ventilator settings and gas-exchange values with 6 months mortality and neurological outcome. Adult patients after an OHCA who were included in the TTM2 trial and who received invasive mechanical ventilation will be eligible for this analysis. Data collected in the TTM2 trial that will be analysed include patients' prehospital characteristics, clinical examination, ventilator settings and arterial blood gases recorded at hospital and intensive care unit (ICU) admission and daily during ICU stay. ETHICS AND DISSEMINATION The TTM2 study has been approved by the regional ethics committee at Lund University and by all relevant ethics boards in participating countries. No further ethical committee approval is required for this secondary analysis. Data will be disseminated to the scientific community by abstracts and by original articles submitted to peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT02908308.
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Affiliation(s)
- Chiara Robba
- Department of Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Genoa, Italy
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care and Clinical Sciences Helsingborg, Helsingborg Hospital, Lund University, Lund, Sweden
| | - Josef Dankiewicz
- Department of Clinical Sciences Lund, Cardiology, Skåne University Hospital,Lund University, Lund, Lund, UK
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de València, Universitat de València, Valencia, Spain
| | - Denise Battaglini
- Department of Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Genoa, Italy
- Department of Medicine, University of Barcelona, Barcelona, Spain, Genoa, Italy
| | - Lorenzo Ball
- Department of Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Genoa, Italy
| | - Iole Brunetti
- Department of Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Wendel-Garcia Pedro David
- Institute of Intensive Care Medicine, Zurich, Switzerland, University Hospital of Zürich, Zürich, Switzerland
| | - Paul Young
- Department of Intensive Care, Wellington Hospital, Wellington, New Zealand
| | - Glenn Eastwood
- Department of Intensive Care, Faculty of Health, Deakin University, Burwood, Victoria, Australia
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Janus Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Copenhagen, UK
| | - Johan Unden
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Operation and Intensive Care, Hallands Hospital Halmstad, Halland, Sweden
| | - Matthew Thomas
- Department of Anaesthesia, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Deptartment of Medicine, Medizinische Universität Innsbruck, Innsbruck, Austria
| | - Alistair Nichol
- Monash University, Melbourne, Victoria, Australia, Melbourne, Ireland
| | - Andreas Lundin
- Department of Anaesthesiology and Intensive Care Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Jacob Hollenberg
- Department of Medicine, Center for Resuscitation Science, Karolinska Institutet, Solna, Sweden
| | - Gisela Lilja
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Naomi E Hammond
- Department of Critical Care, George Institute for Global Health, Newtown, New South Wales, Australia
| | - Manoj Saxena
- St George Hospital, Sydney, New South Wales, Australia
| | - Annborn Martin
- Department of Clinical Medicine, Anaesthesiology and Intensive Care, Lund University, Lund, Sweden
| | - Miroslav Solar
- Department of Internal Medicine, Faculty of Medicine in Hradec Králové, Charles University, Prague, Czech Republic
| | - Fabio Silvio Taccone
- Department of Intensive Care Medicine, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Hans A Friberg
- Department of of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Paolo Pelosi
- Department of Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche, Università degli Studi di Genova, Genoa, Italy
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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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7
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Chien YS, Tsai MS, Huang CH, Lai CH, Huang WC, Chan L, Kuo LK. Outcomes of Targeted Temperature Management for In-Hospital and Out-Of-Hospital Cardiac Arrest: A Matched Case-Control Study Using the National Database of Taiwan Network of Targeted Temperature Management for Cardiac Arrest (TIMECARD) Registry. Med Sci Monit 2021; 27:e931203. [PMID: 34244465 PMCID: PMC8278959 DOI: 10.12659/msm.931203] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND This study aimed to compare outcomes of targeted temperature management (TTM) for patients with in-hospital and out-of-hospital cardiac arrest using the national database of TaIwan network of targeted temperature ManagEment for CARDiac arrest (TIMECARD) registry. MATERIAL AND METHODS A retrospective, matched, case-control study was conducted. Patients with in-hospital cardiac arrest (IHCA) treated with TTM after the return of spontaneous circulation (ROSC) were selected as the case group and controls were defined as the same number of patients with out-of-hospital cardiac arrest (OHCA), matched for sex, age, Charlson comorbidity index, and cerebral performance category. Neurological outcome and survival at hospital discharge were the primary outcome measures. RESULTS Data of 103 patients with IHCA and matched controls with OHCA were analyzed. Patients with IHCA were more likely to experience witnessed arrest and bystander cardiopulmonary resuscitation (CPR). The duration from collapse to the beginning of CPR, CPR time, and the duration from ROSC to initiation of TTM were shorter in the IHCA group but their initial arterial blood pressure after ROSC was lower. Overall, 88% of patients survived to completion of TTM and 43% survived to hospital discharge. Hospital survival (42.7% vs 42.7%, P=1.00) and favorable neurological outcome at discharge (19.4% vs 12.7%, P=0.25) did not differ between the 2 groups. CONCLUSIONS The findings from the national TIMECARD registry showed that clinical outcomes following TTM for patients with IHCA were not significantly different from OHCA when baseline factors were matched.
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Affiliation(s)
- Yu-San Chien
- Department of Critical Care, Mackay Memorial Hospital, Taipei, Taiwan.,Department of Medicine, Mackay Medical College, New Taipei, Taiwan
| | - Min-Shan Tsai
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Chih-Hung Lai
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wei-Chun Huang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Lung Chan
- Department of Neurology, Taipei Medical University, Shuang-Ho Hospital, New Taipei, Taiwan
| | - Li-Kuo Kuo
- Department of Critical Care, Mackay Memorial Hospital, Taipei, Taiwan.,Department of Medicine, Mackay Medical College, New Taipei, Taiwan
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8
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Feng D, Li C, Yang X, Wang L. Gender differences and survival after an out-of-hospital cardiac arrest: a systematic review and meta-analysis. Intern Emerg Med 2021; 16:765-775. [PMID: 33174152 DOI: 10.1007/s11739-020-02552-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 10/23/2020] [Indexed: 11/26/2022]
Abstract
Patients who experience out-of-hospital cardiac arrest (OHCA) have unacceptably high mortality rates. It remains unclear whether gender has an association with survival in this regard. Hence, we aimed to investigate the association between gender and survival by conducting a systematic review and meta-analysis. The databases of PubMed, Embase, and Cochrane Database of Systematic Reviews were searched from inception to 17 March, 2020. Studies assessing the association between gender and survival to discharge or 30-day survival after OHCA were included. Two reviewers independently assessed the eligibility of the identified studies. The random-effects model was used to pool data, and the outcome was reported as odds ratios (ORs) and 95% confidence intervals, as the relative measure of association. Twenty-three eligible studies enrolling 897,805 patients were included in this systematic review. Overall, women were older and less likely to experience arrest in public places. When arrest occurred, women had less initial shockable rhythm, were less likely to be witnessed by bystanders, and were less likely provided with CPR compared with men. After admission, women underwent less coronary angiography, percutaneous coronary angiography, and targeted temperature management therapy. Eleven studies with ORs were pooled, showing a significant survival benefit in women (OR = 1.08, p < 0.05, I2 = 52.3%). In the subgroup analysis, both premenopausal women (< 50 years) (OR = 1.42, p < 0.001, I2 = 0%) and postmenopausal women (≥ 50 years) (OR = 1.07, p < 0.05, I2 = 16.4%) had higher odds of survival compared with age-matched men. Despite the unfavorable factors, the pooled results showed a significant survival benefit in women after OHCA, especially in premenopausal women.
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Affiliation(s)
- Dejing Feng
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chao-Yang Hospital, Capital Medical University, 8# Gong-Ti South Road, Beijing, 10020, China
| | - Chuang Li
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chao-Yang Hospital, Capital Medical University, 8# Gong-Ti South Road, Beijing, 10020, China
| | - Xinchun Yang
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chao-Yang Hospital, Capital Medical University, 8# Gong-Ti South Road, Beijing, 10020, China
| | - Lefeng Wang
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chao-Yang Hospital, Capital Medical University, 8# Gong-Ti South Road, Beijing, 10020, China.
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Dezfulian C, Orkin AM, Maron BA, Elmer J, Girotra S, Gladwin MT, Merchant RM, Panchal AR, Perman SM, Starks MA, van Diepen S, Lavonas EJ. Opioid-Associated Out-of-Hospital Cardiac Arrest: Distinctive Clinical Features and Implications for Health Care and Public Responses: A Scientific Statement From the American Heart Association. Circulation 2021; 143:e836-e870. [PMID: 33682423 DOI: 10.1161/cir.0000000000000958] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Opioid overdose is the leading cause of death for Americans 25 to 64 years of age, and opioid use disorder affects >2 million Americans. The epidemiology of opioid-associated out-of-hospital cardiac arrest in the United States is changing rapidly, with exponential increases in death resulting from synthetic opioids and linear increases in heroin deaths more than offsetting modest reductions in deaths from prescription opioids. The pathophysiology of polysubstance toxidromes involving opioids, asphyxial death, and prolonged hypoxemia leading to global ischemia (cardiac arrest) differs from that of sudden cardiac arrest. People who use opioids may also develop bacteremia, central nervous system vasculitis and leukoencephalopathy, torsades de pointes, pulmonary vasculopathy, and pulmonary edema. Emergency management of opioid poisoning requires recognition by the lay public or emergency dispatchers, prompt emergency response, and effective ventilation coupled to compressions in the setting of opioid-associated out-of-hospital cardiac arrest. Effective ventilation is challenging to teach, whereas naloxone, an opioid antagonist, can be administered by emergency medical personnel, trained laypeople, and the general public with dispatcher instruction to prevent cardiac arrest. Opioid education and naloxone distributions programs have been developed to teach people who are likely to encounter a person with opioid poisoning how to administer naloxone, deliver high-quality compressions, and perform rescue breathing. Current American Heart Association recommendations call for laypeople and others who cannot reliably establish the presence of a pulse to initiate cardiopulmonary resuscitation in any individual who is unconscious and not breathing normally; if opioid overdose is suspected, naloxone should also be administered. Secondary prevention, including counseling, opioid overdose education with take-home naloxone, and medication for opioid use disorder, is important to prevent recurrent opioid overdose.
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10
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Lee DM, Berger DA, Wloszczynski PA, Karabon P, Qu L, Burla MJ. Assessing the impact of resuscitation residents on the treatment of cardiopulmonary resuscitation patients. Am J Emerg Med 2020; 41:46-50. [PMID: 33385885 DOI: 10.1016/j.ajem.2020.12.021] [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: 10/14/2020] [Revised: 12/02/2020] [Accepted: 12/10/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The management of cardiac arrest patients receiving cardiopulmonary resuscitation (CPR) is an essential aspect of emergency medicine (EM) training. At our institution, we have a 1-month Resuscitation Rotation designed to augment resident training in managing critical patients. The objective of this study is to compare 30-day mortality between cardiac arrest patients with resuscitation resident (RR) involvement versus patients without. Our secondary outcome is to determine if RR involvement altered rates of initiating targeted temperature management (TTM). METHODS This study was conducted at a single site tertiary care Level-1 trauma center with an Emergency Department (ED) census of nearly 130,000 visits per year. Data was collected from 01/01/2015 to 01/01/2018 using electronic medical records via query. Patients admitted with cardiac arrest were separated into two groups, one with RR involvement and one without. Initial rhythm of ventricular fibrillation/tachycardia (VFIB/VTACH), 30-day mortality, history of coronary artery disease (CAD), and initiation of TTM were compared. Statistical analysis was performed. RESULTS Out of 885 patient encounters, 91 (10.28%) had RR participation. There was no statistical difference in 30-day mortality between patients with RR involvement compared to those without (71.42% vs 66.36%; P = 0.3613). However, TTM was initiated more in the RR group (20.70% vs 8.86%; P = 0.0025). Patients who received TTM also had a lower 30-day mortality compared to those without TTM (52.94% vs 70.87%; P = 0.0020). Patients who were older and had no history of CAD were also noted to have a statistically significant higher 30-day mortality. All other variables were not statistically significant. CONCLUSION Resuscitation resident involvement with the care of cardiac arrest patients had no impact in 30-day mortality. However, the involvement of RR was associated with a statistically significant increase in the initiation of TTM. One limitation is that RR participated in 10.28% of the cases analyzed herein, thus the two arms are unbalanced in size. Future work may investigate if the increase in TTM in the RR involved cases may portend improved rates of neurologically intact survival or more rapid achievement of goal temperatures.
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Affiliation(s)
- David M Lee
- Oakland University William Beaumont School of Medicine, 586 Pioneer Dr., Rochester, MI 48309, USA.
| | - David A Berger
- Oakland University William Beaumont School of Medicine, 586 Pioneer Dr., Rochester, MI 48309, USA; Department of Emergency Medicine, Beaumont Health System, 3601 W 13 Mile Rd., Royal Oak, MI 48073, USA
| | - Patrick A Wloszczynski
- Department of Emergency Medicine, Beaumont Health System, 3601 W 13 Mile Rd., Royal Oak, MI 48073, USA
| | - Patrick Karabon
- Oakland University William Beaumont School of Medicine, 586 Pioneer Dr., Rochester, MI 48309, USA
| | - Lihua Qu
- Oakland University William Beaumont School of Medicine, 586 Pioneer Dr., Rochester, MI 48309, USA; Research Institute, Beaumont Health System, 3811 W 13 Mile Rd., Royal Oak, MI 48073, USA
| | - Michael J Burla
- Oakland University William Beaumont School of Medicine, 586 Pioneer Dr., Rochester, MI 48309, USA; Department of Emergency Medicine, Beaumont Health System, 3601 W 13 Mile Rd., Royal Oak, MI 48073, USA; Department of Emergency Medicine, Southern Maine Health Care, 1 Medical Center Dr., Biddeford, ME 04005, USA; Tufts University School of Medicine, 145 Harrison Ave., Boston, MA 02111, USA
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11
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The cold truth about postcardiac arrest targeted temperature management: 33°C vs. 36°C. Nursing 2020; 50:24-30. [PMID: 32947373 DOI: 10.1097/01.nurse.0000697148.62653.1a] [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
This article provides nurses with up-to-date evidence to empower them in contributing to the 33°C versus 36°C discussion in postcardiac arrest targeted temperature management (TTM). Presented in debate format, this article addresses the pros and cons of various target temperatures, examines the evidence around TTM, and applies it to clinical scenarios.
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Targeted Temperature Management in Cardiac Arrest Patients With an Initial Non-Shockable Rhythm: A Systematic Review and Meta-Analysis. Shock 2020; 54:623-630. [PMID: 32433212 DOI: 10.1097/shk.0000000000001550] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Targeted temperature management (TTM) is now recommended for patients presenting with an out-of-hospital cardiac arrest. However, there are limited data that support its use in patients with an initial non-shockable rhythm (NSR). METHODS A literature search of PubMed/MEDLINE, Cochrane Library, and Embase was conducted by two independent authors for studies that compared TTM along with standard care versus standard care alone in treating cardiac arrest with initial NSR. Outcomes were short-term and long-term survival, and a Cerebral Performance Category (CPC) score of 1 to 2 at the longest follow-up period. The Mantel-Haenszel random-effects model was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs). Trial sequential analysis (TSA) was performed on the randomized controlled trials (RCTs). RESULTS Thirty studies were included in the final analysis: 25 observational and five RCTs, totalling 10,703 patients, 4,023 of whom received TTM and 6,680 received standard care alone. Compared with standard care, patients who presented with an initial NSR cardiac arrest and received TTM (target of 32°C -34°C) had a significantly higher short-term survival (OR 1.44 95% CI 1.15-1.81; P = 0.002), long-term survival (OR 1.52 95% CI 1.03-2.26; P = 0.04), and CPC score of 1 to 2 (OR 1.63 95% CI 1.22-2.17; P = 0.0010). Sensitivity analyses by including only RCTs showed a trend, although not significant, toward better short-term survival (OR 1.25 95% CI 0.82-1.89; P = 0.30), long-term survival (OR 1.15 95% CI 0.80-1.66; P = 0.46), and neurologic outcomes (OR 1.51 95% CI 0.81-2.80; P = 0.19). However, TSA performed on the RCTs revealed that the results were inconclusive. CONCLUSION Among patients who survived cardiac arrest with an initial NSR, TTM is associated with a higher rate of survival and favorable neurological outcomes compared with no TTM. However, analyses from the included RCTs did not support this conclusion.
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13
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Kuroda Y, Kawakita K. Targeted temperature management for postcardiac arrest syndrome. JOURNAL OF NEUROCRITICAL CARE 2020. [DOI: 10.18700/jnc.200001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Boulé-Laghzali N, Pérez LD, Dyrda K, Tanguay JF, Chabot-Blanchet M, Lamarche Y, Parent D, Dupriez AF, Deschamps A, Ducharme A. Targeted Temperature Management After Cardiac Arrest: The Montreal Heart Institute Experience. CJC Open 2020; 1:238-244. [PMID: 32159115 PMCID: PMC7063633 DOI: 10.1016/j.cjco.2019.07.001] [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: 04/12/2019] [Accepted: 07/10/2019] [Indexed: 11/02/2022] Open
Abstract
Background Targeted temperature management (TTM) has been associated with an improvement in neurological function and survival in patients with cardiac arrest (CA) and an initially shockable rhythm. We report the Montreal Heart Institute (MHI) experience using TTM to evaluate mortality and neurological outcome in patients remaining in coma after CA, regardless of the initial rhythm. Methods We performed a retrospective review of all patients receiving TTM at the MHI between 2008 and 2015. Primary outcome was a composite of mortality and poor neurological outcome at hospital discharge. We also evaluated the long-term outcomes of those who initially survived to hospital discharge. Results A total of 147 patients (120 men, mean age 59.5 ± 12.5 years) underwent TTM at the MHI during the study period. Overall survival to hospital discharge with good neurological outcome was 45.6%. Shockable rhythm was associated with a better outcome (mortality odds ratio, 0.212; 95% confidence interval, 0.068-0.664; P = 0.008). Of the 11 initial survivors with a poor neurological status (Cerebral Performance Category ≥ 3), 4 died rapidly (within 1 month of hospital discharge), but 6 (54.5%) markedly improved their neurological status to Cerebral Performance Category 1. Long-term survival (mean follow-up of 38 ± 26 months) for those alive at hospital discharge (n = 76 patients) was 81.9%. Conclusion Our retrospective analysis of CA survivors treated with TTM at MHI showed good survival, similar to the published results from the landmark randomized controlled trials, despite enrolling patients with nonshockable rhythms. A significant proportion of survivors with poor neurological outcome at discharge improved at follow-up.
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Affiliation(s)
- Nadia Boulé-Laghzali
- Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Laura Dominguez Pérez
- Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Katia Dyrda
- Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Jean-François Tanguay
- Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | | | - Yoan Lamarche
- Department of Cardiac Surgery, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Daniel Parent
- Department of Cardiac Surgery, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Anne-Frédérique Dupriez
- Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Alain Deschamps
- Department of Anesthesiology, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Anique Ducharme
- Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
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15
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Merkulova IA, Avetisyan EA, Terenicheva MA, Pevsner DV, Shakhnovich RM. [Therapeutic Hypothermia in a Cardiac Arrest: Complicated Questions and Unsolved Problems]. ACTA ACUST UNITED AC 2020; 60:104-110. [PMID: 32345206 DOI: 10.18087/cardio.2020.2.n690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 03/05/2020] [Indexed: 11/18/2022]
Abstract
The article aims to review the main trials, meta-analyses and guidelines regarding to various practical aspects and unsolved questions of an appliance of the therapeutic hypothermia in out-of-hospital and in-hospital cardiac arrest.
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Affiliation(s)
- I A Merkulova
- National Medical Research Center of Cardiology, Ministry of Healthcare Russian Federation, Moscow
| | - E A Avetisyan
- National Medical Research Center of Cardiology, Ministry of Healthcare Russian Federation, Moscow
| | - M A Terenicheva
- National Medical Research Center of Cardiology, Ministry of Healthcare Russian Federation, Moscow
| | - D V Pevsner
- National Medical Research Center of Cardiology, Ministry of Healthcare Russian Federation, Moscow
| | - R M Shakhnovich
- National Medical Research Center of Cardiology, Ministry of Healthcare Russian Federation, Moscow
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Predicting the probability of survival with mild or moderate neurological dysfunction after in-hospital cardiopulmonary arrest: The GO-FAR 2 score. Resuscitation 2019; 146:162-169. [PMID: 31821836 DOI: 10.1016/j.resuscitation.2019.12.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 11/18/2019] [Accepted: 12/02/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND The Good Outcome Following Attempted Resuscitation (GO-FAR) Score uses pre-arrest factors to predict survival after In-Hospital Cardiac Arrest (IHCA) with minimal neurological dysfunction, (cerebral performance category (CPC) ≤1). Moderate neurological dysfunction (CPC ≤2) may be a more acceptable outcome. OBJECTIVE To predict survival after IHCA with mild or moderate neurological dysfunction based on pre-arrest factors. METHODS 52,468 patients with IHCA from 2012-2017. Data was divided into training (44%), testing (22%), and validation (34%) sets. Univariate analysis was used to identify variables with >3% difference in survival with CPC ≤2. These variables carried forward to the multivariate logistic regression model. The most parsimonious model that best classified patients as having a very poor (≤5%), below average (≤10%), average (11%-30%), or above average (>30%) likelihood of survival with CPC ≤2 was chosen. RESULTS Age >85, admission CPC <2, and non-surgical admission were strongly association with poor survival (-12.1%, -14.4%, and -18%, respectively). Nine variables were included in the logistic regression analysis. The final updated model, GO FAR 2, categorized 6.2% of patients with a very poor predicted survival, 24.8% of patients with a below average predicted survival, and 11.3% with above average predicted survival. The observed survival among those with very poor predicted survival was 4.5%. CONCLUSION The GO FAR 2 score provides clinicians with a prognostic estimate of the likelihood of a good outcome after IHCA based on pre-arrest patient factors. Future research is required to validate the GO-FAR 2 score.
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17
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Walker AC, Johnson NJ. Targeted Temperature Management and Postcardiac arrest Care. Emerg Med Clin North Am 2019; 37:381-393. [PMID: 31262410 DOI: 10.1016/j.emc.2019.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Despite recent advances, care of the post-cardiac arrest patient remains a challenge. In this article, the authors discuss an approach to the initial care of post-cardiac arrest patients with particular focus on targeted temperature management (TTM). The article starts with history, physiologic rationale, and the major randomized controlled trials that have shaped guidelines for post-cardiac arrest care. It also reviews controversial topics, including TTM for nonshockable rhythms, TTM dose, and surface versus endovascular cooling. The article concludes with a brief review of other key aspects of post-arrest care: coronary angiography, hemodynamic optimization, ventilator management, and prognostication.
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Affiliation(s)
- Amy C Walker
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA.
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA
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18
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Kiehl EL, Amuthan R, Adams MP, Love TE, Enfield KB, Gimple LW, Cantillon DJ, Menon V. Initial arterial pH as a predictor of neurologic outcome after out-of-hospital cardiac arrest: A propensity-adjusted analysis. Resuscitation 2019; 139:76-83. [PMID: 30946922 DOI: 10.1016/j.resuscitation.2019.03.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 02/09/2019] [Accepted: 03/25/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Lower pH after out-of-hospital cardiac arrest (OHCA) has been associated with worsening neurologic outcome, with <7.2 identified as an "unfavorable resuscitation feature" in consensus treatment algorithms despite conflicting data. This study aimed to describe the relationship between decremental post-resuscitation pH and neurologic outcomes after OHCA. METHODS Consecutive OHCA patients treated with targeted temperature management (TTM) at multiple US centers from 2008 to 2017 were evaluated. Poor neurologic outcome at hospital discharge was defined as cerebral performance category ≥3. The exposure was initial arterial pH after return of spontaneous circulation (ROSC) analyzed in decremental 0.05 thresholds. Potential confounders (demographics, history, resuscitation characteristics, initial studies) were defined a priori and controlled for via ATT-weighting on the inverse propensity score plus direct adjustment for the linear propensity score. RESULTS Of 723 patients, 589 (80%) experienced poor neurologic outcome at hospital discharge. After propensity-adjustment with excellent covariate balance, the adjusted odds ratios for poor neurologic outcome by pH threshold were: ≤7.3: 2.0 (1.0-4.0); ≤7.25: 1.9 (1.2-3.1); ≤7.2: 2.1 (1.3-3.3); ≤7.15: 1.9 (1.2-3.1); ≤7.1: 2.4 (1.4-4.1); ≤7.05: 3.1 (1.5-6.3); ≤7.0: 4.5 (1.8-12). CONCLUSIONS No increased hazard of progressively poor neurologic outcomes was observed in resuscitated OHCA patients treated with TTM until the initial post-ROSC arterial pH was at least ≤7.1. This threshold is more acidic than in current guidelines, suggesting the possibility that post-arrest pH may be utilized presently as an inappropriately-pessimistic prognosticator.
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Affiliation(s)
- Erich L Kiehl
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ram Amuthan
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Mark P Adams
- Department of Cardiovascular Medicine, University of Virginia, Charlottesville, VA, USA
| | - Thomas E Love
- Departments of Medicine and of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA; Center for Health Care Research and Policy, MetroHealth Medical Center, Cleveland, OH, USA
| | - Kyle B Enfield
- Department of Pulmonary and Critical Care Medicine, University of Virginia, Charlottesville, VA, USA
| | - Lawrence W Gimple
- Department of Cardiovascular Medicine, University of Virginia, Charlottesville, VA, USA
| | - Daniel J Cantillon
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Venu Menon
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA.
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Khera R, Humbert A, Leroux B, Nichol G, Kudenchuk P, Scales D, Baker A, Austin M, Newgard CD, Radecki R, Vilke GM, Sawyer KN, Sopko G, Idris AH, Wang H, Chan PS, Kurz MC. Hospital Variation in the Utilization and Implementation of Targeted Temperature Management in Out-of-Hospital Cardiac Arrest. Circ Cardiovasc Qual Outcomes 2018; 11:e004829. [DOI: 10.1161/circoutcomes.118.004829] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Rohan Khera
- Division of Cardiology, UT Southwestern Medical Center, Dallas, TX (R.K.)
| | - Andrew Humbert
- Clinical Trial Center, Department of Biostatistics (A.H., B.L.), University of Washington, Seattle
| | - Brian Leroux
- Clinical Trial Center, Department of Biostatistics (A.H., B.L.), University of Washington, Seattle
| | - Graham Nichol
- Department of Medicine (G.N., P.K.), University of Washington, Seattle
| | - Peter Kudenchuk
- Department of Medicine (G.N., P.K.), University of Washington, Seattle
| | - Damon Scales
- Department of Medicine, University of Toronto, Ontario, Canada (D.S., A.B.)
| | - Andrew Baker
- Department of Medicine, University of Toronto, Ontario, Canada (D.S., A.B.)
| | - Mike Austin
- Department of Emergency Medicine, University of Ottawa, Ontario, Canada (M.A.)
| | - Craig D. Newgard
- Department of Emergency Medicine, Oregon Health & Science University, Portland (C.D.N.)
| | - Ryan Radecki
- Department of Emergency Medicine, Kaiser Permanente Northwest, Portland, OR (R.R.)
| | - Gary M. Vilke
- Department of Emergency Medicine, University of California San Diego, CA (G.M.V.)
| | - Kelly N. Sawyer
- Department of Emergency Medicine, University of Pittsburgh, PA (K.N.S.)
| | - George Sopko
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MA (G.S.)
| | - Ahamed H. Idris
- Departments of Emergency Medicine and Internal Medicine, UT Southwestern Medical Center, Dallas, TX (A.H.I.)
| | - Henry Wang
- Department of Emergency Medicine, University of Texas Health Sciences Center at Houston (H.W.)
| | - Paul S. Chan
- Mid America Heart Institute, Kansas City and the University of Missouri-Kansas City, MO (P.S.C.)
| | - Michael C. Kurz
- Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham (M.C.K.)
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Abstract
Therapeutic hypothermia is a relatively new protocol that can improve patients' chances of favorable neurologic outcomes after cardiac arrest. However, implementation rates remain low nationwide. This article describes recommendations for and benefits of therapeutic hypothermia in postresuscitation care.
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21
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Zhang W, Liao J, Liu Z, Weng R, Ye X, Zhang Y, Xu J, Wei H, Xiong Y, Idris A. Out-of-hospital cardiac arrest with Do-Not-Resuscitate orders signed in hospital: Who are the survivors? Resuscitation 2018; 127:68-72. [PMID: 29631004 DOI: 10.1016/j.resuscitation.2018.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 03/23/2018] [Accepted: 04/05/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Signing Do-Not-Resuscitate orders is an important element contributing to a worse prognosis for out-of-hospital cardiac arrest (OHCA). However, our data showed that some of those OHCA patients with Do-Not-Resuscitate orders signed in hospital survived to hospital discharge, and even recovered with favorable neurological function. In this study, we described their clinical features and identified those factors that were associated with better outcomes. METHODS A retrospective, observational analysis was performed on all adult non-traumatic OHCA who were enrolled in the Resuscitation Outcomes Consortium (ROC) PRIMED study but signed Do-Not-Resuscitate orders in hospital after admission. We reported their demographics, characteristics, interventions and outcomes of all enrolled cases. Patients surviving and not surviving to hospital discharge, as well as those who did and did not obtain favorable neurological recovery, were compared. Logistic regression models assessed those factors which might be prognostic to survival and favorable neurological outcomes at discharge. RESULTS Of 2289 admitted patients with Do-Not-Resuscitate order signed in hospital, 132(5.8%) survived to hospital discharge and 28(1.2%) achieved favorable neurological recovery. Those factors, including witnessed arrest, prehospital shock delivered, Return of Spontaneous Circulation (ROSC) obtained in the field, cardiovascular interventions or procedures applied, and no prehospital adrenaline administered, were independently associated with better outcomes. CONCLUSIONS We suggest that some factors should be taken into considerations before Do-Not-Resuscitate decisions are made in hospital for those admitted OHCA patients.
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Affiliation(s)
- Wanwan Zhang
- Department of Emergency Medicine, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou 510080, China
| | - Jinli Liao
- Department of Emergency Medicine, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou 510080, China
| | - Zhihao Liu
- Department of Emergency Medicine, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou 510080, China
| | - Rennan Weng
- Medical School of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou 510080, China
| | - Xiaoqi Ye
- Medical School of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou 510080, China
| | - Yongshu Zhang
- Department of Emergency Medicine, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou 510080, China
| | - Jia Xu
- Department of Emergency Medicine, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou 510080, China
| | - Hongyan Wei
- Department of Emergency Medicine, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou 510080, China.
| | - Yan Xiong
- Department of Emergency Medicine, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou 510080, China; Department of Emergency Medicine, University of Texas, Southwestern Medical Center, 5323 Harry Hines BLVD, Dallas, TX 75390-8579, USA.
| | - Ahamed Idris
- Department of Emergency Medicine, University of Texas, Southwestern Medical Center, 5323 Harry Hines BLVD, Dallas, TX 75390-8579, USA
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Nuzzo A, Peron N, Voicu S, Mégarbane B, Deye N. Targeted temperature management for non-shockable cardiac arrests: the debate must go on. J Thorac Dis 2018; 10:1304-1307. [PMID: 29707282 DOI: 10.21037/jtd.2018.03.32] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Alexandre Nuzzo
- Department of Medical Intensive Care, Lariboisière Hospital, APHP, Paris, France.,Paris Diderot University, Sorbonne Paris Cite, Paris, France
| | - Nicolas Peron
- Department of Medical Intensive Care, Lariboisière Hospital, APHP, Paris, France.,Paris Diderot University, Sorbonne Paris Cite, Paris, France
| | - Sebastian Voicu
- Department of Medical Intensive Care, Lariboisière Hospital, APHP, Paris, France.,Paris Diderot University, Sorbonne Paris Cite, Paris, France
| | - Bruno Mégarbane
- Department of Medical Intensive Care, Lariboisière Hospital, APHP, Paris, France.,Paris Diderot University, Sorbonne Paris Cite, Paris, France
| | - Nicolas Deye
- Department of Medical Intensive Care, Lariboisière Hospital, APHP, Paris, France.,Paris Diderot University, Sorbonne Paris Cite, Paris, France.,INSERM U942, Paris, France
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Contrôle cible de la température en réanimation (hors nouveau-nés). MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Xu DJ, Wang B, Zhao X, Zheng Y, Du JL, Wang YW. General anesthetics protects against cardiac arrest-induced brain injury by inhibiting calcium wave propagation in zebrafish. Mol Brain 2017; 10:44. [PMID: 28870222 PMCID: PMC5583756 DOI: 10.1186/s13041-017-0323-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 08/23/2017] [Indexed: 12/23/2022] Open
Abstract
Cardiac arrest is a leading cause of death and disability worldwide. Although many victims are initially resuscitated, they often suffer from serious brain injury, even leading to a “persistent vegetative state”. Therefore, it is need to explore therapies which restore and protect brain function after cardiac arrest. In the present study, using Tg (HuC:GCaMP5) zebrafish as a model, we found the zebrafish brain generated a burst of Ca2+ wave after cardiac arrest by in vivo time-lapse confocal imaging. The Ca2+ wave was firstly initiated at hindbrain and then sequentially propagated to midbrain and telencephalon, the neuron displayed Ca2+ overload after Ca2+ wave propagation. Consistent with this, our study further demonstrated neuronal apoptosis was increased in cardiac arrest zebrafish by TUNEL staining. The cardiac arrest-induced Ca2+ wave propagation can be prevented by general anesthetics such as midazolam or ketamine pretreatment. Moreover, midazolam or ketamine pretreatment dramatically decreased the neuronal apoptosis and improved the survival rate in CA zebrafish. Taken together, these findings provide the first in vivo evidence that general anesthetics pretreatment protects against cardiac arrest-induced brain injury by inhibiting calcium wave propagation in zebrafish.
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Affiliation(s)
- Dao-Jie Xu
- Department of Anesthesiology, Xinhua Hospital, Medical School, Shanghai Jiaotong University, 1665 Kong-Jiang Road, Shanghai, 200092, China
| | - Bin Wang
- Department of Anesthesiology, Xinhua Hospital, Medical School, Shanghai Jiaotong University, 1665 Kong-Jiang Road, Shanghai, 200092, China
| | - Xuan Zhao
- Department of Anesthesiology, Xinhua Hospital, Medical School, Shanghai Jiaotong University, 1665 Kong-Jiang Road, Shanghai, 200092, China
| | - Yi Zheng
- Department of Anesthesiology, Xinhua Hospital, Medical School, Shanghai Jiaotong University, 1665 Kong-Jiang Road, Shanghai, 200092, China
| | - Jiu-Lin Du
- Institute of Neuroscience, State Key Laboratory of Neuroscience, Center for Excellence in Brain Science and Intelligence Technology Chinese Academy of Sciences, Shanghai, 200031, China
| | - Ying-Wei Wang
- Department of Anesthesiology, Huashan Hospital, Fudan University, No. 12 Wu lu mu qi Road, Shanghai, 200040, China.
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Pinto P, Brown T, Khilkin M, Chuang E. Patient Outcomes After Palliative Care Consultation Among Patients Undergoing Therapeutic Hypothermia. Am J Hosp Palliat Care 2017; 35:570-573. [PMID: 28789562 DOI: 10.1177/1049909117724779] [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: 11/16/2022] Open
Abstract
OBJECTIVES To compare the clinical outcomes of patients who did and did not receive palliative care consultation among those who experienced out-of-hospital cardiac arrest and underwent therapeutic hypothermia. METHODS We identified patients at a single academic medical center who had undergone therapeutic hypothermia after out-of-hospital cardiac arrest between 2009 and 2013. We performed a retrospective chart review for demographic data, hospital and critical care length of stay, and clinical outcomes of care. RESULTS We reviewed the charts of 62 patients, of which 35 (56%) received a palliative care consultation and 27 (44%) did not. Palliative care consultation occurred an average of 8.3 days after admission. Patients receiving palliative care consultation were more likely to have a do-not-resuscitate (DNR) order placed (odds ratio: 2.3, P < .001). The mean length of stay in the hospital was similar for patients seen by palliative care or not (16.7 vs 17.1 days, P = .90). Intensive care length of stay was also similar (11.3 vs 12.6 days, P = .55). CONCLUSIONS Palliative care consultation was underutilized and utilized late in this cohort. Palliative consultation was associated with DNR orders but did not affect measures of utilization such as hospital and intensive care length of stay.
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Affiliation(s)
- Priya Pinto
- 1 Division of Palliative Medicine and Bioethics, Winthrop University Hospital, Mineola, NY, USA
| | - Tartania Brown
- 2 Wyckoff Hospital, MJHS Hospice and Palliative Care, Brooklyn, NY, USA
| | - Michael Khilkin
- 3 Department of Critical Care Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Elizabeth Chuang
- 4 Hospice and Palliative Medicine, Department of Family and Social Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
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Abstract
OBJECTIVES To compare accuracy of a continuous noninvasive cutaneous temperature using zero-heat-flux method to esophageal temperature and arterial temperature. DESIGN Prospective study. SETTING ICU and NeuroICU, University Hospital. PATIENTS Fifty-two ICU patients over a 4-month period who required continuous temperature monitoring were included in the study, after informed consent. INTERVENTIONS All patients had esophageal temperature probe and a noninvasive cutaneous device to monitor their core temperature continuously. In seven patients who required cardiac output monitoring, continuous iliac arterial temperature was collected. Simultaneous core temperatures were recorded from 1 to 5 days. Comparison to the esophageal temperature, considered as the reference in this study, used the Bland and Altman method with adjustment for multiple measurements per patient. MEASUREMENTS AND MAIN RESULTS The esophageal temperature ranged from 33°C to 39.7°C, 61,298 pairs of temperature using zero-heat-flux and esophageal temperature were collected and 1,850 triple of temperature using zero-heat-flux, esophageal temperature, and arterial temperature. Bias and limits of agreement for temperature using zero-heat-flux were 0.19°C ± 0.53°C compared with esophageal temperature with an absolute difference of temperature pairs equal to or lower than 0.5°C of 92.6% (95% CI, 91.9-93.4%) of cases and equal to or lower than 1°C for 99.9% (95% CI, 99.7-100.0%) of cases. Compared with arterial temperature, bias and limits of agreement were -0.00°C ± 0.36°C with an absolute difference of temperature pairs equal to or lower than 0.5°C of 99.8% (95% CI, 95.3-100%) of cases. All absolute difference of temperature pairs between temperature using zero-heat-flux and arterial temperature and between arterial temperature and esophageal temperature were equal to or lower than 1°C. No local or systemic serious complication was observed. CONCLUSIONS These results suggest a comparable reliability of the cutaneous sensor using the zero-heat-flux method compared with esophageal or iliac arterial temperatures measurements.
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Targeted temperature management in the ICU: Guidelines from a French expert panel. Anaesth Crit Care Pain Med 2017; 37:481-491. [PMID: 28688998 DOI: 10.1016/j.accpm.2017.06.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Over the recent period, the use of induced hypothermia has gained an increasing interest for critically ill patients, in particular in brain-injured patients. The term "targeted temperature management" (TTM) has now emerged as the most appropriate when referring to interventions used to reach and maintain a specific level temperature for each individual. TTM may be used to prevent fever, to maintain normothermia, or to lower core temperature. This treatment is widely used in intensive care units, mostly as a primary neuroprotective method. Indications are, however, associated with variable levels of evidence based on inhomogeneous or even contradictory literature. Our aim was to conduct a systematic analysis of the published data in order to provide guidelines. We present herein recommendations for the use of TTM in adult and paediatric critically ill patients developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. These guidelines were conducted by a group of experts from the French Intensive Care Society (Société de réanimation de langue française [SRLF]) and the French Society of Anesthesia and Intensive Care Medicine (Société francaise d'anesthésie réanimation [SFAR]) with the participation of the French Emergency Medicine Association (Société française de médecine d'urgence [SFMU]), the French Group for Pediatric Intensive Care and Emergencies (Groupe francophone de réanimation et urgences pédiatriques [GFRUP]), the French National Association of Neuro-Anesthesiology and Critical Care (Association nationale de neuro-anesthésie réanimation française [ANARLF]), and the French Neurovascular Society (Société française neurovasculaire [SFNV]). Fifteen experts and two coordinators agreed to consider questions concerning TTM and its practical implementation in five clinical situations: cardiac arrest, traumatic brain injury, stroke, other brain injuries, and shock. This resulted in 30 recommendations: 3 recommendations were strong (Grade 1), 13 were weak (Grade 2), and 14 were experts' opinions. After two rounds of rating and various amendments, a strong agreement from voting participants was obtained for all 30 (100%) recommendations, which are exposed in the present article.
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Abstract
Over the recent period, the use of induced hypothermia has gained an increasing interest for critically ill patients, in particular in brain-injured patients. The term “targeted temperature management” (TTM) has now emerged as the most appropriate when referring to interventions used to reach and maintain a specific level temperature for each individual. TTM may be used to prevent fever, to maintain normothermia, or to lower core temperature. This treatment is widely used in intensive care units, mostly as a primary neuroprotective method. Indications are, however, associated with variable levels of evidence based on inhomogeneous or even contradictory literature. Our aim was to conduct a systematic analysis of the published data in order to provide guidelines. We present herein recommendations for the use of TTM in adult and paediatric critically ill patients developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. These guidelines were conducted by a group of experts from the French Intensive Care Society (Société de Réanimation de Langue Française [SRLF]) and the French Society of Anesthesia and Intensive Care Medicine (Société Francaise d’Anesthésie Réanimation [SFAR]) with the participation of the French Emergency Medicine Association (Société Française de Médecine d’Urgence [SFMU]), the French Group for Pediatric Intensive Care and Emergencies (Groupe Francophone de Réanimation et Urgences Pédiatriques [GFRUP]), the French National Association of Neuro-Anesthesiology and Critical Care (Association Nationale de Neuro-Anesthésie Réanimation Française [ANARLF]), and the French Neurovascular Society (Société Française Neurovasculaire [SFNV]). Fifteen experts and two coordinators agreed to consider questions concerning TTM and its practical implementation in five clinical situations: cardiac arrest, traumatic brain injury, stroke, other brain injuries, and shock. This resulted in 30 recommendations: 3 recommendations were strong (Grade 1), 13 were weak (Grade 2), and 14 were experts’ opinions. After two rounds of rating and various amendments, a strong agreement from voting participants was obtained for all 30 (100%) recommendations, which are exposed in the present article.
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Kiehl EL, Parker AM, Matar RM, Gottbrecht MF, Johansen MC, Adams MP, Griffiths LA, Dunn SP, Bidwell KL, Menon V, Enfield KB, Gimple LW. C-GRApH: A Validated Scoring System for Early Stratification of Neurologic Outcome After Out-of-Hospital Cardiac Arrest Treated With Targeted Temperature Management. J Am Heart Assoc 2017; 6:JAHA.116.003821. [PMID: 28528323 PMCID: PMC5524053 DOI: 10.1161/jaha.116.003821] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background Out‐of‐hospital cardiac arrest (OHCA) results in significant morbidity and mortality, primarily from neurologic injury. Predicting neurologic outcome early post‐OHCA remains difficult in patients receiving targeted temperature management. Methods and Results Retrospective analysis was performed on consecutive OHCA patients receiving targeted temperature management (32–34°C) for 24 hours at a tertiary‐care center from 2008 to 2012 (development cohort, n=122). The primary outcome was favorable neurologic outcome at hospital discharge, defined as cerebral performance category 1 to 2 (poor 3–5). Patient demographics, pre‐OHCA diagnoses, and initial laboratory studies post‐resuscitation were compared between favorable and poor neurologic outcomes with multivariable logistic regression used to develop a simple scoring system (C‐GRApH). The C‐GRApH score ranges 0 to 5 using equally weighted variables: (C): coronary artery disease, known pre‐OHCA; (G): glucose ≥200 mg/dL; (R): rhythm of arrest not ventricular tachycardia/fibrillation; (A): age >45; (pH): arterial pH ≤7.0. A validation cohort (n=344) included subsequent patients from the initial site (n=72) and an external quaternary‐care health system (n=272) from 2012 to 2014. The c‐statistic for predicting neurologic outcome was 0.82 (0.74–0.90, P<0.001) in the development cohort and 0.81 (0.76–0.87, P<0.001) in the validation cohort. When subdivided by C‐GRApH score, similar rates of favorable neurologic outcome were seen in both cohorts, 70% each for low (0–1, n=60), 22% versus 19% for medium (2–3, n=307), and 0% versus 2% for high (4–5, n=99) C‐GRApH scores in the development and validation cohorts, respectively. Conclusions C‐GRApH stratifies neurologic outcomes following OHCA in patients receiving targeted temperature management (32–34°C) using objective data available at hospital presentation, identifying patient subsets with disproportionally favorable (C‐GRApH ≤1) and poor (C‐GRApH ≥4) prognoses.
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Affiliation(s)
- Erich L Kiehl
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH
| | - Alex M Parker
- Department of Cardiovascular Medicine, University of Virginia, Charlottesville, VA
| | - Ralph M Matar
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH
| | | | | | - Mark P Adams
- Department of Cardiovascular Medicine, University of Virginia, Charlottesville, VA
| | - Lori A Griffiths
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH
| | - Steven P Dunn
- Department of Pharmacy, University of Virginia, Charlottesville, VA
| | | | - Venu Menon
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH
| | - Kyle B Enfield
- Department of Pulmonary/Critical Care Medicine, University of Virginia, Charlottesville, VA
| | - Lawrence W Gimple
- Department of Cardiovascular Medicine, University of Virginia, Charlottesville, VA
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Geocadin RG, Wijdicks E, Armstrong MJ, Damian M, Mayer SA, Ornato JP, Rabinstein A, Suarez JI, Torbey MT, Dubinsky RM, Lazarou J. Practice guideline summary: Reducing brain injury following cardiopulmonary resuscitation: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology 2017; 88:2141-2149. [PMID: 28490655 DOI: 10.1212/wnl.0000000000003966] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 02/01/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess the evidence and make evidence-based recommendations for acute interventions to reduce brain injury in adult patients who are comatose after successful cardiopulmonary resuscitation. METHODS Published literature from 1966 to August 29, 2016, was reviewed with evidence-based classification of relevant articles. RESULTS AND RECOMMENDATIONS For patients who are comatose in whom the initial cardiac rhythm is either pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF) after out-of-hospital cardiac arrest (OHCA), therapeutic hypothermia (TH; 32-34°C for 24 hours) is highly likely to be effective in improving functional neurologic outcome and survival compared with non-TH and should be offered (Level A). For patients who are comatose in whom the initial cardiac rhythm is either VT/VF or asystole/pulseless electrical activity (PEA) after OHCA, targeted temperature management (36°C for 24 hours, followed by 8 hours of rewarming to 37°C, and temperature maintenance below 37.5°C until 72 hours) is likely as effective as TH and is an acceptable alternative (Level B). For patients who are comatose with an initial rhythm of PEA/asystole, TH possibly improves survival and functional neurologic outcome at discharge vs standard care and may be offered (Level C). Prehospital cooling as an adjunct to TH is highly likely to be ineffective in further improving neurologic outcome and survival and should not be offered (Level A). Other pharmacologic and nonpharmacologic strategies (applied with or without concomitant TH) are also reviewed.
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Affiliation(s)
- Romergryko G Geocadin
- From the Departments of Neurology, Anesthesiology-Critical Care Medicine, and Neurosurgery (R.G.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (E.W., A.R.), Mayo Clinic, Rochester, MN; Department of Neurology (M.J.A.), University of Florida-McKnight Brain Institute, Gainesville; Department of Neurology and Neurocritical Care Unit (M.D.), Cambridge University Hospitals; The Ipswich Hospital (M.D.), Cambridge, UK; Departments of Neurology and Neurosurgery (S.A.M.), Mount Sinai-Icahn School of Medicine, New York, NY; Departments of Emergency Medicine and Internal Medicine (Cardiology) (J.P.O.), Virginia Commonwealth University College of Medicine, Richmond; Department of Neurology (J.I.S.), Baylor College of Medicine, Houston, TX; Department of Neurology and Neurosurgery (M.T.T.), Ohio State University, Columbus; Department of Neurology (R.M.D.), Kansas University Medical Center, Kansas City; and Department of Neurology (J.L.), University of Toronto, Canada
| | - Eelco Wijdicks
- From the Departments of Neurology, Anesthesiology-Critical Care Medicine, and Neurosurgery (R.G.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (E.W., A.R.), Mayo Clinic, Rochester, MN; Department of Neurology (M.J.A.), University of Florida-McKnight Brain Institute, Gainesville; Department of Neurology and Neurocritical Care Unit (M.D.), Cambridge University Hospitals; The Ipswich Hospital (M.D.), Cambridge, UK; Departments of Neurology and Neurosurgery (S.A.M.), Mount Sinai-Icahn School of Medicine, New York, NY; Departments of Emergency Medicine and Internal Medicine (Cardiology) (J.P.O.), Virginia Commonwealth University College of Medicine, Richmond; Department of Neurology (J.I.S.), Baylor College of Medicine, Houston, TX; Department of Neurology and Neurosurgery (M.T.T.), Ohio State University, Columbus; Department of Neurology (R.M.D.), Kansas University Medical Center, Kansas City; and Department of Neurology (J.L.), University of Toronto, Canada
| | - Melissa J Armstrong
- From the Departments of Neurology, Anesthesiology-Critical Care Medicine, and Neurosurgery (R.G.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (E.W., A.R.), Mayo Clinic, Rochester, MN; Department of Neurology (M.J.A.), University of Florida-McKnight Brain Institute, Gainesville; Department of Neurology and Neurocritical Care Unit (M.D.), Cambridge University Hospitals; The Ipswich Hospital (M.D.), Cambridge, UK; Departments of Neurology and Neurosurgery (S.A.M.), Mount Sinai-Icahn School of Medicine, New York, NY; Departments of Emergency Medicine and Internal Medicine (Cardiology) (J.P.O.), Virginia Commonwealth University College of Medicine, Richmond; Department of Neurology (J.I.S.), Baylor College of Medicine, Houston, TX; Department of Neurology and Neurosurgery (M.T.T.), Ohio State University, Columbus; Department of Neurology (R.M.D.), Kansas University Medical Center, Kansas City; and Department of Neurology (J.L.), University of Toronto, Canada
| | - Maxwell Damian
- From the Departments of Neurology, Anesthesiology-Critical Care Medicine, and Neurosurgery (R.G.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (E.W., A.R.), Mayo Clinic, Rochester, MN; Department of Neurology (M.J.A.), University of Florida-McKnight Brain Institute, Gainesville; Department of Neurology and Neurocritical Care Unit (M.D.), Cambridge University Hospitals; The Ipswich Hospital (M.D.), Cambridge, UK; Departments of Neurology and Neurosurgery (S.A.M.), Mount Sinai-Icahn School of Medicine, New York, NY; Departments of Emergency Medicine and Internal Medicine (Cardiology) (J.P.O.), Virginia Commonwealth University College of Medicine, Richmond; Department of Neurology (J.I.S.), Baylor College of Medicine, Houston, TX; Department of Neurology and Neurosurgery (M.T.T.), Ohio State University, Columbus; Department of Neurology (R.M.D.), Kansas University Medical Center, Kansas City; and Department of Neurology (J.L.), University of Toronto, Canada
| | - Stephan A Mayer
- From the Departments of Neurology, Anesthesiology-Critical Care Medicine, and Neurosurgery (R.G.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (E.W., A.R.), Mayo Clinic, Rochester, MN; Department of Neurology (M.J.A.), University of Florida-McKnight Brain Institute, Gainesville; Department of Neurology and Neurocritical Care Unit (M.D.), Cambridge University Hospitals; The Ipswich Hospital (M.D.), Cambridge, UK; Departments of Neurology and Neurosurgery (S.A.M.), Mount Sinai-Icahn School of Medicine, New York, NY; Departments of Emergency Medicine and Internal Medicine (Cardiology) (J.P.O.), Virginia Commonwealth University College of Medicine, Richmond; Department of Neurology (J.I.S.), Baylor College of Medicine, Houston, TX; Department of Neurology and Neurosurgery (M.T.T.), Ohio State University, Columbus; Department of Neurology (R.M.D.), Kansas University Medical Center, Kansas City; and Department of Neurology (J.L.), University of Toronto, Canada
| | - Joseph P Ornato
- From the Departments of Neurology, Anesthesiology-Critical Care Medicine, and Neurosurgery (R.G.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (E.W., A.R.), Mayo Clinic, Rochester, MN; Department of Neurology (M.J.A.), University of Florida-McKnight Brain Institute, Gainesville; Department of Neurology and Neurocritical Care Unit (M.D.), Cambridge University Hospitals; The Ipswich Hospital (M.D.), Cambridge, UK; Departments of Neurology and Neurosurgery (S.A.M.), Mount Sinai-Icahn School of Medicine, New York, NY; Departments of Emergency Medicine and Internal Medicine (Cardiology) (J.P.O.), Virginia Commonwealth University College of Medicine, Richmond; Department of Neurology (J.I.S.), Baylor College of Medicine, Houston, TX; Department of Neurology and Neurosurgery (M.T.T.), Ohio State University, Columbus; Department of Neurology (R.M.D.), Kansas University Medical Center, Kansas City; and Department of Neurology (J.L.), University of Toronto, Canada
| | - Alejandro Rabinstein
- From the Departments of Neurology, Anesthesiology-Critical Care Medicine, and Neurosurgery (R.G.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (E.W., A.R.), Mayo Clinic, Rochester, MN; Department of Neurology (M.J.A.), University of Florida-McKnight Brain Institute, Gainesville; Department of Neurology and Neurocritical Care Unit (M.D.), Cambridge University Hospitals; The Ipswich Hospital (M.D.), Cambridge, UK; Departments of Neurology and Neurosurgery (S.A.M.), Mount Sinai-Icahn School of Medicine, New York, NY; Departments of Emergency Medicine and Internal Medicine (Cardiology) (J.P.O.), Virginia Commonwealth University College of Medicine, Richmond; Department of Neurology (J.I.S.), Baylor College of Medicine, Houston, TX; Department of Neurology and Neurosurgery (M.T.T.), Ohio State University, Columbus; Department of Neurology (R.M.D.), Kansas University Medical Center, Kansas City; and Department of Neurology (J.L.), University of Toronto, Canada
| | - José I Suarez
- From the Departments of Neurology, Anesthesiology-Critical Care Medicine, and Neurosurgery (R.G.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (E.W., A.R.), Mayo Clinic, Rochester, MN; Department of Neurology (M.J.A.), University of Florida-McKnight Brain Institute, Gainesville; Department of Neurology and Neurocritical Care Unit (M.D.), Cambridge University Hospitals; The Ipswich Hospital (M.D.), Cambridge, UK; Departments of Neurology and Neurosurgery (S.A.M.), Mount Sinai-Icahn School of Medicine, New York, NY; Departments of Emergency Medicine and Internal Medicine (Cardiology) (J.P.O.), Virginia Commonwealth University College of Medicine, Richmond; Department of Neurology (J.I.S.), Baylor College of Medicine, Houston, TX; Department of Neurology and Neurosurgery (M.T.T.), Ohio State University, Columbus; Department of Neurology (R.M.D.), Kansas University Medical Center, Kansas City; and Department of Neurology (J.L.), University of Toronto, Canada
| | - Michel T Torbey
- From the Departments of Neurology, Anesthesiology-Critical Care Medicine, and Neurosurgery (R.G.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (E.W., A.R.), Mayo Clinic, Rochester, MN; Department of Neurology (M.J.A.), University of Florida-McKnight Brain Institute, Gainesville; Department of Neurology and Neurocritical Care Unit (M.D.), Cambridge University Hospitals; The Ipswich Hospital (M.D.), Cambridge, UK; Departments of Neurology and Neurosurgery (S.A.M.), Mount Sinai-Icahn School of Medicine, New York, NY; Departments of Emergency Medicine and Internal Medicine (Cardiology) (J.P.O.), Virginia Commonwealth University College of Medicine, Richmond; Department of Neurology (J.I.S.), Baylor College of Medicine, Houston, TX; Department of Neurology and Neurosurgery (M.T.T.), Ohio State University, Columbus; Department of Neurology (R.M.D.), Kansas University Medical Center, Kansas City; and Department of Neurology (J.L.), University of Toronto, Canada
| | - Richard M Dubinsky
- From the Departments of Neurology, Anesthesiology-Critical Care Medicine, and Neurosurgery (R.G.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (E.W., A.R.), Mayo Clinic, Rochester, MN; Department of Neurology (M.J.A.), University of Florida-McKnight Brain Institute, Gainesville; Department of Neurology and Neurocritical Care Unit (M.D.), Cambridge University Hospitals; The Ipswich Hospital (M.D.), Cambridge, UK; Departments of Neurology and Neurosurgery (S.A.M.), Mount Sinai-Icahn School of Medicine, New York, NY; Departments of Emergency Medicine and Internal Medicine (Cardiology) (J.P.O.), Virginia Commonwealth University College of Medicine, Richmond; Department of Neurology (J.I.S.), Baylor College of Medicine, Houston, TX; Department of Neurology and Neurosurgery (M.T.T.), Ohio State University, Columbus; Department of Neurology (R.M.D.), Kansas University Medical Center, Kansas City; and Department of Neurology (J.L.), University of Toronto, Canada
| | - Jason Lazarou
- From the Departments of Neurology, Anesthesiology-Critical Care Medicine, and Neurosurgery (R.G.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (E.W., A.R.), Mayo Clinic, Rochester, MN; Department of Neurology (M.J.A.), University of Florida-McKnight Brain Institute, Gainesville; Department of Neurology and Neurocritical Care Unit (M.D.), Cambridge University Hospitals; The Ipswich Hospital (M.D.), Cambridge, UK; Departments of Neurology and Neurosurgery (S.A.M.), Mount Sinai-Icahn School of Medicine, New York, NY; Departments of Emergency Medicine and Internal Medicine (Cardiology) (J.P.O.), Virginia Commonwealth University College of Medicine, Richmond; Department of Neurology (J.I.S.), Baylor College of Medicine, Houston, TX; Department of Neurology and Neurosurgery (M.T.T.), Ohio State University, Columbus; Department of Neurology (R.M.D.), Kansas University Medical Center, Kansas City; and Department of Neurology (J.L.), University of Toronto, Canada
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Initiation of Therapeutic Hypothermia in the Emergency Department: A Quality Improvement Project. Adv Emerg Nurs J 2017; 39:52-58. [PMID: 28141610 DOI: 10.1097/tme.0000000000000131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Therapeutic hypothermia (TH) postresuscitation has been recommended by the American Heart Association (AHA) since 2005. Early initiation of TH and fast achievement of goal temperatures have been associated with better neurological outcomes. The objective of this study was to evaluate the effectiveness of a specific TH protocol for the emergency department (ED) in increasing ED use of TH and decreasing the time from return of spontaneous circulation (ROSC) to initiation of cooling measures. An ED protocol for TH as recommended by the AHA was implemented. A random sample of 10 patients who received TH prior to the implementation of an ED protocol were analyzed and compared with the first 10 patients who received TH after the ED protocol was implemented. The time from ROSC to initiation of cooling measures and survival to discharge rates were analyzed. After implementation of the ED protocol, 7 of the 10 patients were treated with the ED protocol. The mean time to initiation of TH for the preimplementation group was 127.8 min (SD = 52.9) compared with 15.71 min (SD = 9.552) for the postimplementation group. The difference in initiation time between the pre- and postimplementation study groups was statistically significant, t(9.826) = 6.55, p < 0.05. Survival to discharge rates were 30% for the preimplementation group and 20% for the postimplementation group. The difference was not statistically significant, χ (1, N = 20) = 0.73, p = 0.78. Implementation of an ED protocol for TH reduced mean time to initiation of therapy. Additional study is warranted to determine whether differences in survival and functional recovery for ED patients receiving TH were influenced by age, comorbidities, and total resuscitation time.
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Wong GC, van Diepen S, Ainsworth C, Arora RC, Diodati JG, Liszkowski M, Love M, Overgaard C, Schnell G, Tanguay JF, Wells G, Le May M. Canadian Cardiovascular Society/Canadian Cardiovascular Critical Care Society/Canadian Association of Interventional Cardiology Position Statement on the Optimal Care of the Postarrest Patient. Can J Cardiol 2017; 33:1-16. [DOI: 10.1016/j.cjca.2016.10.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 10/18/2016] [Accepted: 10/19/2016] [Indexed: 02/07/2023] Open
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Gueret RM, Bailitz JM, Sahni AS, Tulaimat A. Therapeutic hypothermia at an urban public hospital: Development, implementation, experience and outcomes. Heart Lung 2017; 46:40-45. [DOI: 10.1016/j.hrtlng.2016.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 09/27/2016] [Accepted: 09/28/2016] [Indexed: 01/10/2023]
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Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care. Neurocrit Care 2016; 24:90-6. [PMID: 26264064 DOI: 10.1007/s12028-015-0184-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Therapeutic hypothermia (TH) improves neurologic outcome in patients resuscitated from ventricular fibrillation. The purpose of this study was to evaluate TH effects on neurologic outcome in patients resuscitated from a non-shockable out-of-hospital cardiac arrest rhythm. DESIGN AND SETTING This is a retrospective cohort study of data reported to a registry in an emergency medical system in a large metropolitan region. Patients achieving field return of spontaneous circulation are transported to designated hospitals with TH protocols. PATIENTS Patients with an initial non-shockable rhythm were identified. Patients were excluded if awake in the Emergency Department or if TH was withheld due to preexisting coma or death prior to initiation. The decision to initiate TH was determined by the treating physician. MEASUREMENTS The primary outcome was survival with good neurologic outcome defined by a cerebral performance category of 1 or 2. MAIN RESULTS Of the 2772 patients treated for cardiac arrest during the study period, there were 1713 patients resuscitated from cardiac arrest with an initial non-shockable rhythm and 1432 patients met inclusion criteria. The median age was 69 years [IQR 59-82]; 802 (56%) male. TH was induced in 596 (42%) patients. Survival with good neurologic outcome was 14% in the group receiving TH, compared with 5% in those not treated with TH (risk difference = 8%, 95% CI 5-12%). The adjusted OR for a CPC 1 or 2 with TH was 2.9 (95% CI 1.9-4.4). CONCLUSION Analyzing the data collected from the registry of the standard practice in a large metropolitan region, TH is associated with improved neurologic outcome in patients resuscitated from initial non-shockable rhythms in a regionalized system for post-resuscitation care.
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Engsig M, Søholm H, Folke F, Gadegaard PJ, Wiis JT, Molin R, Mohr T, Engsig FN. Similar long-term survival of consecutive in-hospital and out-of-hospital cardiac arrest patients treated with targeted temperature management. Clin Epidemiol 2016; 8:761-768. [PMID: 27877067 PMCID: PMC5108475 DOI: 10.2147/clep.s114946] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective The long-term survival of in-hospital cardiac arrest (IHCA) patients treated with targeted temperature management (TTM) is poorly described. The aim of this study was to compare the outcomes of consecutive IHCA with out-of-hospital cardiac arrest (OHCA) patients treated with TTM. Design, setting, and patients Retrospectively collected data on all consecutive adult patients treated with TTM at a university tertiary heart center between 2005 and 2011 were analyzed. Measurements Primary endpoints were survival to hospital discharge and long-term survival. Secondary endpoint was neurological outcome assessed using the Pittsburgh cerebral performance category (CPC). Results A total of 282 patients were included in this study; 233 (83%) OHCA and 49 (17%) IHCA. The IHCA group presented more often with asystole, received bystander cardiopulmonary resuscitation (CPR) in all cases, and had shorter time to return of spontaneous circulation (ROSC). Survival to hospital discharge was 54% for OHCA and 53% for IHCA (adjusted odds ratio 0.98 [95% confidence interval {CI}; 0.43–2.24]). Age ≤60 years, bystander CPR, time to ROSC ≤10 min, and shockable rhythm at presentation were associated with survival to hospital discharge. Good neurologic outcome among survivors was achieved by 86% of OHCA and 92% of IHCA (P=0.83). After a median follow-up time of >5 years, 83% of OHCA and 77% of IHCA were alive (adjusted hazard ratio [HR] 1.51 [95% CI; 0.59–3.91]). Age ≤60 years was the only factor associated with long-term survival (adjusted HR 2.73 [95% CI; 1.36–5.52]). Conclusion There was no difference in short- and long-term survival and no difference in neurologic outcome to hospital discharge between IHCA and OHCA patients treated with TTM despite higher frequency of asystole in IHCA.
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Affiliation(s)
- Magaly Engsig
- Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital, Hellerup
| | - Helle Søholm
- Department of Cardiology, Copenhagen University Hospital, Herlev
| | - Fredrik Folke
- Department of Cardiology, Copenhagen University Hospital, Hellerup; Pre-Hospital Emergency Medical Services, Capital Region of Denmark, Ballerup
| | - Peter J Gadegaard
- Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital, Hellerup
| | - Julie Therese Wiis
- Department of Intensive Care, Copenhagen University Hospital, Copenhagen
| | - Rune Molin
- Department of Anaesthesiology, Copenhagen University Hospital, Hillerød
| | - Thomas Mohr
- Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital, Hellerup
| | - Frederik N Engsig
- Department of Infectious Diseases, Copenhagen University Hospital, Hvidovre, Denmark
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Grossestreuer AV, Gaieski DF, Donnino MW, Wiebe DJ, Abella BS. Magnitude of temperature elevation is associated with neurologic and survival outcomes in resuscitated cardiac arrest patients with postrewarming pyrexia. J Crit Care 2016; 38:78-83. [PMID: 27866109 DOI: 10.1016/j.jcrc.2016.11.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 10/18/2016] [Accepted: 11/02/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE Avoidance of pyrexia is recommended in resuscitation guidelines, including after treatment with targeted temperature management (TTM). Which aspects of postresuscitation pyrexia are harmful and modifiable have not been conclusively determined. MATERIALS AND METHODS This retrospective multicenter registry study collected serial temperatures during 72 hours postrewarming to assess the relationship between 3 aspects of pyrexia (maximum temperature, pyrexia duration, timing of first pyrexia) and neurologic outcome (primary) and survival (secondary) at hospital discharge. Adult TTM-treated patients from 13 US hospitals between 2005 and 2015 were included. RESULTS One hundred seventy-nine of 465 patients had at least 1 temperature greater than or equal to 38°C. Pyrexic temperatures were associated with better survival than nonpyrexic temperatures (adjusted odds ratio [aOR], 1.54; 95% confidence interval [CI], 1.00-2.35). Higher maximum temperature was associated with worse outcome (neurologic aOR, 0.30 [95% CI, 0.10-0.84]; survival aOR, 0.25 [95% CI, 0.10-0.59]) in pyrexic patients. There was no significant relationship between pyrexia duration and outcomes unless duration was calculated as hours greater than or equal to 38.8°C, when longer duration was associated with worse outcomes (neurologic aOR, 0.86 [95% CI, 0.75-1.00]; survival aOR, 0.82 [95% CI, 0.72-0.93]). CONCLUSIONS In postarrest TTM-treated patients, pyrexia was associated with increased survival. Patients experiencing postrewarming pyrexia had worse outcomes at higher temperatures. Longer pyrexia duration was associated with worse outcomes at higher temperatures.
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Affiliation(s)
- Anne V Grossestreuer
- Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA 19104; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA 19104; Leonard Davis Institute of Healthcare Economics, University of Pennsylvania, Philadelphia, PA 19104.
| | - David F Gaieski
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA 19107.
| | - Michael W Donnino
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215; Department of Medicine, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215.
| | - Douglas J Wiebe
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA 19104; Leonard Davis Institute of Healthcare Economics, University of Pennsylvania, Philadelphia, PA 19104.
| | - Benjamin S Abella
- Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA 19104.
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Song L, Wei L, Zhang L, Lu Y, Wang K, Li Y. The Role of Targeted Temperature Management in Adult Patients Resuscitated from Nonshockable Cardiac Arrests: An Updated Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2016; 2016:2350974. [PMID: 27847808 PMCID: PMC5099489 DOI: 10.1155/2016/2350974] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 09/04/2016] [Accepted: 09/27/2016] [Indexed: 01/08/2023]
Abstract
Routine targeted temperature management is recommended for comatose adult patients with return of spontaneous circulation after cardiac arrest. However, the role of targeted temperature management in patients resuscitated from nonshockable cardiac arrests remains uncertain. We conducted an updated systematic review and meta-analysis to evaluate the effects of targeted temperature management in this population. Medline, EMBASE, and Cochrane databases were systematically reviewed for studies published between January 2005 and March 2016, in which targeted temperature management was compared with standard care or normothermia for adult patients resuscitated from nonshockable cardiac arrests. A total of 25 trials that included 5715 patients were identified from 10985 relevant papers. Pooled data showed that targeted temperature management not only associated with improved short-term survival (RR = 1.42, 95% CI: 1.28-1.57) and neurological function (RR = 1.63, 95% CI: 1.39-1.91) but also associated with improved long-term survival (RR = 1.64, 95% CI: 1.27-2.12) and neurological recovery (RR = 1.42, 95% CI: 1.07-1.90) in observational cohort studies. However, more frequent infectious complications were reported in hypothermia-treated patients (RR = 1.46, 95% CI: 1.26-1.70) and the quality of the evidence ranged from moderate to very low.
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Affiliation(s)
- Lijuan Song
- School of Biomedical Engineering, Third Military Medical University, Chongqing 400038, China
| | - Liang Wei
- School of Biomedical Engineering, Third Military Medical University, Chongqing 400038, China
| | - Lei Zhang
- Emergency Department, Southwest Hospital, Third Military Medical University, Chongqing 400038, China
| | - Yubao Lu
- Emergency Department, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Kaifa Wang
- School of Biomedical Engineering, Third Military Medical University, Chongqing 400038, China
| | - Yongqin Li
- School of Biomedical Engineering, Third Military Medical University, Chongqing 400038, China
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Liu P, Yang R, Zuo Z. Application of a novel rectal cooling device in hypothermia therapy after cerebral hypoxia-ischemia in rats. BMC Anesthesiol 2016; 16:77. [PMID: 27613331 PMCID: PMC5017120 DOI: 10.1186/s12871-016-0239-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 08/24/2016] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND A new rectal cooling device for therapeutic hypothermia (TH) therapy is designed and is applied in TH treatment of SD rats with ischemic-hypoxic brain damage. METHODS Healthy adult SD rats (n = 45) were randomly assigned into four groups: the healthy control group (n = 5), the ischemia and hypoxia group (n = 10), the rectal TH cooling group (n = 18), and the ice blanket TH cooling group (n = 11). The rats in the rectal cooling and ice blanket TH groups received 12 h treatment after hypoxic-ischemic brain damage had been established, while those in the ischemia and hypoxia group did not. Taking the start of TH as the zero point, rats were sacrificed after 24 h and the brain and rectum tissues were sampled for histological analysis. RESULTS The TH induction time (37.3 ± 14.7 min) in the rectal cooling group was significantly shorter (F = 4.937, P < 0.05) than that in the ice blanket cooling group (75.6 ± 27.2 min). The HE and NISSL staining results showed that rats in the rectal TH cooling group had significantly decreased (P < 0.01) positive neurons cell count compared to those in ischemia and hypoxia group. In addition, TUNEL staining indicated that the number of apoptotic cells (3.9 ± 1.8 cells / × 400 field) and the apoptosis index (4.4 % ± 1.5) were significantly lower in rectal TH cooling group (P < 0.05) than in ischemia and hypoxia group (23.2 ± 12.1 cells / × 400 field, 26.6 % ± 12.1). Also, no rectal frostbite or inflammatory infiltration was observed in rats in the rectal TH treatment groups. CONCLUSION Our new cooling device realized rapid TH induction in SD rats with ischemic-hypoxic brain damage, inhibited the apoptosis of cells in the hippocampal CAl region, and did not cause histological damage to the rectal tissues.
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Affiliation(s)
- Peng Liu
- Department of PICU, Children’s Hospital of Chongqing Medical University, Chongqing, 400014 China
- Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, 400014 China
| | - Rui Yang
- Department of PICU, Children’s Hospital of Chongqing Medical University, Chongqing, 400014 China
| | - Zelan Zuo
- Department of PICU, Children’s Hospital of Chongqing Medical University, Chongqing, 400014 China
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Scantling D, Frank B, Pontell ME, Medinilla S. Inducing Therapeutic Hypothermia in Cardiac Arrest Caused by Lightning Strike. Wilderness Environ Med 2016; 27:401-4. [PMID: 27451005 DOI: 10.1016/j.wem.2016.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Revised: 05/09/2016] [Accepted: 05/11/2016] [Indexed: 10/21/2022]
Abstract
Only limited clinical scenarios are grounds for induction of therapeutic hypothermia. Its use in traumatic cardiac arrests, including those from lightning strikes, is not well studied. Nonshockable cardiac arrest rhythms have only recently been included in resuscitation guidelines. We report a case of full neurological recovery with therapeutic hypothermia after a lightning-induced pulseless electrical activity cardiac arrest in an 18-year-old woman. We also review the important pathophysiology of lightning-induced cardiac arrest and neurologic sequelae, elaborate upon the mechanism of therapeutic hypothermia, and add case-based evidence in favor of the use of targeted temperature management in lightning-induced cardiac arrest.
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Affiliation(s)
- Dane Scantling
- Department of General Surgery, Drexel University College of Medicine, Hahnemann University Hospital, Philadelphia, PA(Drs Scantling and Pontell)?>.
| | - Brian Frank
- Department of Surgery and Critical Care, Christiana Care Health System, Newark, DE
| | - Mathew E Pontell
- Department of General Surgery, Drexel University College of Medicine, Hahnemann University Hospital, Philadelphia, PA(Drs Scantling and Pontell)?>
| | - Sandra Medinilla
- Department of Surgery and Critical Care, Christiana Care Health System, Newark, DE
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Bosson NE, Kaji AH, Koenig WJ, Niemann JT. Effect of Therapeutic Hypothermia on Survival and Neurologic Outcome in the Elderly. Ther Hypothermia Temp Manag 2016; 6:71-5. [DOI: 10.1089/ther.2015.0030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Nichole E. Bosson
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, California
- David Geffen School of Medicine at UCLA, Los Angeles, California
- Los Angeles County Emergency Medical Services Agency, Santa Fe Springs, California
| | - Amy H. Kaji
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, California
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - William J. Koenig
- Los Angeles County Emergency Medical Services Agency, Santa Fe Springs, California
| | - James T. Niemann
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, California
- David Geffen School of Medicine at UCLA, Los Angeles, California
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Long-term neurologic outcomes following paediatric out-of-hospital cardiac arrest. Resuscitation 2016; 102:122-6. [DOI: 10.1016/j.resuscitation.2016.01.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 11/25/2015] [Accepted: 01/06/2016] [Indexed: 11/22/2022]
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Meisenheimer ES, Bevis ZJ, Tagawa CW, Glorioso JE. Drowning Injuries: An Update on Terminology, Environmental Factors, and Management. Curr Sports Med Rep 2016; 15:91-3. [PMID: 26963016 DOI: 10.1249/jsr.0000000000000241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Picchi A, Valente S, Gensini G. Therapeutic hypothermia in the intensive cardiac care unit. J Cardiovasc Med (Hagerstown) 2016; 16:363-71. [PMID: 25022927 DOI: 10.2459/jcm.0000000000000108] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Therapeutic hypothermia has demonstrated to improve both survival and neurological outcome in patients who experienced an out-of-hospital cardiac arrest. Nevertheless, many aspects of its clinical application are still controversial. Current guidelines recommend to cool patients who survive a cardiac arrest due to either ventricular fibrillation or ventricular tachycardia, whereas the beneficial effect of lowering body temperature in nonshockable rhythms is still questionable due to the lack of randomized controlled trial involving this subgroup of patients. Although therapeutic hypothermia is often begun before hospital arrival, the optimal time to start cooling is still a matter of debate. Furthermore, different methods are available to low body temperature, but no direct comparisons are available to establish which device performs better than others, and a combination of external and endovascular cooling is usually preferred. The present review is aimed at summarizing the available evidence supporting the use in clinical practice of mild hypothermia in comatose survivors from cardiac arrest and at evaluating its adverse events and their treatment.
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Affiliation(s)
- Andrea Picchi
- aDepartment of Cardiology, Misericordia Hospital, Grosseto bDepartment of Medical and Surgical Critical Care, University of Florence, Florence, Italy
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Choi SW, Shin SD, Ro YS, Song KJ, Lee EJ, Ahn KO. Effect of therapeutic hypothermia on the outcomes after out-of-hospital cardiac arrest according to initial ECG rhythm and witnessed status: A nationwide observational interaction analysis. Resuscitation 2016; 100:51-9. [PMID: 26774175 DOI: 10.1016/j.resuscitation.2015.12.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 12/08/2015] [Accepted: 12/30/2015] [Indexed: 01/01/2023]
Abstract
BACKGROUND The use of mild therapeutic hypothermia (TH) in out-of-hospital cardiac arrest (OHCA) with shockable rhythms is recommended and widely used. However, it is unclear whether TH is associated with better outcomes in non-shockable rhythms. METHODS This is a retrospective observational study using a national OHCA cohort database composed of emergency medical services (EMS) and hospital data. We included adult EMS-treated OHCA patients of presumed cardiac etiology who were admitted to the hospital during Jan. 2008 to Dec. 2013. Patients without hospital outcome data were excluded. The primary outcome was good neurological outcome at discharge; secondary outcome was survival to discharge. The primary exposure was TH. We compared outcomes between TH and non-TH groups using multivariable logistic regression, adjusting for individual and Utstein factors. Interactions of initial ECG rhythm and witnessed status on the effect of TH on outcomes were tested. RESULTS There were 11,256 patients in the final analysis. TH was performed in 1703 patients (15.1%). Neurological outcome was better in TH (23.5%) than non-TH (15.0%) (Adjusted OR=1.25, 95% CI 1.05-1.48). The effect of TH on the odds for good neurological outcome was highest in the witnessed PEA group (Adjusted OR=3.91, 95% CI 1.87-8.14). Survival to discharge was significantly higher in the TH group (55.1%) than non-TH (35.9%) (Adjusted OR=1.76, 95% CI 1.56-2.00). CONCLUSIONS In a nationwide observational study, TH is associated with better neurological outcome and higher survival to discharge. The effect of TH is greatest in witnessed OHCA patients with PEA as the initial ECG rhythm.
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Affiliation(s)
- Sae Won Choi
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Laboratory, Republic of Korea.
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University College of Medicine, Republic of Korea.
| | - Young Sun Ro
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Republic of Korea.
| | - Kyoung Jun Song
- Department of Emergency Medicine, Seoul National University College of Medicine, Republic of Korea.
| | - Eui Jung Lee
- Department of Emergency Medicine, Seoul National University Hospital, Republic of Korea.
| | - Ki Ok Ahn
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Republic of Korea.
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Doshi P, Patel K, Banuelos R, Darger B, Baker S, Chambers KA, Thangam M, Gates K. Effect of Therapeutic Hypothermia on Survival to Hospital Discharge in Out-of-hospital Cardiac Arrest Secondary to Nonshockable Rhythms. Acad Emerg Med 2016; 23:14-20. [PMID: 26670621 DOI: 10.1111/acem.12847] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 07/22/2015] [Accepted: 08/04/2015] [Indexed: 01/17/2023]
Abstract
OBJECTIVES Therapeutic hypothermia has been shown to improve neurologic outcome and survival in out-of-hospital cardiac arrest (OHCA) following return of spontaneous circulation (ROSC), and current guidelines recommend therapeutic hypothermia for all comatose survivors of OHCA. However, recommendations for nonshockable rhythms are not as strongly supported. Our study aims to provide further evidence on the use of therapeutic hypothermia in nonshockable rhythms. METHODS A multivariate analysis with propensity score matching was performed using a cardiac arrest registry maintained by the Houston Fire Department. The analysis was limited to adult patients achieving ROSC following OHCA secondary to nonshockable rhythm in Houston from 2007 to 2012 with definitive information regarding the implementation of therapeutic hypothermia. The primary outcome was survival to hospital discharge. RESULTS Of 9,479 records identified for analysis, 7,839 had an initial nonshockable rhythm. Of these, 2,609 (33.3%) had sustained ROSC and 1,768 (22.6%) were admitted to the hospital. Data on therapeutic hypothermia use were available for 696 patients, with 335 (48.1%) receiving therapeutic hypothermia. Propensity score matching yielded 260 case/control pairs. The odds of survival to hospital discharge was an odds ratio of 1.07 (95% confidence interval = 0.71 to 1.60) for those in the therapeutic hypothermia group versus the nontherapeutic hypothermia group (p = 0.79). CONCLUSIONS Based on this retrospective study, therapeutic hypothermia is not associated with improved survival in patients with OHCA secondary to nonshockable rhythms. Given the limitations of our study, further prospective trials to assess the effect of therapeutic hypothermia for OHCA with nonshockable rhythms are warranted.
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Affiliation(s)
- Pratik Doshi
- Department of Emergency Medicine; University of Texas Health Science Center; Houston TX
| | - Kishan Patel
- Department of Emergency Medicine; University of Texas Health Science Center; Houston TX
| | - Rosa Banuelos
- Department of Emergency Medicine; University of Texas Health Science Center; Houston TX
| | - Bryan Darger
- Department of Emergency Medicine; University of Texas Health Science Center; Houston TX
| | - Steven Baker
- Department of Emergency Medicine; University of Texas Health Science Center; Houston TX
| | - Kimberly A. Chambers
- Department of Emergency Medicine; University of Texas Health Science Center; Houston TX
| | - Manoj Thangam
- Department of Internal Medicine; University of Texas Health Science Center; Houston TX
| | - Keith Gates
- Department of Emergency Medicine; University of Texas Health Science Center; Houston TX
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Breathett K, Mehta N, Yildiz V, Abel E, Husa R. The impact of body mass index on patient survival after therapeutic hypothermia after resuscitation. Am J Emerg Med 2015; 34:722-5. [PMID: 26806177 DOI: 10.1016/j.ajem.2015.12.077] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 12/07/2015] [Accepted: 12/28/2015] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES Therapeutic hypothermia improves survival in patients after cardiac arrest, yet the impact of body mass index (BMI) on survival is lesser known. We hypothesized that nonobese patients would have greater survival post-therapeutic hypothermia than obese patients. METHODS We retrospectively evaluated 164 patients who underwent therapeutic hypothermia after resuscitation for cardiac arrest from January 2012 to September 2014. Logistic regression analysis was used to assess for survival based upon BMI and comorbidities (odds ratio, 95% confidence interval). RESULTS Forty-one percent of patients were obese. Obese patients presented less frequently with ventricular fibrillation (P=.046) but had similar rates of pulseless electrical activity (P=.479) and ventricular tachycardia (P=.262) to nonobese patients. In multivariable analysis, BMI less than 30 kg/m(2), hypertension, presence of pacemaker/implantable cardioverter-defibrillator, high glomerular filtration rate, and low neuron-specific enolase were all associated with increased survival post-therapeutic hypothermia, respectively: 0.36 (0.16-0.78), 0.28 (0.12-0.66), 0.23 (0.08-0.62), 0.25 (0.11-0.56), and 0.37 (0.14-0.96). Other comorbidities demonstrated no association with survival. CONCLUSIONS Body mass index at least 30 kg/m(2) compared with BMI less than 30 kg/m(2) was a significant risk factor for mortality post-therapeutic hypothermia protocol. Absence of history of hypertension, lack of pacemaker/implantable cardioverter-defibrillator, high neuron-specific enolase, and renal disease had greater associations with death. Larger studies will be needed to validate these findings.
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Affiliation(s)
| | - Nishaki Mehta
- Division of Cardiology, Brigham and Women's Hospital, Boston, MA
| | - Vedat Yildiz
- Center for Biostatistics, The Ohio State University, Columbus, OH
| | - Erik Abel
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Ruchika Husa
- Division of Cardiology, The Ohio State University Wexner Medical Center, Columbus, OH
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Mak M, Moulaert VRM, Pijls RW, Verbunt JA. Measuring outcome after cardiac arrest: construct validity of Cerebral Performance Category. Resuscitation 2015; 100:6-10. [PMID: 26744101 DOI: 10.1016/j.resuscitation.2015.12.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 12/01/2015] [Accepted: 12/16/2015] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Approximately half of the survivors of cardiac arrest have cognitive impairments due to hypoxic brain injury. To describe the outcome after a cardiac arrest, the Cerebral Performance Category (CPC) is frequently used. Although widely used, its validity is still debatable. OBJECTIVE To investigate the construct validity of the Cerebral Performance Category in survivors of a cardiac arrest. Participants were 18 years and older that survived a cardiac arrest more than six months. METHODS Cross-sectional design. A method to administer the CPC in a structured and reproducible manner was developed. This 'Structured CPC' was administered by a structured interview. Construct variables were Cognitive Failure Questionnaire (CFQ), Barthel Index (BI), Frenchay Activity Index (FAI), Community Integration Questionnaire (CIQ) and Quality of Life after Brain Injury (Qolibri). Associations were tested based on Spearman correlation coefficients. RESULTS A total of 62 participants responded. In 58 (94%) patients the CPC was determined, resulting in CPC 1 (48%), CPC 2 (23%) and CPC 3 (23%). The CPC-scoring correlated significantly with the CFQ (r=-0.40); BI (r=-0.57); FAI (r=-0.65), CIQ (r=-0.53) and Qolibri (r=-0.67). DISCUSSION AND CONCLUSIONS In this study we developed the 'Structured CPC' to improve the transparency and reproducibility of the original CPC. A moderate correlation between the 'Structured CPC' and the constructs 'activities', 'participation' and 'quality of life' confirmed the validity of the 'Structured CPC'. CLINICAL MESSAGE The 'Structured CPC' can be used as an instrument to measure the level of functioning after cardiac arrest.
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Affiliation(s)
- M Mak
- Adelante, Centre of Expertise in Rehabilitation and Audiology, Zandbergsweg 111, 6432 CC Hoensbroek, The Netherlands; Revant Rehabilitation Centre Breda, Brabantlaan 1, 4817 JW Breda, The Netherlands.
| | - V R M Moulaert
- Adelante, Centre of Expertise in Rehabilitation and Audiology, Zandbergsweg 111, 6432 CC Hoensbroek, The Netherlands; CAPHRI School for Public Health and Primary Care, Department of Rehabilitation Medicine, Maastricht University Medical Centre, PO Box 616, 6200 MD Maastricht, The Netherlands
| | - R W Pijls
- CAPHRI School for Public Health and Primary Care, Department of Cardiology, Maastricht University Medical Centre, PO Box 5800, 6202 AZ Maastricht, The Netherlands
| | - J A Verbunt
- Adelante, Centre of Expertise in Rehabilitation and Audiology, Zandbergsweg 111, 6432 CC Hoensbroek, The Netherlands; CAPHRI School for Public Health and Primary Care, Department of Rehabilitation Medicine, Maastricht University Medical Centre, PO Box 616, 6200 MD Maastricht, The Netherlands
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Starzl R, Wolfram D, Zamora R, Jefferson B, Barclay D, Ho C, Gorantla V, Brandacher G, Schneeberger S, Andrew Lee WP, Carbonell J, Vodovotz Y. Cardiac Arrest Disrupts Caspase-1 and Patterns of Inflammatory Mediators Differently in Skin and Muscle Following Localized Tissue Injury in Rats: Insights from Data-Driven Modeling. Front Immunol 2015; 6:587. [PMID: 26635801 PMCID: PMC4653302 DOI: 10.3389/fimmu.2015.00587] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 11/02/2015] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Trauma often cooccurs with cardiac arrest and hemorrhagic shock. Skin and muscle injuries often lead to significant inflammation in the affected tissue. The primary mechanism by which inflammation is initiated, sustained, and terminated is cytokine-mediated immune signaling, but this signaling can be altered by cardiac arrest. The complexity and context sensitivity of immune signaling in general has stymied a clear understanding of these signaling dynamics. METHODOLOGY/PRINCIPAL FINDINGS We hypothesized that advanced numerical and biological function analysis methods would help elucidate the inflammatory response to skin and muscle wounds in rats, both with and without concomitant shock. Based on the multiplexed analysis of inflammatory mediators, we discerned a differential interleukin (IL)-1α and IL-18 signature in skin vs. muscle, which was suggestive of inflammasome activation in the skin. Immunoblotting revealed caspase-1 activation in skin but not muscle. Notably, IL-1α and IL-18, along with caspase-1, were greatly elevated in the skin following cardiac arrest, consistent with differential inflammasome activation. CONCLUSION/SIGNIFICANCE Tissue-specific activation of caspase-1 and the NLRP3 inflammasome appear to be key factors in determining the type and severity of the inflammatory response to tissue injury, especially in the presence of severe shock, as suggested via data-driven modeling.
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Affiliation(s)
- Ravi Starzl
- Language Technologies Institute, Carnegie Mellon University, Pittsburgh, PA, USA
- Department of Plastic and Reconstructive Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Dolores Wolfram
- Department of Plastic and Reconstructive Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Ruben Zamora
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Inflammation and Regenerative Modeling, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Derek Barclay
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Chien Ho
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Vijay Gorantla
- Department of Plastic and Reconstructive Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Stefan Schneeberger
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Medicine, Baltimore, MD, USA
| | - W. P. Andrew Lee
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Jaime Carbonell
- Language Technologies Institute, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Inflammation and Regenerative Modeling, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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49
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Perman SM, Grossestreuer AV, Wiebe DJ, Carr BG, Abella BS, Gaieski DF. The Utility of Therapeutic Hypothermia for Post-Cardiac Arrest Syndrome Patients With an Initial Nonshockable Rhythm. Circulation 2015; 132:2146-51. [PMID: 26572795 DOI: 10.1161/circulationaha.115.016317] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 09/10/2015] [Indexed: 01/16/2023]
Abstract
BACKGROUND Therapeutic hypothermia (TH) attenuates reperfusion injury in comatose survivors of cardiac arrest. The utility of TH in patients with nonshockable initial rhythms has not been widely accepted. We sought to determine whether TH improved neurological outcome and survival in postarrest patients with nonshockable rhythms. METHODS AND RESULTS We identified 519 patients after in- and out-of-hospital cardiac arrest with nonshockable initial rhythms from the Penn Alliance for Therapeutic Hypothermia (PATH) registry between 2000 and 2013. Propensity score matching was used. Patient and arrest characteristics used to estimate the propensity to receive TH were age, sex, location of arrest, witnessed arrest, and duration of arrest. To determine the association between TH and outcomes, we created 2 multivariable logistic models controlling for confounders. Of 201 propensity score-matched pairs, mean age was 63 ± 17 years, 51% were male, and 60% had an initial rhythm of pulseless electric activity. Survival to hospital discharge was greater in patients who received TH (17.6% versus 28.9%; P < 0.01), as was a discharge Cerebral Performance Category of 1 to 2 (13.7% versus 21.4%; P = 0.04). In adjusted analyses, patients who received TH were more likely to survive (odds ratio, 2.8; 95% confidence interval, 1.6-4.7) and to have better neurological outcome (odds ratio, 3.5; 95% confidence interval, 1.8-6.6) than those that did not receive TH. CONCLUSIONS Using propensity score matching, we found that patients with nonshockable initial rhythms treated with TH had better survival and neurological outcome at hospital discharge than those who did not receive TH. Our findings further support the use of TH in patients with initial nonshockable arrest rhythms.
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Affiliation(s)
- Sarah M Perman
- From the University of Colorado School of Medicine, Department of Emergency Medicine, Aurora (S.M.P.); University of Pennsylvania, Perelman School of Medicine, Department of Biostatistics and Epidemiology, Philadelphia (A.V.G., D.J.W.); University of Pennsylvania, Center for Resuscitation Science, Philadelphia (A.V.G., B.S.A.); University of Pennsylvania, Perelman School of Medicine, Department of Emergency Medicine, Philadelphia (A.V.G., D.J.W., B.S.A.); and Thomas Jefferson University, Sidney Kimmel School of Medicine, Department of Emergency Medicine, Philadelphia, PA (B.G.C., D.F.G.).
| | - Anne V Grossestreuer
- From the University of Colorado School of Medicine, Department of Emergency Medicine, Aurora (S.M.P.); University of Pennsylvania, Perelman School of Medicine, Department of Biostatistics and Epidemiology, Philadelphia (A.V.G., D.J.W.); University of Pennsylvania, Center for Resuscitation Science, Philadelphia (A.V.G., B.S.A.); University of Pennsylvania, Perelman School of Medicine, Department of Emergency Medicine, Philadelphia (A.V.G., D.J.W., B.S.A.); and Thomas Jefferson University, Sidney Kimmel School of Medicine, Department of Emergency Medicine, Philadelphia, PA (B.G.C., D.F.G.)
| | - Douglas J Wiebe
- From the University of Colorado School of Medicine, Department of Emergency Medicine, Aurora (S.M.P.); University of Pennsylvania, Perelman School of Medicine, Department of Biostatistics and Epidemiology, Philadelphia (A.V.G., D.J.W.); University of Pennsylvania, Center for Resuscitation Science, Philadelphia (A.V.G., B.S.A.); University of Pennsylvania, Perelman School of Medicine, Department of Emergency Medicine, Philadelphia (A.V.G., D.J.W., B.S.A.); and Thomas Jefferson University, Sidney Kimmel School of Medicine, Department of Emergency Medicine, Philadelphia, PA (B.G.C., D.F.G.)
| | - Brendan G Carr
- From the University of Colorado School of Medicine, Department of Emergency Medicine, Aurora (S.M.P.); University of Pennsylvania, Perelman School of Medicine, Department of Biostatistics and Epidemiology, Philadelphia (A.V.G., D.J.W.); University of Pennsylvania, Center for Resuscitation Science, Philadelphia (A.V.G., B.S.A.); University of Pennsylvania, Perelman School of Medicine, Department of Emergency Medicine, Philadelphia (A.V.G., D.J.W., B.S.A.); and Thomas Jefferson University, Sidney Kimmel School of Medicine, Department of Emergency Medicine, Philadelphia, PA (B.G.C., D.F.G.)
| | - Benjamin S Abella
- From the University of Colorado School of Medicine, Department of Emergency Medicine, Aurora (S.M.P.); University of Pennsylvania, Perelman School of Medicine, Department of Biostatistics and Epidemiology, Philadelphia (A.V.G., D.J.W.); University of Pennsylvania, Center for Resuscitation Science, Philadelphia (A.V.G., B.S.A.); University of Pennsylvania, Perelman School of Medicine, Department of Emergency Medicine, Philadelphia (A.V.G., D.J.W., B.S.A.); and Thomas Jefferson University, Sidney Kimmel School of Medicine, Department of Emergency Medicine, Philadelphia, PA (B.G.C., D.F.G.)
| | - David F Gaieski
- From the University of Colorado School of Medicine, Department of Emergency Medicine, Aurora (S.M.P.); University of Pennsylvania, Perelman School of Medicine, Department of Biostatistics and Epidemiology, Philadelphia (A.V.G., D.J.W.); University of Pennsylvania, Center for Resuscitation Science, Philadelphia (A.V.G., B.S.A.); University of Pennsylvania, Perelman School of Medicine, Department of Emergency Medicine, Philadelphia (A.V.G., D.J.W., B.S.A.); and Thomas Jefferson University, Sidney Kimmel School of Medicine, Department of Emergency Medicine, Philadelphia, PA (B.G.C., D.F.G.)
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50
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Abstract
OBJECTIVES Glibenclamide confers neuroprotection in animal models as well as in retrospective clinical studies. This study determines whether glibenclamide improves outcome after cardiac arrest in rats. DESIGN Prospective randomized laboratory study. SETTING University research laboratory. SUBJECTS Male Sprague-Dawley rats (n = 126). INTERVENTIONS Rats successfully resuscitated from 8-minute asphyxial cardiac arrest were randomized to glibenclamide or vehicle group. Rats in the glibenclamide group were intraperitoneally administered glibenclamide with a loading dose of 10 μg/kg at 10 minutes and a maintenance dose of 1.2 μg at 6, 12, 18, and 24 hours after return of spontaneous circulation, whereas rats in the vehicle group received equivalent volume of vehicle solution. MEASUREMENTS AND MAIN RESULTS Survival was recorded every day, and neurologic deficit scores were assessed at 24, 48, and 72 hours and 7 days after return of spontaneous circulation (n = 22 in each group). Results showed that glibenclamide treatment increased 7-day survival rate, reduced neurologic deficit scores, and prevented neuronal loss in the hippocampal cornu ammonis 1 region. To investigate the neuroprotective effects of glibenclamide in acute phase, we observed neuronal injury at 24 hours after return of spontaneous circulation and found that glibenclamide significantly decreased the rate of neuronal necrosis and apoptosis. In addition, glibenclamide reduced the messenger RNA expression of tumor necrosis factor-α and monocyte chemoattractant protein-1 in the cortex after return of spontaneous circulation. Furthermore, the sulfonylurea receptor 1 and transient receptor potential M4 heteromers, the putative therapeutic targets of glibenclamide, were up-regulated after cardiac arrest and cardiopulmonary resuscitation, indicating that they might be involved in neuroprotective effect of glibenclamide. CONCLUSIONS Glibenclamide treatment substantially improved survival and neurologic outcome throughout a 7-day period after return of spontaneous circulation. The salutary effects of glibenclamide were associated with suppression of neuronal necrosis and apoptosis, as well as inflammation in the brain.
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