1
|
Senay B, Ibekwe E, Gokun Y, Elmer J, Hinduja A. Clinical Factors Associated With Mode of Death Following Cardiac Arrest. Am J Crit Care 2024; 33:290-297. [PMID: 38945819 DOI: 10.4037/ajcc2024145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
BACKGROUND Death after resuscitation from cardiac arrest is common. Although associated factors have been identified, knowledge about their relationship with specific modes of death is limited. OBJECTIVE To identify clinical factors associated with specific modes of death following cardiac arrest. METHODS This study involved a retrospective medical record review of patients admitted to a single health care center from January 2015 to March 2020 after resuscitation from cardiac arrest who died during their index hospitalization. Mode of death was categorized as either brain death, withdrawal of life-sustaining therapies due to neurologic causes, death due to medical causes, or withdrawal of life-sustaining therapies due to patient preference. Clinical characteristics across modes of death were compared. RESULTS The analysis included 731 patients. Death due to medical causes was the most common mode of death. Compared with the other groups of patients, those with brain death were younger, had fewer comorbidities, were more likely to have experienced unwitnessed and longer cardiac arrest, and had more severe acidosis and hyperglycemia on presentation. Patients who died owing to medical causes or withdrawal of life-sustaining therapies due to patient preference were older and had more comorbidities, fewer unfavorable cardiac arrest characteristics, and fewer days between cardiac arrest and death. CONCLUSIONS Significant associations were found between several clinical characteristics and specific mode of death following cardiac arrest. Decision-making regarding withdrawal of care after resuscitation from cardiac arrest should be based on a multimodal approach that takes account of a variety of personal and clinical factors.
Collapse
Affiliation(s)
- Blake Senay
- Blake Senay is a neurocritical care fellow, The Ohio State University, Columbus
| | - Elochukwu Ibekwe
- Elochukwu Ibekwe is a neurology resident, The Ohio State University, Columbus
| | - Yevgeniya Gokun
- Yevgeniya Gokun is a senior biostatistician, Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University
| | - Jonathan Elmer
- Jonathan Elmer is an associate professor, Department of Emergency Medicine, Critical Care Medicine, and Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Archana Hinduja
- Archana Hinduja is an associate professor, Department of Neurocritical Care, The Ohio State University
| |
Collapse
|
2
|
Zhou D, Lv Y, Wang C, Li D. The early change in pH values after out-of-hospital cardiac arrest is not associated with neurological outcome at hospital discharge. Resusc Plus 2024; 18:100650. [PMID: 38711912 PMCID: PMC11070929 DOI: 10.1016/j.resplu.2024.100650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/10/2024] [Accepted: 04/19/2024] [Indexed: 05/08/2024] Open
Abstract
Background The association between pH values and outcome for patients after out-of-hospital cardiac arrest (OHCA) was not fully elucidated; besides, the relationship of change in pH values and neurological outcome was unknown. The aim was to explore the association of pH values as well as change in pH values and neurological outcome for OHCA cardiac patients. Methods The adult patients with non-traumatic out-of-hospital cardiac arrest, shock-refractory ventricular fibrillation or pulseless ventricular tachycardia, and at least two arterial blood gases analysis recorded after admission were included. The change in pH values is calculated as the difference between the second and first pH value, and divided by time interval got the rate of change in pH values. The primary outcome was modified Rankin Score (mRS), dichotomized to good (mRS 0-3) and poor (mRS 4-6) outcomes at hospital discharge. The independent relationship of the first pH value, second pH value, and changes in pH values with neurological outcome was investigated with multivariable logistic regression models, respectively. Results A total of 1388 adult patients were included for analysis, of which 514 (37%) had good neurological outcome. The median first pH value and second pH value after admission were 7.21 (interquartile range [IQR] 7.09-7.29) and 7.28 (IQR 7.20-7.36), respectively. The median absolute, relative change, and rate of changes in pH values were 0.08 (IQR 0.01-0.16), 1.10% (IQR 0.11-2.22%), and 0.02 (IQR 0-0.06) per hour, respectively. After adjusting for confounders, the higher first pH value (odds ratio [OR] 3.81, confidence interval [CI] 1.60-9.24, P = 0.003) and higher second pH value (OR 9.54, CI 3.45-26.87, P < 0.001) after admission were associated with good neurological outcome, respectively. The absolute (OR 1.58, CI 0.58-4.30, P = 0.368) and relative (OR 1.03, CI 0.96-1.11, P = 0.399) change as well as the rate of change (OR 0.98, CI 0.33-2.71, P = 974) in pH values were not associated with neurological outcome. Conclusions For OHCA patients, abnormality in pH values was very common, with a more acidic pH value indicating poor neurological outcome. However, the change in pH values was not associated with outcomes.
Collapse
Affiliation(s)
- Dawei Zhou
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Yi Lv
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Chao Wang
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Dan Li
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
3
|
Wu D, Zhang D, Yin H, Zhang B, Xing J. Meta-analysis of the effects of inert gases on cerebral ischemia-reperfusion injury. Sci Rep 2023; 13:16896. [PMID: 37803128 PMCID: PMC10558482 DOI: 10.1038/s41598-023-43859-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 09/29/2023] [Indexed: 10/08/2023] Open
Abstract
Recently, noble gas has become a hot spot within the medical field like respiratory organ cerebral anemia, acute urinary organ injury and transplantation. However, the shield performance in cerebral ischemia-reperfusion injury (CIRI) has not reached an accord. This study aims to evaluate existing evidence through meta-analysis to determine the effects of inert gases on the level of blood glucose, partial pressure of oxygen, and lactate levels in CIRI. We searched relevant articles within the following both Chinese and English databases: PubMed, Web of science, Embase, CNKI, Cochrane Library and Scopus. The search was conducted from the time of database establishment to the end of May 2023, and two researchers independently entered the data into Revman 5.3 and Stata 15.1. There were total 14 articles were enclosed within the search. The results showed that the amount of partial pressure of blood oxygen in the noble gas cluster was beyond that in the medicine gas cluster (P < 0.05), and the inert gas group had lower lactate acid and blood glucose levels than the medical gas group. The partial pressure of oxygen (SMD = 1.51, 95% CI 0.10 ~ 0.91 P = 0.04), the blood glucose level (SMD = - 0.59, 95% CI - 0.92 ~ - 0.27 P = 0.0004) and the lactic acid level (SMD = - 0.42, 95% CI - 0.80 ~ - 0.03 P = 0.03) (P < 0.05). These results are evaluated as medium-quality evidence. Inert gas can effectively regulate blood glucose level, partial pressure of oxygen and lactate level, and this regulatory function mainly plays a protective role in the small animal ischemia-reperfusion injury model. This finding provides an assessment and evidence of the effectiveness of inert gases for clinical practice, and provides the possibility for the application of noble gases in the treatment of CIRI. However, more operations are still needed before designing clinical trials, such as the analysis of the inhalation time, inhalation dose and efficacy of different inert gases, and the effective comparison of the effects in large-scale animal experiments.
Collapse
Affiliation(s)
- Di Wu
- Department of Emergency Medicine, The First Hospital of Jilin University, No.71 Xinmin Street, Changchun, 130021, Jilin, China
| | - Daoyu Zhang
- The First Hospital of Jilin University, Changchun, 130021, Jilin, China
| | - Hang Yin
- Baicheng Medical College, Baicheng, 137000, Jilin, China
| | - Bo Zhang
- The Second Foreign Department, Corps Hospital of the Chinese People's Armed Police Force of Jilin Province, Changchun, 130052, Jilin, China
| | - Jihong Xing
- Department of Emergency Medicine, The First Hospital of Jilin University, No.71 Xinmin Street, Changchun, 130021, Jilin, China.
| |
Collapse
|
4
|
Carr C, Carson KA, Millin MG. Acidemia Detected on Venous Blood Gas After Out-of-Hospital Cardiac Arrest Predicts Likelihood to Survive to Hospital Discharge. J Emerg Med 2020; 59:e105-e111. [PMID: 32684378 DOI: 10.1016/j.jemermed.2020.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 05/04/2020] [Accepted: 06/01/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Sudden cardiac arrest is the most common cause of death worldwide, and prognostication after survival remains challenging. Decisions regarding prognosis can be fraught with error in the immediate postarrest period, with guidelines recommending the use of various tests, including blood gas pH, to determine which interventions to perform. Despite these recommendations, the prognostic utility of blood gas pH remains unclear. OBJECTIVES In this retrospective cohort study, we aimed to demonstrate the prognostic utility of emergency department blood gas pH after return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest. METHODS A retrospective cohort study was performed, including all adult survivors of out-of-hospital cardiac arrest (n = 79). Primary disease-oriented outcome was venous blood pH after ROSC and survival to hospital discharge. RESULTS In patients with out-of-hospital cardiac arrest, pH < 7.2 was associated with decreased likelihood of survival to hospital discharge (odds ratio 0.06), with every 0.1-unit increase in pH being associated with an increased likelihood of survival (1.98). Based on the area under the receiver curve, the pH that optimizes sensitivity and specificity for predicting survival was 7.04. CONCLUSION Both presence and degree of acidemia on initial blood gas after ROSC was associated with a decreased likelihood of survival to hospital discharge. The optimal cutoff for prediction in this cohort of patients was 7.04. Using a higher pH cutoff would result in fewer patients receiving intervention that would otherwise have survived.
Collapse
Affiliation(s)
- Casey Carr
- Departments of Emergency Medicine and Critical Care, University of Florida - Shands Hospital, Gainesville, Florida
| | - Kathryn A Carson
- Department of Emergency Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Michael G Millin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| |
Collapse
|
5
|
Corral Torres E, Hernández-Tejedor A, Suárez Bustamante R, de Elías Hernández R, Casado Flórez I, San Juan Linares A. Prognostic value of venous blood analysis at the start of CPR in non-traumatic out-of-hospital cardiac arrest: association with ROSC and the neurological outcome. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:60. [PMID: 32087761 PMCID: PMC7036225 DOI: 10.1186/s13054-020-2762-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 02/05/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The knowledge of new prognostic factors in out-of-hospital cardiac arrest (OHCA) that can be evaluated since the beginning of cardiopulmonary resuscitation (CPR) manoeuvres could be helpful in the decision-making process of prehospital care. We aim to identify metabolic variables at the start of advanced CPR at the scene that may be associated with two main outcomes of CPR (recovery of spontaneous circulation (ROSC) and neurological outcome). METHODS Prospective observational study of all non-traumatic OHCA in patients older than 17 years assisted by emergency medical services (EMS), with doctor and nurse on board, between January 2012 and December 2017. Venous blood gases were sampled upon initially obtaining venous access to determine the initial values of pH, pCO2, HCO3-, base excess (BE), Na+, K+, Ca2+ and lactate. ROSC upon arrival at the hospital and neurological status 30 days later (Cerebral Performance Categories (CPC) scale) were recorded. RESULTS We included 1552 patients with OHCA with blood test data in a 6-year period. ROSC was achieved in 906 cases (58.4%), and good neurological recovery at 30 days (CPC I-II) occurred in 383 cases (24.68%). In multivariate analysis, we found a significant relationship between non-recovery of spontaneous circulation (no-ROSC) and low pH levels (adjusted odds ratio (OR) 0.03 (0.002-0.59), p = 0.020), high pCO2 levels (adjusted OR 1.03 [1.01-1.05], p = 0.008) and high potassium levels (adjusted OR 2.28 [1.43-3.61], p = 0.008). Poor neurological outcomes were associated with low pH levels (adjusted OR 0.06 [0.02-0.18], p < 0.001), high pCO2 (adjusted OR 1.05 [1.03-1.08], p < 0.001), low HCO3- (adjusted OR 0.97 [0.94-0.999], p = 0.044), low BE (adjusted OR 0.96 [0.93-0.98], p < 0.001) and high potassium levels (adjusted OR 1.37 [1.16-1.60], p < 0.001). CONCLUSION There is a significant relationship between severe alterations of venous blood-gas variables and potassium at the start of CPR of non-traumatic OHCA and low-ROSC rate and neurological prognosis.
Collapse
|
6
|
Balan P, Hsi B, Thangam M, Zhao Y, Monlezun D, Arain S, Charitakis K, Dhoble A, Johnson N, Anderson HV, Persse D, Warner M, Ostermayer D, Prater S, Wang H, Doshi P. The cardiac arrest survival score: A predictive algorithm for in-hospital mortality after out-of-hospital cardiac arrest. Resuscitation 2019; 144:46-53. [PMID: 31539610 DOI: 10.1016/j.resuscitation.2019.09.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 08/21/2019] [Accepted: 09/06/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Out-of-hospital cardiac arrest (OHCA) is associated with high mortality. Current methods for predicting mortality post-arrest require data unavailable at the time of initial medical contact. We created and validated a risk prediction model for patients experiencing OHCA who achieved return of spontaneous circulation (ROSC) which relies only on objective information routinely obtained at first medical contact. METHODS We performed a retrospective evaluation of 14,892 OHCA patients in a large metropolitan cardiac arrest registry, of which 3952 patients had usable data. This population was divided into a derivation cohort (n = 2,635) and a verification cohort (n = 1,317) in a 2:1 ratio. Backward stepwise logistic regression was used to identify baseline factors independently associated with death after sustained ROSC in the derivation cohort. The cardiac arrest survival score (CASS) was created from the model and its association with in-hospital mortality was examined in both the derivation and verification cohorts. RESULTS Baseline characteristics of the derivation and verification cohorts were not different. The final CASS model included age >75 years (odds ratio [OR] = 1.61, confidence interval [CI][1.30-1.99], p < 0.001), unwitnessed arrest (OR = 1.95, CI[1.58-2.40], p < 0.001), home arrest (OR = 1.28, CI[1.07-1.53], p = 0.008), absence of bystander CPR (OR = 1.35, CI[1.12-1.64], p = 0.003), and non-shockable initial rhythm (OR = 3.81, CI[3.19-4.56], p < 0.001). The area under the curve for the model derivation and model verification cohorts were 0.7172 and 0.7081, respectively. CONCLUSION CASS accurately predicts mortality in OHCA patients. The model uses only binary, objective clinical data routinely obtained at first medical contact. Early risk stratification may allow identification of more patients in whom timely and aggressive invasive management may improve outcomes.
Collapse
Affiliation(s)
- Prakash Balan
- Department of Internal Medicine, Division of Cardiology McGovern Medical School at The University of Texas Health Science Center Houston, United States.
| | - Brian Hsi
- Department of Internal Medicine, Division of Cardiology Houston Methodist Hospital, Weill Cornell Medical College, United States
| | - Manoj Thangam
- Department of Internal Medicine, Division of Cardiovascular Medicine Washington University School of Medicine St. Louis, United States
| | - Yelin Zhao
- Department of Internal Medicine, Division of Cardiology McGovern Medical School at The University of Texas Health Science Center Houston, United States
| | - Dominique Monlezun
- Department of Internal Medicine, Division of Cardiology McGovern Medical School at The University of Texas Health Science Center Houston, United States
| | - Salman Arain
- Department of Internal Medicine, Division of Cardiology McGovern Medical School at The University of Texas Health Science Center Houston, United States
| | - Konstantinos Charitakis
- Department of Internal Medicine, Division of Cardiology McGovern Medical School at The University of Texas Health Science Center Houston, United States
| | - Abhijeet Dhoble
- Department of Internal Medicine, Division of Cardiology McGovern Medical School at The University of Texas Health Science Center Houston, United States
| | - Nils Johnson
- Department of Internal Medicine, Division of Cardiology McGovern Medical School at The University of Texas Health Science Center Houston, United States
| | - H Vernon Anderson
- Department of Internal Medicine, Division of Cardiology McGovern Medical School at The University of Texas Health Science Center Houston, United States
| | - David Persse
- Physician Director of Emergency Medical Services City of Houston, United States
| | - Mark Warner
- Department of Internal Medicine, Division of Pulmonary/Critical Care Medicine McGovern Medical School at The University of Texas Health Science Center Houston, United States
| | - Daniel Ostermayer
- Department of Emergency Medicine McGovern Medical School at The University of Texas Health Science Center Houston, United States
| | - Samuel Prater
- Department of Emergency Medicine McGovern Medical School at The University of Texas Health Science Center Houston, United States
| | - Henry Wang
- Department of Emergency Medicine McGovern Medical School at The University of Texas Health Science Center Houston, United States
| | - Pratik Doshi
- Department of Internal Medicine, Division of Pulmonary/Critical Care Medicine McGovern Medical School at The University of Texas Health Science Center Houston, United States; Department of Emergency Medicine McGovern Medical School at The University of Texas Health Science Center Houston, United States
| |
Collapse
|
7
|
Eshcol JO, Chhatriwalla AK. Selective Coronary Angiography Following Cardiac Arrest. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2019. [DOI: 10.15212/cvia.2017.0060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
|
8
|
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.
Collapse
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.
| |
Collapse
|
9
|
Shih HM, Chen YC, Chen CY, Huang FW, Chang SS, Yu SH, Wu SY, Chen WK. Derivation and Validation of the SWAP Score for Very Early Prediction of Neurologic Outcome in Patients With Out-of-Hospital Cardiac Arrest. Ann Emerg Med 2019; 73:578-588. [PMID: 30819521 DOI: 10.1016/j.annemergmed.2019.01.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 12/19/2018] [Accepted: 01/04/2019] [Indexed: 02/07/2023]
Abstract
STUDY OBJECTIVE For patients with out-of-hospital cardiac arrest who receive cardiopulmonary resuscitation in an emergency department (ED), the early evaluation of their neurologic prognosis is essential for emergency physicians. The aim of this study is to establish a simple and useful assessment tool for rapidly estimating the prognosis of patients with out-of-hospital cardiac arrest after their arrival at an ED. METHODS A total of 852 patients admitted from January 1, 2015, to June 30, 2017, were prospectively registered and enrolled in the derivation cohort. Multivariate logistic regression on this cohort identified 4 independent factors associated with unfavorable outcomes: initial nonshockable rhythm (odds ratio [OR] 3.40; 95% confidence interval [CI] 1.58 to 7.32), no witness of collapse (OR 3.19; 95% CI 1.51 to 6.75), older than 60 years (OR 3.65; 95% CI 1.64 to 8.09), and pH less than or equal to 7.00 (OR 3.27; 95% CI 1.42 to 7.54). The shockable rhythm-witness-age-pH (SWAP) score was developed and 1 point was assigned to each predictor. RESULTS For a SWAP score of 4, the specificity was 97.14% (95% CI 91.62% to 100%) for unfavorable outcomes in the derivation cohort. For validation, we retrospectively collected data for 859 patients with out-of-hospital cardiac arrest from January 1, 2012, to December 31, 2014. A SWAP score of 4 was 100% specific (95% CI 99.9% to 100%) for unfavorable outcomes in the validation cohort. CONCLUSION The SWAP score is a simple and useful predictive model that may provide information for the very early estimation of prognosis for patients with out-of-hospital cardiac arrest. Further research is required to integrate ultrasonographic findings and validate the SWAP score's application in other populations.
Collapse
Affiliation(s)
- Hong-Mo Shih
- Department of Emergency Medicine, China Medical University Hospital, Taichung City, Taiwan; School of Medicine, College of Medicine, China Medical University, Taichung City, Taiwan
| | - Yi-Chuan Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi, Puzi City, Taiwan; Department of Nursing, Chang Gung University of Science and Technology, Chiayi Campus, Puzi City, Taiwan
| | - Chih-Yu Chen
- Department of Emergency Medicine, China Medical University Hospital, Taichung City, Taiwan; School of Medicine, College of Medicine, China Medical University, Taichung City, Taiwan
| | - Fen-Wei Huang
- Emergency and Critical Care Foundation, Taipei, Taiwan
| | - Shih-Sheng Chang
- Division of Cardiovascular Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung City, Taiwan; School of Medicine, College of Medicine, China Medical University, Taichung City, Taiwan
| | - Shao-Hua Yu
- Department of Emergency Medicine, China Medical University Hospital, Taichung City, Taiwan; School of Medicine, College of Medicine, China Medical University, Taichung City, Taiwan; Graduate Institute of Biomedical Sciences, China Medical University, Taichung City, Taiwan
| | - Shih-Yun Wu
- Department of Emergency Medicine, China Medical University Hospital, Taichung City, Taiwan; School of Medicine, College of Medicine, China Medical University, Taichung City, Taiwan
| | - Wei-Kung Chen
- Department of Emergency Medicine, China Medical University Hospital, Taichung City, Taiwan; School of Medicine, College of Medicine, China Medical University, Taichung City, Taiwan.
| |
Collapse
|
10
|
Babini G, Ristagno G, Boccardo A, De Giorgio D, De Maglie M, Affatato R, Ceriani S, Zani D, Novelli D, Staszewsky L, Masson S, Pravettoni D, Latini R, Belloli A, Scanziani E, Skrifvars M. Effect of mild hypercapnia on outcome and histological injury in a porcine post cardiac arrest model. Resuscitation 2019; 135:110-117. [DOI: 10.1016/j.resuscitation.2018.10.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 10/02/2018] [Accepted: 10/25/2018] [Indexed: 10/28/2022]
|
11
|
Jakkula P, Reinikainen M, Hästbacka J, Loisa P, Tiainen M, Pettilä V, Toppila J, Lähde M, Bäcklund M, Okkonen M, Bendel S, Birkelund T, Pulkkinen A, Heinonen J, Tikka T, Skrifvars MB. Targeting two different levels of both arterial carbon dioxide and arterial oxygen after cardiac arrest and resuscitation: a randomised pilot trial. Intensive Care Med 2018; 44:2112-2121. [PMID: 30430209 PMCID: PMC6280824 DOI: 10.1007/s00134-018-5453-9] [Citation(s) in RCA: 127] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 11/03/2018] [Indexed: 12/21/2022]
Abstract
Purpose We assessed the effects of targeting low-normal or high-normal arterial carbon dioxide tension (PaCO2) and normoxia or moderate hyperoxia after out-of-hospital cardiac arrest (OHCA) on markers of cerebral and cardiac injury. Methods Using a 23 factorial design, we randomly assigned 123 patients resuscitated from OHCA to low-normal (4.5–4.7 kPa) or high-normal (5.8–6.0 kPa) PaCO2 and to normoxia (arterial oxygen tension [PaO2] 10–15 kPa) or moderate hyperoxia (PaO2 20–25 kPa) and to low-normal or high-normal mean arterial pressure during the first 36 h in the intensive care unit. Here we report the results of the low-normal vs. high-normal PaCO2 and normoxia vs. moderate hyperoxia comparisons. The primary endpoint was the serum concentration of neuron-specific enolase (NSE) 48 h after cardiac arrest. Secondary endpoints included S100B protein and cardiac troponin concentrations, continuous electroencephalography (EEG) and near-infrared spectroscopy (NIRS) results and neurologic outcome at 6 months. Results In total 120 patients were included in the analyses. There was a clear separation in PaCO2 (p < 0.001) and PaO2 (p < 0.001) between the groups. The median (interquartile range) NSE concentration at 48 h was 18.8 µg/l (13.9–28.3 µg/l) in the low-normal PaCO2 group and 22.5 µg/l (14.2–34.9 µg/l) in the high-normal PaCO2 group, p = 0.400; and 22.3 µg/l (14.8–27.8 µg/l) in the normoxia group and 20.6 µg/l (14.2–34.9 µg/l) in the moderate hyperoxia group, p = 0.594). High-normal PaCO2 and moderate hyperoxia increased NIRS values. There were no differences in other secondary outcomes. Conclusions Both high-normal PaCO2 and moderate hyperoxia increased NIRS values, but the NSE concentration was unaffected. Registration ClinicalTrials.gov, NCT02698917. Registered on January 26, 2016. Electronic supplementary material The online version of this article (10.1007/s00134-018-5453-9) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Pekka Jakkula
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Matti Reinikainen
- Department of Intensive Care, North Karelia Central Hospital, Joensuu, Finland
| | - Johanna Hästbacka
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Pekka Loisa
- Department of Intensive Care, Päijät-Häme Central Hospital, Lahti, Finland
| | - Marjaana Tiainen
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ville Pettilä
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jussi Toppila
- Clinical Neurophysiology, HUS Medical Imaging Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marika Lähde
- Department of Anaesthesia and Intensive Care, Päijät-Häme Central Hospital, Lahti, Finland
| | - Minna Bäcklund
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marjatta Okkonen
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Stepani Bendel
- Department of Intensive Care, Kuopio University Hospital, Kuopio, Finland
| | | | - Anni Pulkkinen
- Department of Anaesthesia and Intensive Care, Central Finland Central Hospital, Jyväskylä, Finland
| | - Jonna Heinonen
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tuukka Tikka
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Markus B Skrifvars
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Department of Emergency Medicine and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | |
Collapse
|
12
|
Shin J, Lim YS, Kim K, Lee HJ, Lee SJ, Jung E, You KM, Yang HJ, Kim JJ, Kim J, Jo YH, Lee JH, Hwang SY. Initial blood pH during cardiopulmonary resuscitation in out-of-hospital cardiac arrest patients: a multicenter observational registry-based study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:322. [PMID: 29268775 PMCID: PMC5740770 DOI: 10.1186/s13054-017-1893-9] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Accepted: 11/20/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND When an out-of-hospital cardiac arrest (OHCA) patient receives cardiopulmonary resuscitation (CPR) in the emergency department (ED), blood laboratory test results can be obtained by using point-of-care testing during CPR. In the present study, the relationship between blood laboratory test results during CPR and outcomes of OHCA patients was investigated. METHODS This study was a multicenter retrospective analysis of prospective registered data that included 2716 OHCA patients. Data from the EDs of three university hospitals in different areas were collected from January 2009 to December 2014. Univariate and multivariable analyses were conducted to elucidate the factors associated with survival to discharge and neurological outcomes. A final analysis was conducted by including patients who had no prehospital return of spontaneous circulation and those who underwent rapid blood laboratory examination during CPR. RESULTS Overall, 2229 OHCA patients were included in the final analysis. Among them, the rate of survival to discharge and a good Cerebral Performance Categories Scale score were 14% and 4.4%, respectively. The pH level was independently related to survival to hospital discharge (adjusted OR 6.287, 95% CI 2.601-15.197; p < 0.001) and good neurological recovery (adjusted OR 15.395, 95% CI 3.439-68.911; p < 0.001). None of the neurologically intact patients had low pH levels (< 6.8) or excessive potassium levels (> 8.5 mEq/L) during CPR. CONCLUSIONS Among the blood laboratory test results during CPR of OHCA patients, pH and potassium levels were observed as independent factors associated with survival to hospital discharge, and pH level was considered as an independent factor related to neurological recovery.
Collapse
Affiliation(s)
- Jonghwan Shin
- Department of Emergency Medicine, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Republic of Korea
| | - Yong Su Lim
- Department of Emergency Medicine, Gachon University Gil Medical Center, 21, Namdong-daero 774 Beon-gil, Namdong-gu, Incheon, 21565, Republic of Korea.
| | - Kyuseok Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea
| | - Hui Jai Lee
- Department of Emergency Medicine, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Republic of Korea
| | - Se Jong Lee
- Department of Emergency Medicine, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Republic of Korea
| | - Euigi Jung
- Department of Emergency Medicine, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Republic of Korea
| | - Kyoung Min You
- Department of Emergency Medicine, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Republic of Korea
| | - Hyuk Jun Yang
- Department of Emergency Medicine, Gachon University Gil Medical Center, 21, Namdong-daero 774 Beon-gil, Namdong-gu, Incheon, 21565, Republic of Korea
| | - Jin Joo Kim
- Department of Emergency Medicine, Gachon University Gil Medical Center, 21, Namdong-daero 774 Beon-gil, Namdong-gu, Incheon, 21565, Republic of Korea
| | - Joonghee Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea
| | - Jae Hyuk Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea
| | - Seong Youn Hwang
- Department of Emergency Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, 158, Palyong-ro, Masanhoewon-gu, Changwon-si, Gyeongsangnam-do, 51353, Republic of Korea
| |
Collapse
|
13
|
Johnson NJ, Carlbom DJ, Gaieski DF. Ventilator Management and Respiratory Care After Cardiac Arrest: Oxygenation, Ventilation, Infection, and Injury. Chest 2017; 153:1466-1477. [PMID: 29175085 DOI: 10.1016/j.chest.2017.11.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 10/16/2017] [Accepted: 11/10/2017] [Indexed: 01/14/2023] Open
Abstract
Return of spontaneous circulation after cardiac arrest results in a systemic inflammatory state called the post-cardiac arrest syndrome, which is characterized by oxidative stress, coagulopathy, neuronal injury, and organ dysfunction. Perturbations in oxygenation and ventilation may exacerbate secondary injury after cardiac arrest and have been shown to be associated with poor outcome. Further, patients who experience cardiac arrest are at risk for a number of other pulmonary complications. Up to 70% of patients experience early infection after cardiac arrest, and the respiratory tract is the most common source. Vigilance for early-onset pneumonia, as well as aggressive diagnosis and early antimicrobial agent administration are important components of critical care in this population. Patients who experience cardiac arrest are at risk for the development of ARDS. Risk factors include aspiration, pulmonary contusions (from chest compressions), systemic inflammation, and reperfusion injury. Early evidence suggests that they may benefit from ventilation with low tidal volumes. Meticulous attention to mechanical ventilation, early assessment and optimization of respiratory gas exchange, and therapies targeted at potential pulmonary complications may improve outcomes after cardiac arrest.
Collapse
Affiliation(s)
- Nicholas J Johnson
- Department of Emergency Medicine, University of Washington, Seattle, WA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA.
| | - David J Carlbom
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA
| | - David F Gaieski
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| |
Collapse
|
14
|
Jakkula P, Reinikainen M, Hästbacka J, Pettilä V, Loisa P, Karlsson S, Laru-Sompa R, Bendel S, Oksanen T, Birkelund T, Tiainen M, Toppila J, Hakkarainen A, Skrifvars MB. Targeting low- or high-normal Carbon dioxide, Oxygen, and Mean arterial pressure After Cardiac Arrest and REsuscitation: study protocol for a randomized pilot trial. Trials 2017; 18:507. [PMID: 29084585 PMCID: PMC5663085 DOI: 10.1186/s13063-017-2257-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 10/16/2017] [Indexed: 12/02/2022] Open
Abstract
Background Arterial carbon dioxide tension (PaCO2), oxygen tension (PaO2), and mean arterial pressure (MAP) are modifiable factors that affect cerebral blood flow (CBF), cerebral oxygen delivery, and potentially the course of brain injury after cardiac arrest. No evidence regarding optimal treatment targets exists. Methods The Carbon dioxide, Oxygen, and Mean arterial pressure After Cardiac Arrest and REsuscitation (COMACARE) trial is a pilot multi-center randomized controlled trial (RCT) assessing the feasibility of targeting low- or high-normal PaCO2, PaO2, and MAP in comatose, mechanically ventilated patients after out-of-hospital cardiac arrest (OHCA), as well as its effect on brain injury markers. Using a 23 factorial design, participants are randomized upon admission to an intensive care unit into one of eight groups with various combinations of PaCO2, PaO2, and MAP target levels for 36 h after admission. The primary outcome is neuron-specific enolase (NSE) serum concentration at 48 h after cardiac arrest. The main feasibility outcome is the between-group differences in PaCO2, PaO2, and MAP during the 36 h after ICU admission. Secondary outcomes include serum concentrations of NSE, S100 protein, and cardiac troponin at 24, 48, and 72 h after cardiac arrest; cerebral oxygenation, measured with near-infrared spectroscopy (NIRS); potential differences in epileptic activity, monitored via continuous electroencephalogram (EEG); and neurological outcomes at six months after cardiac arrest. Discussion The trial began in March 2016 and participant recruitment has begun in all seven study sites as of March 2017. Currently, 115 of the total of 120 patients have been included. When completed, the results of this trial will provide preliminary clinical evidence regarding the feasibility of targeting low- or high-normal PaCO2, PaO2, and MAP values and its effect on developing brain injury, brain oxygenation, and epileptic seizures after cardiac arrest. The results of this trial will be used to evaluate whether a larger RCT on this subject is justified. Trial registration ClinicalTrials.gov, NCT02698917. Registered on 26 January 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2257-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Pekka Jakkula
- University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | | | - Johanna Hästbacka
- University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ville Pettilä
- University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Pekka Loisa
- Päijät-Häme Central Hospital, Lahti, Finland
| | | | | | | | | | | | - Marjaana Tiainen
- University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jussi Toppila
- University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Antti Hakkarainen
- University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Markus B Skrifvars
- University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Australia and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | | |
Collapse
|
15
|
Clinical signs, profound acidemia, hypoglycemia, and hypernatremia are predictive of mortality in 1,400 critically ill neonatal calves with diarrhea. PLoS One 2017; 12:e0182938. [PMID: 28817693 PMCID: PMC5560544 DOI: 10.1371/journal.pone.0182938] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 07/26/2017] [Indexed: 01/09/2023] Open
Abstract
Profound acidemia impairs cellular and organ function and consequently should be associated with an increased risk of mortality in critically ill humans and animals. Neonatal diarrhea in calves can result in potentially serious metabolic derangements including profound acidemia due to strong ion (metabolic) acidosis, hyper-D-lactatemia, hyper-L-lactatemia, azotemia, hypoglycemia, hyperkalemia and hyponatremia. The aim of this retrospective study was to assess the prognostic relevance of clinical and laboratory findings in 1,400 critically ill neonatal calves with diarrhea admitted to a veterinary teaching hospital. The mortality rate was 22%. Classification tree analysis indicated that mortality was associated with clinical signs of neurologic disease, abdominal emergencies, cachexia, orthopedic problems such as septic arthritis, and profound acidemia (jugular venous blood pH < 6.85). When exclusively considering laboratory parameters, classification tree analysis identified plasma glucose concentrations < 3.2 mmol/L, plasma sodium concentrations ≥ 151 mmol/L, serum GGT activity < 31 U/L and a thrombocyte count < 535 G/L as predictors of mortality. However, multivariable logistic regression models based on these laboratory parameters did not have a sufficiently high enough sensitivity (59%) and specificity (79%) to reliably predict treatment outcome. The sensitivity and specificity of jugular venous blood pH < 6.85 were 11% and 97%, respectively, for predicting non-survival in this study population. We conclude that laboratory values (except jugular venous blood pH < 6.85) are of limited value for predicting outcome in critically ill neonatal calves with diarrhea. In contrast, the presence of specific clinical abnormalities provides valuable prognostic information.
Collapse
|
16
|
Neurologic Recovery After Cardiac Arrest: a Multifaceted Puzzle Requiring Comprehensive Coordinated Care. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:52. [PMID: 28536893 DOI: 10.1007/s11936-017-0548-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OPINION STATEMENT Surviving cardiac arrest (CA) requires a longitudinal approach with multiple levels of responsibility, including fostering a culture of action by increasing public awareness and training, optimization of resuscitation measures including frequent updates of guidelines and their timely implementation into practice, and optimization of post-CA care. This clearly goes beyond resuscitation and targeted temperature management. Brain-directed physiologic goals should dictate the post-CA management, as accumulating evidence suggests that the degree of hypoxic brain injury is the main determinant of survival, regardless of the etiology of arrest. Early assessment of the need for further hemodynamic and electrophysiologic cardiac interventions, adjusting ventilator settings to avoid hyperoxia/hypoxia while targeting high-normal to mildly elevated PaCO2, maintaining mean arterial blood pressures >65 mmHg, evaluating for and treating seizures, maintaining euglycemia, and aggressively pursuing normothermia are key steps in reducing the bioenergetic failure that underlies secondary brain injury. Accurate neuroprognostication requires a multimodal approach with standardized assessments accounting for confounders while recognizing the importance of a delayed prognostication when there is any uncertainty regarding outcome. The concept of a highly specialized post-CA team with expertise in the management of post-CA syndrome (mindful of the brain-directed physiologic goals during the early post-resuscitation phase), TTM, and neuroprognostication, guiding the comprehensive care to the CA survivor, is likely cost-effective and should be explored by institutions that frequently care for these patients. Finally, providing tailored rehabilitation care with systematic reassessment of the needs and overall goals is key for increasing independence and improving quality-of-life in survivors, thereby also alleviating the burden on families. Emerging evidence from multicenter collaborations advances the field of resuscitation at an incredible pace, challenging previously well-established paradigms. There is no more room for "conventional wisdom" in saving the survivors of cardiac arrest.
Collapse
|
17
|
Prevalence of hemolysis and metabolic acidosis in patients with circulatory failure supported with extracorporeal life support: a marker for survival? Eur J Heart Fail 2017; 19 Suppl 2:110-116. [DOI: 10.1002/ejhf.854] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Revised: 03/27/2017] [Accepted: 04/01/2017] [Indexed: 12/30/2022] Open
|
18
|
Tolins ML, Henning DJ, Gaieski DF, Grossestreuer AV, Jaworski A, Johnson NJ. Initial arterial carbon dioxide tension is associated with neurological outcome after resuscitation from cardiac arrest. Resuscitation 2017; 114:53-58. [PMID: 28268187 DOI: 10.1016/j.resuscitation.2017.03.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 02/20/2017] [Accepted: 03/02/2017] [Indexed: 10/20/2022]
Abstract
STUDY OBJECTIVES To determine the relationships between partial pressure of arterial carbon dioxide (PaCO2), prescribed minute ventilation (MV), and neurologic outcome in patients resuscitated from cardiac arrest. METHODS This was a retrospective cohort study utilizing a multicenter database of adult patients with return of spontaneous circulation (ROSC) after cardiac arrest. The primary outcome was neurologic status at hospital discharge, defined by Cerebral Performance Category (CPC) score: CPC 1-2 was favorable, CPC 3-5 was poor. We compared rates of initial normocarbia (PaCO2 31-49mmHg) and mean sequential PaCO2 measurements obtained over the first 24h. We also assessed the influence of MV on the PaCO2 at initial, 6, 12, 18, and 24h after cardiac arrest using univariate linear regression. RESULTS One hundred and fourteen patients from 3 institutions met inclusion criteria. Overall, 46/114 (40.4%, 95% CI: 31.4-49.4%) patients survived to hospital discharge, and 33/114 (28.9%, 20.6-37.2%) had CPC 1-2 at the time of discharge. A total of 38.9% (95% CI: 29.9-47.9%) of patients had initial normocarbia; 43.2% (28.6-57.8%) of these patients were discharged with CPC 1-2, compared with 20.3% (10.8-29.8%) of dyscarbic patients. By 6h, neurologic outcomes were not significantly associated with PaCO2. Prescribed MV was not associated with PaCO2 at any time point with the exception of a weak correlation at hour 18. CONCLUSION Initial normocarbia was associated with favorable neurological outcome in patients resuscitated from cardiac arrest. This relationship was not seen at subsequent time points. There was no significant association between prescribed MV and PaCO2 or neurologic outcome.
Collapse
Affiliation(s)
- Molly L Tolins
- Division of Emergency Medicine, Department of Medicine, University of Washington, Seattle WA, United States.
| | - Daniel J Henning
- Division of Emergency Medicine, Department of Medicine, University of Washington, Seattle WA, United States
| | - David F Gaieski
- Department of Emergency Medicine, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, PA, United States
| | - Anne V Grossestreuer
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Alison Jaworski
- Department of Emergency Medicine, Boston Medical Center, Boston, MA, United States
| | - Nicholas J Johnson
- Division of Emergency Medicine, Department of Medicine, University of Washington, Seattle WA, United States; Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA, United States
| |
Collapse
|
19
|
Milonas A, Hutchinson A, Charlesworth D, Doric A, Green J, Considine J. Post resuscitation management of cardiac arrest patients in the critical care environment: A retrospective audit of compliance with evidence based guidelines. Aust Crit Care 2016; 30:299-305. [PMID: 27993546 DOI: 10.1016/j.aucc.2016.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Revised: 10/31/2016] [Accepted: 12/08/2016] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND There is a clear relationship between evidence-based post resuscitation care and survival and functional status at hospital discharge. The Australian Resuscitation Council (ARC) recommends protocol driven care to enhance chance of survival following cardiac arrest. Healthcare providers have an obligation to ensure protocol driven post resuscitation care is timely and evidence based. OBJECTIVES The aim of this study was to examine adherence to best practice guidelines for post resuscitation care in the first 24h from Return of Spontaneous Circulation for patients admitted to the intensive care unit from the emergency department having suffered out of hospital or emergency department cardiac arrest and survived initial resuscitation. METHOD A retrospective audit of medical records of patients who met the criteria for survivors of cardiac arrest was conducted at two health services in Melbourne, Australia. Criteria audited were: primary cardiac arrest characteristics, oxygenation and ventilation management, cardiovascular care, neurological care and patient outcomes. FINDINGS The four major findings were: (i) use of fraction of inspired oxygen (FiO2) of 1.0 and hyperoxia was common during the first 24h of post resuscitation management, (ii) there was variability in cardiac care, with timely 12 lead Electrocardiograph and majority of patients achieving systolic blood pressure (SBP) greater than 100mmHg, but delays in transfer to cardiac catheterisation laboratory, (iii) neurological care was suboptimal with a high incidence of hyperglycaemia and failure to provide therapeutic hypothermia in almost 50% of patients and (iv) there was an association between in-hospital mortality and specific elements of post resuscitation care during the first 24h of hospital admission. CONCLUSION Evidence-based context-specific guidelines for post resuscitation care that span the whole patient journey are needed. Reliance on national guidelines does not necessarily translate to evidence based care at a local level, so strategies to ensure effective guideline implementation are urgently required.
Collapse
Affiliation(s)
- Annabel Milonas
- Northern Health, Epping, 185 Cooper St., Epping, 3076, Victoria, Australia.
| | - Ana Hutchinson
- Northern Health, Epping, 185 Cooper St., Epping, 3076, Victoria, Australia; Deakin University, School of Nursing and Midwifery/Centre for Quality and Patient Safety Research, Geelong, Australia.
| | | | - Andrea Doric
- Eastern Health, Nelson Road, Box Hill, 3128, Victoria, Australia.
| | - John Green
- Northern Health, Epping, 185 Cooper St., Epping, 3076, Victoria, Australia.
| | - Julie Considine
- Deakin University, School of Nursing and Midwifery/Centre for Quality and Patient Safety Research, Geelong, Australia; Eastern Health, Nelson Road, Box Hill, 3128, Victoria, Australia.
| |
Collapse
|
20
|
Early Administration of Glutamine Protects Cardiomyocytes from Post-Cardiac Arrest Acidosis. BIOMED RESEARCH INTERNATIONAL 2016; 2016:2106342. [PMID: 28058255 PMCID: PMC5183754 DOI: 10.1155/2016/2106342] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 11/14/2016] [Indexed: 12/31/2022]
Abstract
Postcardiac arrest acidosis can decrease survival. Effective medications without adverse side effects are still not well characterized. We aimed to analyze whether early administration of glutamine could improve survival and protect cardiomyocytes from postcardiac arrest acidosis using animal and cell models. Forty Wistar rats with postcardiac arrest acidosis (blood pH < 7.2) were included. They were divided into study (500 mg/kg L-alanyl-L-glutamine, n = 20) and control (normal saline, n = 20) groups. Each of the rats received resuscitation. The outcomes were compared between the two groups. In addition, cardiomyocytes derived from human induced pluripotent stem cells were exposed to HBSS with different pH levels (7.3 or 6.5) or to culture medium (control). Apoptosis-related markers and beating function were analyzed. We found that the duration of survival was significantly longer in the study group (p < 0.05). In addition, in pH 6.5 or pH 7.3 HBSS buffer, the expression levels of cell stress (p53) and apoptosis (caspase-3, Bcl-xL) markers were significantly lower in cardiomyocytes treated with 50 mM L-glutamine than those without L-glutamine (RT-PCR). L-glutamine also increased the beating function of cardiomyocytes, especially at the lower pH level (6.5). More importantly, glutamine decreased cardiomyocyte apoptosis and increased these cells' beating function at a low pH level.
Collapse
|
21
|
Bader MK, Cahoon WD, Figueroa SA, Laux C, Kurczewski L, Wavra T, Mathiesen C, Livesay SL. Clinical Q & A: Translating Therapeutic Temperature Management from Theory to Practice. Ther Hypothermia Temp Manag 2016; 6:102-8. [PMID: 27136399 DOI: 10.1089/ther.2016.29011.mkb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - William D Cahoon
- 2 Coronary and Cardiothoracic Intensive Care , VCU Health System, Richmond, Virginia
| | - Stephen A Figueroa
- 3 Division of Neurocritical Care, The University of Texas Southwestern Medical Center , Dallas, Texas
| | - Chris Laux
- 4 Harborview Medical Center , Seattle, Washington
| | - Lisa Kurczewski
- 5 Neurocritical Care, Virginia Commonwealth University Health System , Richmond, Virginia.,6 VCU School of Pharmacy , Richmond, Virginia
| | | | | | | |
Collapse
|
22
|
Tasan E, Jesinger ME, Charnigo RJ, Kramer SP, Kim S, Clements L, Bailey AL, Campbell CL. Early Prognosticators for Induction of Therapeutic Hypothermia Following Cardiac Arrest. Ther Hypothermia Temp Manag 2016; 6:122-9. [PMID: 27105285 DOI: 10.1089/ther.2015.0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The American Heart Association recommends therapeutic hypothermia for comatose patients with return of spontaneous circulation after out-of-hospital ventricular fibrillation cardiac arrest. While there is a growing body of evidence for the general efficacy of therapeutic hypothermia, the individualized benefit of therapy is not currently predictable. Ninety-one consecutive patients, from April 2011 to July 2014, were treated at the University of Kentucky Medical Center with the therapeutic hypothermia protocol. Medical records were reviewed retrospectively. Data, such as preexisting comorbidities, cardiac arrest characteristics, and hospital course, were used to compose a multivariate logistic regression with mortality serving as the primary endpoint. The overall in-hospital mortality was 64% (n = 58) in this group. The arrest was considered cardiac etiology in 84% (n = 76) of patients, of which 49% (n = 45) were classed as ventricular fibrillation and 9% (n = 8) as ventricular tachycardia. The presence of a shockable rhythm, as well as shorter duration of cardiac arrest, was associated with increased survival, whereas time to target temperature was not. The presence of a preexisting neurologic disease was associated with a 10-fold increase in estimated odds of mortality. Age, serum lactate, ionized calcium, arterial pH, estimated glomerular filtration rate, and APACHE score were all predictors of mortality. Cardiac arrest is a devastating condition with a high mortality rate. Given the limited resources of the resuscitation community, the ability to predict survivors based on routinely obtained measures upon admission would be of tremendous value. In this study, we show a series of admission parameters that demonstrate predictive ability in identifying patients more likely to survive with therapeutic hypothermia.
Collapse
Affiliation(s)
- Ediz Tasan
- 1 Department of Internal Medicine, University of Kentucky , Lexington, Kentucky
| | - Michael E Jesinger
- 1 Department of Internal Medicine, University of Kentucky , Lexington, Kentucky
| | - Richard J Charnigo
- 2 Department of Biostatistics, University of Kentucky , Lexington, Kentucky
| | - Sage P Kramer
- 3 College of Medicine, University of Kentucky , Lexington, Kentucky
| | - Sooyeon Kim
- 3 College of Medicine, University of Kentucky , Lexington, Kentucky
| | - Linda Clements
- 4 Chandler Medical Center, University of Kentucky , Lexington, Kentucky
| | - Alison L Bailey
- 5 Division of Cardiovascular Medicine, University of Tennessee at Erlanger , Chattanooga, Tennessee
| | - Charles L Campbell
- 5 Division of Cardiovascular Medicine, University of Tennessee at Erlanger , Chattanooga, Tennessee
| |
Collapse
|
23
|
Dawkins S, Curzen N, Banning A. Out-of-hospital cardiac arrest: should everyone go to the cath lab? Postgrad Med J 2016; 92:61-2. [DOI: 10.1136/postgradmedj-2015-133421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 12/21/2015] [Indexed: 11/04/2022]
|
24
|
Kurz M, Lundbye J, Lyden PD. Clinical Studies Targeting Stroke and In-Hospital Cardiac Arrest. Ther Hypothermia Temp Manag 2016; 6:6-8. [PMID: 26799665 DOI: 10.1089/ther.2016.29008.mjk] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Affiliation(s)
- Michael Kurz
- 1 Department of Emergency Medicine, University of Alabama at Birmingham , Birmingham, Alabama
| | - Justin Lundbye
- 2 Department of Cardiology, Hospital of Central Connecticut , New Britain, Connecticut
| | - Patrick D Lyden
- 3 Department of Neurology, Cedars-Sinai Medical Center , Los Angeles, California
| |
Collapse
|
25
|
Whittaker A, Lehal M, Calver AL, Corbett S, Deakin CD, Gray H, Simpson I, Wilkinson JR, Curzen N. Predictors of inhospital mortality following out-of-hospital cardiac arrest: Insights from a single-centre consecutive case series. Postgrad Med J 2016; 92:250-4. [PMID: 26739845 DOI: 10.1136/postgradmedj-2015-133575] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 12/07/2015] [Indexed: 11/04/2022]
Abstract
PURPOSE OF THE STUDY Out-of-hospital cardiac arrest (OHCA) has a poor prognosis despite bystander resuscitation and rapid transfer to hospital. Optimal management of patients after arrival to hospital continues to be contentious, especially the timing of emergency coronary angiography±revascularisation. Robust predictors of inhospital outcome would be of clinical value for initial decision-making. STUDY DESIGN A retrospective analysis of consecutive patients who presented to a university hospital following OHCA over a 70-month period (2008-2013). Patients were identified from the emergency department electronic patient registration and coding system. For those patients who underwent emergency percutaneous coronary intervention, details were crosschecked with national databases. RESULTS We identified 350 consecutive patients who were brought to our hospital following OHCA. Return of spontaneous circulation (ROSC) for >20 min was achieved either before arrival or inhospital in 196 individuals. From the 350 subjects, 114 (32.6%) survived to hospital discharge. When sustained ROSC was achieved, either before or inhospital, survival to discharge was 58.2% (114 of 196). Non-shockable rhythm, absence of bystander cardiopulmonary resuscitation, 'downtime' >15 min and initial pH ≤7.11 were predictors of inhospital death. 12% patients who underwent angiography in the presence of ST elevation had no acute coronary occlusion. 21% patients with acute coronary occlusion at angiography did not have ST elevation. CONCLUSIONS In our cohort of patients with OHCA, those who achieve ROSC had a survival-to-discharge rate of 58.2%. We identified four predictors of inhospital death, which are readily available at the time of patient presentation. Reliance on ST elevation to decide about coronary angiography and revascularisation may be flawed. More data are required.
Collapse
Affiliation(s)
- Andrew Whittaker
- Department of Cardiology, Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Manpreet Lehal
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Alison L Calver
- Department of Cardiology, Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Simon Corbett
- Department of Cardiology, Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Charles D Deakin
- Department of Cardiology, Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK Faculty of Medicine, University of Southampton, Southampton, UK
| | - Huon Gray
- Department of Cardiology, Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Iain Simpson
- Department of Cardiology, Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - James R Wilkinson
- Department of Cardiology, Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Nicholas Curzen
- Department of Cardiology, Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK Faculty of Medicine, University of Southampton, Southampton, UK
| |
Collapse
|
26
|
Bergman L, Lundbye JB. Acid–base optimization during hypothermia. Best Pract Res Clin Anaesthesiol 2015; 29:465-70. [DOI: 10.1016/j.bpa.2015.09.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 09/20/2015] [Accepted: 09/22/2015] [Indexed: 10/23/2022]
|
27
|
Bellomo R, Märtensson J, Eastwood GM. Metabolic and electrolyte disturbance after cardiac arrest: How to deal with it. Best Pract Res Clin Anaesthesiol 2015; 29:471-84. [DOI: 10.1016/j.bpa.2015.10.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 09/02/2015] [Accepted: 10/05/2015] [Indexed: 12/15/2022]
|
28
|
Tetsuhara K, Kato H, Kanemura T, Okada I, Kiriu N. Severe acidemia on arrival not predictive of neurologic outcomes in post-cardiac arrest patients. Am J Emerg Med 2015; 34:425-8. [PMID: 26682673 DOI: 10.1016/j.ajem.2015.11.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Accepted: 11/14/2015] [Indexed: 11/18/2022] Open
Abstract
PURPOSE This study aimed to determine whether severe acidemia (pH <7.2) on arrival at the emergency department (ED) is a predictive factor for neurologic outcomes of post-cardiac arrest patients treated with targeted temperature management (TTM). MATERIALS AND METHODS Data in the National Disaster Medical Center, a tertiary care hospital, were used to perform a case-control study on post-cardiac arrest patients treated with TTM from January 2013 to April 2015. The case group comprised patients with good neurologic outcomes (cerebral performance categories 1 and 2), whereas the control group comprised patients with poor neurologic outcomes (cerebral performance categories 3-5). Exposure was defined as arterial pH less than 7.2 on arrival at the ED. RESULTS We identified 32 patients matching our criteria, of which 13 had good outcomes and 19 poor outcomes. Arterial pH on arrival was not significantly associated with neurologic outcomes (P = .47; odds ratio, 0.5; 95% confidence interval, 0.09-2.61). In 24 patients with cardiogenic causes of cardiac arrest, pH on arrival was not significantly associated with neurologic outcomes (P = .68; odds ratio, 0.5; 95% confidence interval, 0.09-2.73) after matched-pair analysis by age, sex, and presence of light reflex. CONCLUSION Severe acidemia on arrival at the ED is not a significant predictive factor for neurologic outcomes in post-cardiac arrest patients treated with TTM, particularly in patients with cardiogenic causes of cardiac arrest. These results suggest that treatment should not be withheld in post-cardiac arrest patients with severe acidemia.
Collapse
Affiliation(s)
- Kenichi Tetsuhara
- Department of Critical Care Medicine and Trauma, National Disaster Medical Center, 3256 Tachikawa City, Tokyo, Japan.
| | - Hiroshi Kato
- Department of Critical Care Medicine and Trauma, National Disaster Medical Center, 3256 Tachikawa City, Tokyo, Japan.
| | - Takashi Kanemura
- Department of Critical Care Medicine and Trauma, National Disaster Medical Center, 3256 Tachikawa City, Tokyo, Japan.
| | - Ichiro Okada
- Department of Critical Care Medicine and Trauma, National Disaster Medical Center, 3256 Tachikawa City, Tokyo, Japan.
| | - Nobuaki Kiriu
- Department of Critical Care Medicine and Trauma, National Disaster Medical Center, 3256 Tachikawa City, Tokyo, Japan.
| |
Collapse
|
29
|
Rab T, Kern KB, Tamis-Holland JE, Henry TD, McDaniel M, Dickert NW, Cigarroa JE, Keadey M, Ramee S. Cardiac Arrest: A Treatment Algorithm for Emergent Invasive Cardiac Procedures in the Resuscitated Comatose Patient. J Am Coll Cardiol 2015; 66:62-73. [PMID: 26139060 DOI: 10.1016/j.jacc.2015.05.009] [Citation(s) in RCA: 137] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 04/28/2015] [Accepted: 05/05/2015] [Indexed: 12/14/2022]
Abstract
Patients who are comatose after cardiac arrest continue to be a challenge, with high mortality. Although there is an American College of Cardiology Foundation/American Heart Association Class I recommendation for performing immediate angiography and percutaneous coronary intervention (when indicated) in patients with ST-segment elevation myocardial infarction, no guidelines exist for patients without ST-segment elevation. Early introduction of mild therapeutic hypothermia is an established treatment goal. However, there are no established guidelines for risk stratification of patients for cardiac catheterization and possible percutaneous coronary intervention, particularly in patients who have unfavorable clinical features in whom procedures may be futile and affect public reporting of mortality. An algorithm is presented to improve the risk stratification of these severely ill patients with an emphasis on consultation and evaluation of patients prior to activation of the cardiac catheterization laboratory.
Collapse
Affiliation(s)
- Tanveer Rab
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
| | - Karl B Kern
- Sarver Heart Center, University of Arizona, Tucson, Arizona
| | | | - Timothy D Henry
- Division of Cardiology, Department of Medicine, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Michael McDaniel
- Division of Cardiology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia
| | - Neal W Dickert
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Joaquin E Cigarroa
- Knight Cardiovascular Institute, Oregon Health and Sciences University, Portland, Oregon
| | - Matthew Keadey
- Division of Emergency Medicine, Emory University Hospital, Emory University School of Medicine, Atlanta, Georgia
| | - Stephen Ramee
- Structural and Valvular Heart Disease Program, Ochsner Medical Center, New Orleans, Louisiana
| |
Collapse
|
30
|
Abstract
Targeted temperature management has an established role in treating the post-cardiac arrest syndrome after out-of-hospital cardiac arrest with an initial rhythm of ventricular tachycardia/ventricular fibrillation. There is less certain benefit if the initial rhythm is pulseless electrical activity/asystole or for in-hospital cardiac arrest. Targeted temperature management may have a role as salvage modality for conditions causing intracranial hypertension, such as traumatic brain injury, hepatic encephalopathy, intracerebral hemorrhage, and acute stroke. There is variable evidence for its use early in these disorders to minimize secondary neurologic injury.
Collapse
Affiliation(s)
- John McGinniss
- Pulmonary, Allergy & Critical Care Division, Hospital of the University of Pennsylvania, 3400 Spruce Street, 839 West Gates Building, Philadelphia, PA 19104, USA.
| | - Peter Marshall
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06520-8057, USA
| | - Shyoko Honiden
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06520-8057, USA
| |
Collapse
|
31
|
Uribarri A, Bueno H, Pérez-Castellanos A, Loughlin G, Sousa I, Viana-Tejedor A, Fernández-Avilés F. Impact of time to cooling initiation and time to target temperature in patients treated with hypothermia after cardiac arrest. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 4:365-72. [PMID: 25344490 DOI: 10.1177/2048872614557241] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 10/07/2014] [Indexed: 01/21/2023]
Abstract
PURPOSE Little is known about the role of time to initiation of therapeutic hypothermia and time to target temperature (TTT) in the prognosis of patients resuscitated from cardiac arrest. METHODS A retrospective analysis was performed in 145 survivors of cardiac arrest who underwent therapeutic hypothermia between January 2003 and January 2013. The objective was to identify predictors of survival free from significant neurological sequelae (Cerebral Performance Categories Scale (CPC): >2) six months after cardiac arrest. We evaluated the effect of faster and earlier cooling. RESULTS Overall survival at six months was 42.1% (61 patients); 59 of these were considered to have a good neurological status (CPC ≤ 2), and in whom therapeutic hypothermia was initiated earlier (87 ± 17 min vs. 111 ± 14 min; p=0.042), and the target temperature was reached at an earlier time (TTT: 316 ± 30 min vs. 365 ± 27 min; p=0.017). Multivariate analysis selected longer duration of cardiac arrest (odds ratio (OR) = 1.06 per min), a non-shockable initial rhythm (OR=13.8), severe acidosis (OR=0.009 per 0.01 unit), older age (OR=1.04 per year) and longer TTT (OR=1.005 per min) as associated with poor prognosis. CONCLUSION The most important prognostic factors for death or lack of neurological recovery in patients with cardiac arrest treated with therapeutic hypothermia are initial-rhythm, time from cardiac arrest to return of spontaneous circulation and arterial-pH at admission. Although the speed of cooling initiation and the time to reach target temperature may play a role, its influence on prognosis seems to be less important.
Collapse
Affiliation(s)
- Aitor Uribarri
- Cardiology Department, Hospital General Universitario 'Gregorio Marañón', Madrid, Spain
| | - Héctor Bueno
- Cardiology Department, Hospital General Universitario 'Gregorio Marañón', Madrid, Spain
| | | | - Gerard Loughlin
- Cardiology Department, Hospital General Universitario 'Gregorio Marañón', Madrid, Spain
| | - Iago Sousa
- Cardiology Department, Hospital General Universitario 'Gregorio Marañón', Madrid, Spain
| | - Ana Viana-Tejedor
- Cardiology Department, Hospital General Universitario 'Gregorio Marañón', Madrid, Spain
| | | |
Collapse
|
32
|
Dell'Anna AM, Lamanna I, Vincent JL, Taccone FS. How much oxygen in adult cardiac arrest? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:555. [PMID: 25636001 PMCID: PMC4520204 DOI: 10.1186/s13054-014-0555-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Although experimental studies have suggested that a high arterial oxygen pressure (PaO2) might aggravate post-anoxic brain injury, clinical studies in patients resuscitated from cardiac arrest (CA) have given conflicting results. Some studies found that a PaO2 of more than 300 mm Hg (hyperoxemia) was an independent predictor of poor outcome, but others reported no association between blood oxygenation and neurological recovery in this setting. In this article, we review the potential mechanisms of oxygen toxicity after CA, animal data available in this field, and key human studies dealing with the impact of oxygen management in CA patients, highlighting some potential confounders and limitations and indicating future areas of research in this field. From the currently available literature, high oxygen concentrations during cardiopulmonary resuscitation seem preferable, whereas hyperoxemia should be avoided in the post-CA care. A specific threshold for oxygen toxicity has not yet been identified. The mechanisms of oxygen toxicity after CA, such as seizure development, reactive oxygen species production, and the development of organ dysfunction, need to be further evaluated in prospective studies.
Collapse
Affiliation(s)
- Antonio Maria Dell'Anna
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Belgium, Route de Lennik 808, 1070, Brussels, Belgium.
| | - Irene Lamanna
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Belgium, Route de Lennik 808, 1070, Brussels, Belgium.
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Belgium, Route de Lennik 808, 1070, Brussels, Belgium.
| | - Fabicpro Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Belgium, Route de Lennik 808, 1070, Brussels, Belgium.
| |
Collapse
|
33
|
Lundbye J, Adams MP, Sawyer K, Klein D. Targeted temperature management in nursing care. Ther Hypothermia Temp Manag 2014; 4:111-4. [PMID: 25090371 DOI: 10.1089/ther.2014.1511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Justin Lundbye
- 1 Hospital of Central Connecticut , New Britain, Connecticut
| | | | | | | |
Collapse
|
34
|
|
35
|
Dietrich MWD, Le May PM, Lundbye JB, Adams MP. Therapeutic Hypothermia in Post Cardiac Arrest. Ther Hypothermia Temp Manag 2013; 3:161-5. [DOI: 10.1089/ther.2013.1515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | - Justin B. Lundbye
- Department of Cardiology, The Hospital of Central Connecticut, New Britain, Connecticut
| | - Mark Preston Adams
- Coronary Care Unit, University of Virginia Health System, Charlottesville, Virginia
| |
Collapse
|