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Lin V, Tian C, Wahlster S, Castillo-Pinto C, Mainali S, Johnson NJ. Temperature Control in Acute Brain Injury: An Update. Semin Neurol 2024; 44:308-323. [PMID: 38593854 DOI: 10.1055/s-0044-1785647] [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: 04/11/2024]
Abstract
Temperature control in severe acute brain injury (SABI) is a key component of acute management. This manuscript delves into the complex role of temperature management in SABI, encompassing conditions like traumatic brain injury (TBI), acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), aneurysmal subarachnoid hemorrhage (aSAH), and hypoxemic/ischemic brain injury following cardiac arrest. Fever is a common complication in SABI and is linked to worse neurological outcomes due to increased inflammatory responses and intracranial pressure (ICP). Temperature management, particularly hypothermic temperature control (HTC), appears to mitigate these adverse effects primarily by reducing cerebral metabolic demand and dampening inflammatory pathways. However, the effectiveness of HTC varies across different SABI conditions. In the context of post-cardiac arrest, the impact of HTC on neurological outcomes has shown inconsistent results. In cases of TBI, HTC seems promising for reducing ICP, but its influence on long-term outcomes remains uncertain. For AIS, clinical trials have yet to conclusively demonstrate the benefits of HTC, despite encouraging preclinical evidence. This variability in efficacy is also observed in ICH, aSAH, bacterial meningitis, and status epilepticus. In pediatric and neonatal populations, while HTC shows significant benefits in hypoxic-ischemic encephalopathy, its effectiveness in other brain injuries is mixed. Although the theoretical basis for employing temperature control, especially HTC, is strong, the clinical outcomes differ among various SABI subtypes. The current consensus indicates that fever prevention is beneficial across the board, but the application and effectiveness of HTC are more nuanced, underscoring the need for further research to establish optimal temperature management strategies. Here we provide an overview of the clinical evidence surrounding the use of temperature control in various types of SABI.
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Affiliation(s)
- Victor Lin
- Department of Neurology, University of Washington, Seattle, Washington
| | - Cindy Tian
- Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Sarah Wahlster
- Department of Neurology, University of Washington, Seattle, Washington
- Department of Neurosurgery, University of Washington, Seattle, Washington
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | | | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
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2
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Ochiai K, Otomo Y. Factors influencing deviation from target temperature during targeted temperature management in postcardiac arrest patients. Open Heart 2023; 10:e002459. [PMID: 38101858 PMCID: PMC10729178 DOI: 10.1136/openhrt-2023-002459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 11/09/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Targeted temperature management (TTM) is a recommended therapy for postcardiac arrest patients. Hyperthermia worsened the patient outcome, and overcooling increased the incidence of complications; therefore, a high-quality TTM is required. The target temperature tended to be modified worldwide after the TTM trial in 2013. Our institute modified the target temperature to 35°C in 2017. This study aimed to compare the conventional and modified protocols, assess the relationship between target temperature deviation and patient outcomes, and identify the factors influencing temperature deviation. METHODS This single-centre, retrospective, observational study included adult out-of-hospital cardiac arrest patients who underwent TTM between April 2013 and October 2019. We compared the conventional and modified protocol groups to evaluate the difference in the background characteristics and details on TTM. Subsequently, we assessed the relationship of deviation (>±0.5°C, >37°C, or<33°C) rates from the target temperature with mortality and neurological outcomes. We assessed the factors that influenced the deviation from the target temperature. RESULTS Temperature deviation was frequently observed in the conventional protocol group (p=0.012), and the modified protocol group required higher doses of neuromuscular blocking agents (NMBAs) during TTM (p=0.016). Other background data, completion of protocol, incidence of complications, mortality and rate of favourable neurological outcomes were not significantly different. The performance rate of TTM was significantly higher in the modified group than in the conventional protocol group (p<0.001). Temperature deviation did not have an impact on the outcomes. Age, sex, body surface area, NMBA doses and type of cooling device were the factors influencing temperature deviation. CONCLUSIONS A target temperature of 35°C might be acceptable and easily attainable if shivering of the patients was well controlled using NMBAs. Temperature deviation did not have an impact on outcomes. The identified factors influencing deviation from target temperature might be useful for ensuring a high-quality TTM.
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Affiliation(s)
- Kanae Ochiai
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital, Bunkyo-ku, Tokyo, Japan
- Department of Emergency and Critical Care Medicine, Tokyo Women's Medical University Yachiyo Medical Center, Yachiyo, Chiba, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital, Bunkyo-ku, Tokyo, Japan
- National Disaster Medical Center, Tachikawa, Tokyo, Japan
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3
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Sajid B, Tufail Z, Asim M, Riaz S, Imtiaz S, Khan H, Shabbir MA, Shah SMB, Ejaz F, Anis MW, Khan A, Ahmed A, Rana M, Sohail F, Anjum MU, Larik MO. Comparison of Clopidogrel Versus Ticagrelor for Percutaneous Coronary Intervention (PCI) Patients Managed with Therapeutic Hypothermia: A Systematic Review and Meta-Analysis. Ther Hypothermia Temp Manag 2023. [PMID: 37870599 DOI: 10.1089/ther.2023.0055] [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: 10/24/2023] Open
Abstract
Various antiplatelet drugs, such as clopidogrel and ticagrelor, are available on the market for use after percutaneous coronary intervention (PCI). However, the efficacy of such drugs in patients being managed with therapeutic hypothermia (TH) has always been debated. In light of this controversy, this systematic review and meta-analysis was performed to enhance existing literature. Various databases were searched for potentially relevant studies from inception to April 2023, including PubMed, Cochrane Library, and Scopus. The risk of bias was assessed using the Newcastle-Ottawa scale for cohort studies and the Cochrane risk of bias tool for randomized controlled trials. Outcomes of interest included risk of bleeding, stent thrombosis, and all-cause mortality. Five studies were shortlisted for inclusion into the meta-analysis, featuring a total of 245 patients receiving either clopidogrel or ticagrelor. Overall, no significant differences were noted when the use of clopidogrel and ticagrelor was compared in PCI patients being managed with TH. To the best of our knowledge, this is the most comprehensive meta-analysis comparing the outcomes of clopidogrel and ticagrelor in PCI patients being managed with TH. Despite existing studies claiming an altered efficacy of clopidogrel in such conditions, our meta-analytic findings could not prove this relationship. Due to the limited sample size, further comprehensive and randomized studies are encouraged to arrive at a robust conclusion.
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Affiliation(s)
| | | | - Maria Asim
- Fazaia Ruth Pfau Medical College, Karachi, Pakistan
| | - Sania Riaz
- Allama Iqbal Medical College, Lahore, Pakistan
| | | | | | | | | | - Fariha Ejaz
- Karachi Medical and Dental College, Karachi, Pakistan
| | | | - Arais Khan
- Islamabad Medical and Dental College, Islamabad, Pakistan
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Itenov TS, Kromann ME, Ostrowski SR, Bestle MH, Mohr T, Gyldensted L, Lindhardt A, Thormar K, Sessler DI, Juffermans NP, Lundgren JD, Jensen JU. Mild induced hypothermia and coagulation and platelet function in patients with septic shock: Secondary outcome of a randomized trial. Acta Anaesthesiol Scand 2023. [PMID: 37129236 DOI: 10.1111/aas.14254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 04/05/2023] [Accepted: 04/12/2023] [Indexed: 05/03/2023]
Abstract
Coagulation abnormalities and microthrombi contribute to septic shock, but the impact of body temperature regulation on coagulation in patients with sepsis is unknown. We tested the hypothesis that mild induced hypothermia reduces coagulation and platelet aggregation in patients with septic shock. Secondary analysis of randomized controlled trial. Adult patients with septic shock who required mechanical ventilation from eight intensive care units in Denmark were randomly assigned to mild induced hypothermia for 24 h or routine thermal management. Viscoelastography and platelet aggregation were assessed at trial inclusion, after 12 h of thermal management, and 24 h after inclusion. A total of 326 patients were randomized to mild induced hypothermia (n = 163) or routine thermal management (n = 163). Mild induced hypothermia slightly prolonged activated partial thromboplastin time and thrombus initiation time (R time 8.0 min [interquartile range, IQR 6.6-11.1] vs. 7.2 min [IQR 5.8-9.2]; p = .004) and marginally inhibited thrombus propagation (angle 68° [IQR 59-73] vs. 71° [IQR 63-75]; p = .014). The effect was also present after 24 h. Clot strength remained unaffected (MA 71 mm [IQR 66-76] with mild induced hypothermia vs. 72 mm (65-77) with routine thermal management, p = .9). The proportion of patients with hyperfibrinolysis was not affected (0.7% vs. 3.3%; p = .19), but the proportion of patients with no fibrinolysis was high in the mild hypothermia group (8.8% vs. 40.4%; p < .001). The mild induced hypothermia group had lower platelet aggregation: ASPI 85U (IQR 50-113) versus 109U (IQR 74-148, p < .001), ADP 61U (IQR 40-83) versus 79 U (IQR 54-101, p < .001), TRAP 108 (IQR 83-154) versus 119 (IQR 94-146, p = .042) and COL 50U (IQR 34-66) versus 67U (IQR 46-92, p < .001). In patients with septic shock, mild induced hypothermia slightly impaired clot initiation, but did not change clot strength. Platelet aggregation was slightly impaired. The effect of mild induced hypothermia on viscoelastography and platelet aggregation was however not in a range that would have clinical implications. We did observe a substantial reduction in fibrinolysis.
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Affiliation(s)
- Theis S Itenov
- CHIP/PERSIMUNE, Department of infectious diseases, Rigshospitalet, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Anesthesiology, Copenhagen University Hospital - Bispebjerg, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health sciences, University of Copenhagen, Copenhagen, Denmark
| | - Maria E Kromann
- CHIP/PERSIMUNE, Department of infectious diseases, Rigshospitalet, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Sisse R Ostrowski
- Department of Clinical Medicine, Faculty of Health sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Immunology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Morten H Bestle
- Department of Clinical Medicine, Faculty of Health sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital - North Zealand, Copenhagen, Denmark
| | - Thomas Mohr
- Department of Anesthesiology, Copenhagen University Hospital - Herlev-Gentofte, Copenhagen, Denmark
| | - Louise Gyldensted
- Department of Anesthesiology, Copenhagen University Hospital - Herlev-Gentofte, Copenhagen, Denmark
| | - Anne Lindhardt
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital - North Zealand, Copenhagen, Denmark
| | - Katrin Thormar
- Department of Anesthesiology, Copenhagen University Hospital - Bispebjerg, Copenhagen, Denmark
| | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nicole P Juffermans
- Department of Intensive Care, OLVG Hospital, Amsterdam, the Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Jens D Lundgren
- CHIP/PERSIMUNE, Department of infectious diseases, Rigshospitalet, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens-Ulrik Jensen
- CHIP/PERSIMUNE, Department of infectious diseases, Rigshospitalet, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health sciences, University of Copenhagen, Copenhagen, Denmark
- Respiratory Section, Department of Internal Medicine, Copenhagen University Hospital - Gentofte, Copenhagen, Denmark
- Outcomes Research Consortium, Cleveland, Ohio, USA
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Fernandez Hernandez S, Barlow B, Pertsovskaya V, Maciel CB. Temperature Control After Cardiac Arrest: A Narrative Review. Adv Ther 2023; 40:2097-2115. [PMID: 36964887 PMCID: PMC10129937 DOI: 10.1007/s12325-023-02494-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 03/08/2023] [Indexed: 03/26/2023]
Abstract
Cardiac arrest (CA) is a critical public health issue affecting more than half a million Americans annually. The main determinant of outcome post-CA is hypoxic-ischemic brain injury (HIBI), and temperature control is currently the only evidence-based, guideline-recommended intervention targeting secondary brain injury. Temperature control is a key component of a post-CA care bundle; however, conflicting evidence challenges its wide implementation across the vastly heterogeneous population of CA survivors. Here, we critically appraise the available literature on temperature control in HIBI, detail how the evidence has been integrated into clinical practice, and highlight the complications associated with its use and the timing of neuroprognostication after CA. Future clinical trials evaluating different temperature targets, rates of rewarming, duration of cooling, and identifying which patient phenotype benefits from different temperature control methods are needed to address these prevailing knowledge gaps.
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Affiliation(s)
| | - Brooke Barlow
- Department of Pharmacy, Memorial Hermann the Woodlands Medical Center, The Woodlands, TX, USA
| | - Vera Pertsovskaya
- The George Washington University School of Medicine and Health Sciences, Washington, DC, 20037, USA
| | - Carolina B Maciel
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, 32611, USA
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, 32611, USA
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Department of Neurology, University of Utah, Salt Lake City, UT, 84132, USA
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6
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Mizugaki A, Wada T, Tsuchida T, Gando S. Association of Histones With Coagulofibrinolytic Responses and Organ Dysfunction in Adult Post-cardiac Arrest Syndrome. Front Cardiovasc Med 2022; 9:885406. [PMID: 35837604 PMCID: PMC9273886 DOI: 10.3389/fcvm.2022.885406] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 06/03/2022] [Indexed: 11/23/2022] Open
Abstract
Background Patients successfully resuscitated from cardiac arrest often develop organ dysfunction caused by systemic inflammation and increased coagulation, leading to disseminated intravascular coagulation (DIC). The involvement of histones in DIC and organ dysfunction in patients with sepsis and trauma has been previously reported, raising the probability that histones may also be associated with pathophysiology in patients after cardiac arrest and resuscitation. This study evaluated the relationship between histones and organ dysfunction related to coagulofibrinolytic changes in patients with post-cardiac arrest syndrome (PCAS). Methods This prospective single-center observational study assessed 35 adult patients with PCAS who were divided into two groups, i.e., 15 patients with multiple organ dysfunction syndrome (MODS) and 20 patients without MODS. MODS was defined as a sequential organ failure assessment score of ≥12. The plasma levels of histones and coagulofibrinolytic markers, including soluble fibrin, tissue-type plasminogen activator, plasminogen activator inhibitor-1, plasmin-alpha 2-plasmin inhibitor complex (PIC), and soluble thrombomodulin, were measured in patients with PCAS immediately after admission to the emergency department, and 3 and 24 h after arriving at the hospital. Results PCAS patients with MODS had higher DIC scores [4 (3.0–5.0) vs. 1 (0.0–3.0), p = 0.012] and higher mortality rates (66.7% vs. 20.0%, p = 0.013) than those without MODS. Moreover, patients with MODS exhibited higher histone levels than those without MODS during the early phase of the post-resuscitation period. Severe endothelial injury and higher thrombin and plasmin generation were observed in the MODS group. Plasma levels of histones were positively correlated with those of soluble fibrin immediately after resuscitation (rho = 0.367, p = 0.030) and PIC 3 h after arriving at the hospital (rho = 0.480, p = 0.005). This correlation was prominent in the patient population with MODS (soluble fibrin: rho = 0.681, p = 0.005, PIC: rho = 0.742, p = 0.002). Conclusions This study demonstrated that elevated histone levels were associated with increased levels of thrombin, and subsequent plasmin generation in PCAS patients, especially those with MODS. Further studies are required to elucidate the causal relationship between histones and organ dysfunction related to DIC in PCAS.
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Affiliation(s)
- Asumi Mizugaki
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
- *Correspondence: Takeshi Wada
| | - Takumi Tsuchida
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
- Department of Acute and Critical Care Center, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
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7
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Scherz T, Hofbauer TM, Ondracek AS, Simon D, Sterz F, Testori C, Lang IM, Mangold A. Mild Therapeutic Hypothermia Alters Hemostasis in ST Elevation Myocardial Infarction Patients. Front Cardiovasc Med 2021; 8:707367. [PMID: 34295929 PMCID: PMC8290912 DOI: 10.3389/fcvm.2021.707367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 06/15/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Rationale: Mild therapeutic hypothermia (MTH) is a concept to reduce infarct size and improve outcome after ST-segment elevation myocardial infarction (STEMI). In the STATIM trial, we investigated MTH as an additional therapy for STEMI patients. In the intention-to-treat set, 101 patients were included. No difference in primary and secondary endpoints measured by cardiac magnetic resonance imaging was found. Platelet activation and plasmatic coagulation are key in the pathophysiology of STEMI. In the present study, we investigated the effect of MTH on primary and secondary hemostasis in STEMI patients. Methods and Results: Platelet function and morphology were assessed by routine blood count, aggregometry testing, and flow cytometry. Soluble platelet markers were determined by enzyme-linked immunosorbent assay (ELISA) testing. Plasmatic coagulation was measured throughout the study. Platelet count remained unchanged, irrespective of treatment, whereas platelet size decreased in both patient groups. Platelet aggregometry indicated increased platelet reactivity in the MTH group. Furthermore, higher adenosine diphosphate (ADP) plasma levels were found in MTH patients. Expression of glycoprotein IIb/IIIa was increased on platelets of STEMI patients treated with MTH. Lower patient temperatures correlated with longer clotting times and resulted in reduced pH. Lower pH values were positively correlated with longer clotting times. Conclusion: Present data indicate longer clotting times and higher platelet reactivity in STEMI patients treated with MTH. These changes did not correspond to clinical bleeding events or larger infarct size.
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Affiliation(s)
- Thomas Scherz
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University of Vienna, Vienna, Austria.,Department of Dermatology, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
| | - Thomas M Hofbauer
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Anna S Ondracek
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Daniel Simon
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University of Vienna, Vienna, Austria.,Department of Internal Medicine I, Cardiology, Klinikum Bamberg, Bamberg, Germany
| | - Fritz Sterz
- Department of Emergency Medicine, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Christoph Testori
- Department of Emergency Medicine, Vienna General Hospital, Medical University of Vienna, Vienna, Austria.,Department of Internal Medicine, Cardiology and Nephrology, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
| | - Irene M Lang
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Andreas Mangold
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
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8
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Kosmopoulos M, Bartos JA, Yannopoulos D. ST-Elevation Myocardial Infarction Complicated by Out-of-Hospital Cardiac Arrest. Interv Cardiol Clin 2021; 10:359-368. [PMID: 34053622 DOI: 10.1016/j.iccl.2021.03.007] [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: 11/26/2022]
Abstract
5-10% of ST-elevated myocardial infarctions (STEMI) present with out-of-hospital cardiac arrest (OHCA). Although this subgroup of patients carries the highest in-hospital mortality among the STEMI population, it is the least likely to undergo coronary angiography and revascularization. Due to the concomitant neurologic injury, patients with OHCA STEMI require prolonged hospitalization and adjustments to standard MI management. This review systematically assesses the course of patients with OHCA STEMI from development of the arrest to hospital discharge, assesses the limiting factors for their treatment access, and presents the evidence-based optimal intervention strategy for this high-risk MI population.
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Affiliation(s)
- Marinos Kosmopoulos
- Cardiovascular Division, Center for Resuscitation Medicine, University of Minnesota Medical School, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN 55455, USA
| | - Jason A Bartos
- Cardiovascular Division, Center for Resuscitation Medicine, University of Minnesota Medical School, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN 55455, USA
| | - Demetris Yannopoulos
- Cardiovascular Division, Center for Resuscitation Medicine, University of Minnesota Medical School, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN 55455, USA.
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Gaisendrees C, Vollmer M, Walter SG, Djordjevic I, Eghbalzadeh K, Kaya S, Elderia A, Ivanov B, Gerfer S, Kuhn E, Sabashnikov A, Kahlert HA, Deppe AC, Kröner A, Mader N, Wahlers T. Management of out-of hospital cardiac arrest patients with extracorporeal cardiopulmonary resuscitation in 2021. Expert Rev Med Devices 2021; 18:179-188. [PMID: 33538204 DOI: 10.1080/17434440.2021.1886076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Over the last decade, eCPR programs have become more and more popular, at least amongst high-volume centers. Despite its rise in popularity and promising outcome, strategies concerning pre- and post-implantation of VA-ECMO remain at least debatable. Besides, integrating the appropriate set-up, managing anticoagulation, implementing LV-venting, and predicting neurological outcome play important roles in caring for thise highly selective patient-collective. We sought to present our institutional´s techniques for establishing an eCPR program and managing patients peri- and post implantation in eCPR-runs. AREAS COVERED This manuscript covers the majority of clinical concerns and parameters for establishing an eCPR program and its recent advantages. We will describe a safe way of cannulation, setting anticoagulation goals, strategies for LV-venting and ICU-treatment. Also included, an elaboration on neurological and cardiac prognostication. EXPERT OPINION We advocate ultrasound-guided cannula placement in eCPR patients. Also, we emphasize the importance of using stiffer wires and smaller arterial cannula sizes due to the different physiological parameters of OHCA patients. After cannulation, we aim for lower flow goals, the concept of 'partial VA-ECMO,' and lower anticoagulatory targets. LV-venting with Impella should remain an individual case to case decision.
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Affiliation(s)
- Christopher Gaisendrees
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Matias Vollmer
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Sebastian G Walter
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Süreyya Kaya
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Ahmed Elderia
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Borko Ivanov
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Stephen Gerfer
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Elmar Kuhn
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Heike A Kahlert
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Antje C Deppe
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Axel Kröner
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Navid Mader
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University Hospital of Cologne, the City is Cologne (Köln), Germany
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10
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Mullen I, Abella BS. Practical considerations for postarrest targeted temperature management. Turk J Emerg Med 2020; 20:157-162. [PMID: 33089022 PMCID: PMC7549514 DOI: 10.4103/2452-2473.297466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 06/21/2020] [Indexed: 11/04/2022] Open
Abstract
Out-of-hospital cardiac arrest remains a major challenge worldwide, with survival to discharge rates of <20% in the great majority of countries. Advancements in prehospital care, including increasing deployment of automated external defibrillators and improvements in bystander cardiopulmonary resuscitation, have led to more victims achieving return of spontaneous circulation (ROSC), yet the majority of patients with ROSC suffer in-hospital mortality or significant neurologic injuries that persist after discharge. This postarrest morbidity and mortality is largely due to a complex syndrome of mitochondrial dysfunction, inflammatory cascades and cellular injuries known as the postcardiac arrest syndrome (PCAS). The management of PCAS represents a formidable task for emergency and critical care providers. A cornerstone of PCAS treatment is the use of aggressive core body temperature control using thermostatically controlled devices, known as targeted temperature management (TTM). This therapy, demonstrated to be effective in improving both survival and neurologic recovery by several randomized controlled trials nearly 20 years ago, remains a major topic of clinical investigation. Important practical questions about TTM remain: How soon must providers initiate the therapy? What TTM goal temperature maximizes benefit while limiting potential adverse effects? How long should TTM therapy be continued in patients following resuscitation? In this review, we will address these issues and summarize clinical research over the past decade that has added to our fund of knowledge surrounding this important treatment of patients following cardiac arrest.
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Affiliation(s)
- Isabelle Mullen
- Department of Emergency Medicine, The Center for Resuscitation Science, School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin S Abella
- Department of Emergency Medicine, The Center for Resuscitation Science, School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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11
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Lund University Cardiac Assist System Induced Liver Laceration and Anterior Cord Infarction After Cardiac Arrest: A Case Report. A A Pract 2020; 14:79-82. [PMID: 31842196 DOI: 10.1213/xaa.0000000000001153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We describe a hepatic laceration and subsequent anterior spinal artery syndrome in a 21-year-old man, secondary to prolonged cardiopulmonary resuscitation with a Lund University Cardiac Assist System (LUCAS2) mechanical cardiac compression device. We briefly review the current literature pertaining to hepatic injury from trauma due to cardiopulmonary resuscitation. The etiology of the anterior spinal artery syndrome in this patient is discussed. This case highlights that intra-abdominal causes of hypotension should be considered in patients after a prolonged resuscitation attempt. Extending focused cardiac ultrasound to exclude intra-abdominal free fluid should be routinely considered in these patients.
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Quine EJ, Murray L, Trapani T, Cooper DJ. Thromboelastography to Assess Coagulopathy in Traumatic Brain Injury Patients Undergoing Therapeutic Hypothermia. Ther Hypothermia Temp Manag 2020; 11:53-57. [PMID: 32833584 DOI: 10.1089/ther.2020.0025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Therapeutic hypothermia has been a treatment option for patients with severe traumatic brain injury (TBI) for many years. There has, however, been uncertainty whether hypothermia in this context also increased clinical bleeding risk, perhaps due to platelet dysfunction. Standard coagulation tests do not allow accurate assessment of in vivo coagulation. We studied specific coagulation abnormalities in patients undergoing therapeutic hypothermia for severe TBI using bedside thromboelastography (TEG).We studied 20 patients with severe blunt TBI from a single tertiary ICU who were enrolled in the prophylactic hypothermia to lessen traumatic brain injury (POLAR) trial. Ten patients had been randomized to hypothermia, and 10 were controls receiving normothermic standard care. TEG was undertaken during and after therapeutic hypothermia, and at the same time points in controls. Coagulation profiles were then compared between the hypothermic and control patients, and also between hypothermia and later normothermia in the study patients. Patients were primarily young (mean age 34 years) and male (85%). Measures of injury severity, including Glasgow coma score and injury severity scale, were not different between groups. Using TEG, the median alpha angle was reduced in hypothermic patients compared with controls (69.2° vs. 72.0°, p = 0.02), although both were within the normal range. LY30 was also reduced (0.0% vs. 0.5%, p < 0.01). Both differences persisted when hypothermic patients were compared with themselves during later normothermia. Therapeutic hypothermia during severe TBI causes a small decrease in the rate of clot formation. However, this decrease is within the normal range, and is unlikely to be clinically significant.
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Affiliation(s)
- Edward J Quine
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Lynnette Murray
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Tony Trapani
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia.,Department of Intensive Care, Alfred Health, Melbourne, Australia
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Yu G, Kim YJ, Kim JS, Kim SI, Ryoo SM, Ahn S, Kim WY. Prognostic value of repeated thromboelastography measurement for favorable neurologic outcome during targeted temperature management in out-of-hospital cardiac arrest survivors. Resuscitation 2020; 155:65-73. [PMID: 32755664 DOI: 10.1016/j.resuscitation.2020.07.019] [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: 03/12/2020] [Revised: 05/31/2020] [Accepted: 07/14/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cardiac arrest can activate blood coagulation, which clinically manifests as obstruction of the microcirculation and multiple organ dysfunction. Thromboelastography (TEG) provides a rapid and comprehensive assessment of hemostatic processes, but there are limited data on the use of sequential TEG values during targeted temperature management (TTM) in out-of-hospital cardiac arrest (OHCA) survivors. The aim of this study was to investigate the prognostic value of coagulopathy assessed by repeated TEG to predict neurologically intact survival. METHODS A prospective cohort of consecutive non-trauma OHCA patients who were successfully resuscitated and treated with TTM. Patients with a target temperature of 36 ℃, no TEG data, and who declined appropriate treatment were excluded. TEG was measured at three time points of TTM (initial phase, target phase, and rewarming phase). The primary outcome was 28 day favorable neurologic function, defined as a Cerebral Performance Category of 1 or 2. RESULTS A total of 125 patients (mean age, 61 years; 63.2% male) were analyzed. A favorable neurologic outcome at 28 days was seen in 40 patients (32.0%). TEG values of R and LY30 in the initial phase were significantly lower in the favorable neurologic outcome group than in the unfavorable group (5.8 vs. 8.1 and 0.1 vs. 0.7, respectively; p < 0.01). TEG values of R < 5 or LY30 < 7.5 in the initial phase were more frequently seen in the favorable outcomes group than in the unfavorable group (37.5% vs. 12.9%, p = 0.002 and 95.0% vs. 72.9%, p = 0.004, respectively). However, no significant differences were seen between the two groups in other TEG values (R, K, alpha, and MA) in the target and rewarming phases (p > 0.05 for all). Univariate analysis showed higher D-dimer levels, prothrombin time, and activated partial thromboplastin time in the unfavorable outcome group. In the multivariable analysis, TEG values of combination of R < 5 and LY30 < 7.5 in the initial phase were the only coagulation profiles seen to be independently associated with favorable neurologic outcome (OR, 4.508, 95% CI, 1.254-16.210). CONCLUSION TEG results are available within minutes, and shorted R values or the absence of prolonged LY30 values in the initial phase are an early predictor of neurologically intact survival in successfully resuscitated OHCA patients.
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Affiliation(s)
- Gina Yu
- Department of Emergency Medicine, University of Yonsei College of Medicine, Seoul, Republic of Korea
| | - Youn-Jung Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - June-Sung Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Sang-Il Kim
- Department of Emergency Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Seung Mok Ryoo
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Shin Ahn
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Won Young Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea.
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Abstract
It must be remembered that clinically important haemostasis occurs in vivo and not in a tube, and that variables such as the number of bleeding events and bleeding volume are more robust measures of bleeding risk than the results of analyses. In this narrative review, we highlight trauma, surgery, and mild induced hypothermia as three clinically important situations in which the effects of hypothermia on haemostasis are important. In observational studies of trauma, hypothermia (body temperature <35°C) has demonstrated an association with mortality and morbidity, perhaps owing to its effect on haemostatic functions. Randomised trials have shown that hypothermia causes increased bleeding during surgery. Although causality between hypothermia and bleeding risk has not been well established, there is a clear association between hypothermia and negative outcomes in connection with trauma, surgery, and accidental hypothermia; thus, it is crucial to rewarm patients in these clinical situations without delay. Mild induced hypothermia to ≥33°C for 24 hours does not seem to be associated with either decreased total haemostasis or increased bleeding risk.
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Affiliation(s)
- Thomas Kander
- Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Intensive and Perioperative Care, Lund, Sweden
| | - Ulf Schött
- Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Intensive and Perioperative Care, Lund, Sweden
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Postresuscitation Care after Out-of-hospital Cardiac Arrest: Clinical Update and Focus on Targeted Temperature Management. Anesthesiology 2020; 131:186-208. [PMID: 31021845 DOI: 10.1097/aln.0000000000002700] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Out-of-hospital cardiac arrest is a major cause of mortality and morbidity worldwide. With the introduction of targeted temperature management more than a decade ago, postresuscitation care has attracted increased attention. In the present review, we discuss best practice hospital management of unconscious out-of-hospital cardiac arrest patients with a special focus on targeted temperature management. What is termed post-cardiac arrest syndrome strikes all organs and mandates access to specialized intensive care. All patients need a secured airway, and most patients need hemodynamic support with fluids and/or vasopressors. Furthermore, immediate coronary angiography and percutaneous coronary intervention, when indicated, has become an essential part of the postresuscitation treatment. Targeted temperature management with controlled sedation and mechanical ventilation is the most important neuroprotective strategy to take. Targeted temperature management should be initiated as quickly as possible, and according to international guidelines, it should be maintained at 32° to 36°C for at least 24 h, whereas rewarming should not increase more than 0.5°C per hour. However, uncertainty remains regarding targeted temperature management components, warranting further research into the optimal cooling rate, target temperature, duration of cooling, and the rewarming rate. Moreover, targeted temperature management is linked to some adverse effects. The risk of infection and bleeding is moderately increased, as is the risk of hypokalemia and magnesemia. Circulation needs to be monitored invasively and any deviances corrected in a timely fashion. Outcome prediction in the individual patient is challenging, and a self-fulfilling prophecy poses a real threat to early prognostication based on clinical assessment alone. Therefore, delayed and multimodal prognostication is now considered a key element of postresuscitation care. Finally, modern postresuscitation care can produce good outcomes in the majority of patients but requires major diagnostic and therapeutic resources and specific training. Hence, recent international guidelines strongly recommend the implementation of regional prehospital resuscitation systems with integrated and specialized cardiac arrest centers.
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Picard F, Llitjos JF, Diefenbronn M, Laghlam D, Seret G, Sokoloff A, Cariou A, Dumas F, Varenne O. The balance of thrombosis and hemorrhage in STEMI patients with or without associated cardiac arrest: An observational study. Resuscitation 2019; 145:83-90. [DOI: 10.1016/j.resuscitation.2019.10.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 09/25/2019] [Accepted: 10/23/2019] [Indexed: 01/21/2023]
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17
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Rolfes C, Muellenbach RM, Lepper PM, Spangenberg T, Swol J, Lorusso R, Weber K, Foerstner S, Lotz C, Belohlavek J. Targeted temperature management in patients undergoing extracorporeal life support after out-of-hospital cardiac arrest: an EURO-ELSO 2018 annual conference survey. Perfusion 2019; 34:714-716. [PMID: 31146629 DOI: 10.1177/0267659119847033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Targeted temperature management and extracorporeal life support, particularly extracorporeal membrane oxygenation in patients undergoing cardiopulmonary resuscitation, represent outcome-enhancing strategies for patients following in- and out-of-hospital cardiac arrest. Although targeted temperature management with hypothermia between 32°C and 34°C and extracorporeal cardiopulmonary resuscitation bear separate potentials to improve outcome after out-of-hospital cardiac arrest, each is associated with bleeding risk and risk of infection. Whether the combination imposes excessive risk on patients is, however, unknown.
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Affiliation(s)
- Caroline Rolfes
- Department of Critical Care, Emergency Medicine and Anaesthesia, ECMO-Centre, Klinikum Kassel, Kassel, Germany
| | - Ralf M Muellenbach
- Department of Critical Care and Anaesthesia, ECMO-Centre, Klinikum Kassel, Kassel, Germany
| | - Philipp M Lepper
- Department of Internal Medicine V - Pneumology, Allergology and Critical Care Medicine, Saarland University Medical Center, Homburg, Germany
| | - Tobias Spangenberg
- Hanseatic Cardiac Arrest Center, Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Justyna Swol
- Department of Pulmonology, Intensive Care Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Roberto Lorusso
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Klaus Weber
- Department of Emergency Medicine, Klinikum Kassel, Kassel, Germany
| | - Sarina Foerstner
- Department of Critical Care and Anaesthesia, ECMO-Centre, Klinikum Kassel, Kassel, Germany
| | - Christopher Lotz
- Department of Anaesthesia and Critical Care, University of Würzburg, Würzburg, Germany
| | - Jan Belohlavek
- Department of Cardiovascular Medicine, 2nd Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
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Kim HJ, Park KN, Kim SH, Lee BK, Oh SH, Jeung KW, Cho IS, Youn CS. Time course of platelet counts in relation to the neurologic outcome in patients undergoing targeted temperature management after cardiac arrest. Resuscitation 2019; 140:113-119. [PMID: 31132395 DOI: 10.1016/j.resuscitation.2019.05.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/27/2019] [Accepted: 05/16/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Thrombocytopenia is common and associated with mortality in critically ill patients. However, the time course of platelet counts and its association with the neurologic outcome after out-of-hospital cardiac arrest (OHCA) are not well known. The purpose of this study is to describe the time course of platelet counts in relation to the neurologic outcome in patients undergoing targeted temperature management (TTM) after CA. METHODS Review of consecutive patients receiving TTM after out-of-hospital CA between 2009 and 2016. The blood sample was collected daily until 7 days. The primary outcome was poor neurologic outcome at 6 months after CA defined as Cerebral Performance Category of 3-5 and secondary outcome was mortality at 6 months. RESULTS A total of 261 consecutive patients treated with TTM after OHCA between 2009 and 2016. One hundred seventy-five patients (67.0%) had poor neurologic outcomes 6 months after CA. The changes in the platelet counts over time between the good and poor outcome groups were statistically significant (p < 0.001). The platelet counts declined during TTM in both groups. The platelet counts recovered to the normal range at the end of the first week in the good neurologic outcome group. However, the platelet counts remained low in the poor outcome group. Low platelet counts on the 7th day were associated with poor neurologic outcomes (aOR 0.975, 95% CI, 0.961-0.989) and mortality at 6 months (aOR 0.986, 95% CI, 0.975-0.997) after adjusting for covariates. CONCLUSION The changes in platelet counts in OHCA patients have a biphasic pattern that is significantly different in patients with good neurologic outcomes and those with poor neurologic outcomes at 6 months. A low platelet count 7 days after CA was associated with a poor neurologic outcome and mortality at 6 months.
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Affiliation(s)
- Hyo Joon Kim
- Department of Emergency Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul 137-701, South Korea
| | - Kyu Nam Park
- Department of Emergency Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul 137-701, South Korea
| | - Soo Hyun Kim
- Department of Emergency Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul 137-701, South Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, South Korea
| | - Sang Hoon Oh
- Department of Emergency Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul 137-701, South Korea
| | - Kyung Woon Jeung
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, South Korea
| | - In Soo Cho
- Department of Emergency Medicine, Hanil General Hospital, Korea Electric Power Medical Corporation, Seoul, South Korea
| | - Chun Song Youn
- Department of Emergency Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul 137-701, South Korea.
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Kander T, Ullén S, Dankiewicz J, Wise MP, Schött U, Rundgren M. Bleeding Complications After Cardiac Arrest and Targeted Temperature Management, a Post Hoc Study of the Targeted Temperature Management Trial. Ther Hypothermia Temp Manag 2018; 9:177-183. [PMID: 30523732 DOI: 10.1089/ther.2018.0024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Target Temperature Management (TTM) is standard care following out of hospital cardiac arrest (OHCA). The aim of the study was to evaluate if treatment temperature (33°C or 36°C) or other predefined variables were associated with the occurrence of bleeding in the TTM study. This study is a predefined, post hoc analysis of the TTM trial, a multinational randomized controlled trial comparing treatment at 33°C and 36°C for 24 hours after OHCA with return of spontaneous circulation. Bleeding events from several locations were registered daily. The main outcome measure was occurrence of any bleeding during the first 3 days of intensive care. Risk factors for bleeding, including temperature allocation, were evaluated. Complete data were available for 722/939 patients. Temperature allocation was not associated with bleeding either in the univariable (p = 0.95) or in the primary multivariable analysis (odds ratio [OR] 0.95; 95% confidence interval [CI] 0.64-1.41, p = 0.80). A multiple imputation model, including all patients, was used as a sensitivity analysis, rendering similar results (OR 0.98; 95% CI 0.69-1.38, p = 0.92). Factors associated with bleeding were increasing age, female sex, and angiography with percutaneous coronary intervention (PCI) within 36 hours of cardiac arrest (CA) in both the primary and the sensitivity analysis. TTM at 33°C, when compared to TTM at 36°C, was not associated with an increased incidence of bleeding during the first 3 days of intensive care after CA. Increasing age, female gender, and PCI were independently associated with any bleeding the first 3 days after CA.
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Affiliation(s)
- Thomas Kander
- Department of Clinical Sciences, Anesthesia and Intensive Care, Skane University Hospital, Lund University, Lund, Sweden
| | - Susann Ullén
- Clinical Studies Sweden-Forum South Skane University Hospital, Lund, Sweden
| | - Josef Dankiewicz
- Department of Cardiology, Skane University Hospital, Lund University, Lund, Sweden
| | - Matt P Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, United Kingdom
| | - Ulf Schött
- Department of Clinical Sciences, Anesthesia and Intensive Care, Skane University Hospital, Lund University, Lund, Sweden
| | - Malin Rundgren
- Department of Clinical Sciences, Anesthesia and Intensive Care, Skane University Hospital, Lund University, Lund, Sweden
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Karcioglu O, Topacoglu H, Dikme O, Dikme O. A systematic review of safety and adverse effects in the practice of therapeutic hypothermia. Am J Emerg Med 2018; 36:1886-1894. [PMID: 30017685 DOI: 10.1016/j.ajem.2018.07.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/27/2018] [Accepted: 07/10/2018] [Indexed: 10/28/2022] Open
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21
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Endovascular cooling versus standard femoral catheters and intravascular complications: A propensity-matched cohort study. Resuscitation 2018; 124:1-6. [DOI: 10.1016/j.resuscitation.2017.12.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 12/07/2017] [Accepted: 12/11/2017] [Indexed: 11/21/2022]
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22
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Disseminated intravascular coagulation is associated with the neurologic outcome of cardiac arrest survivors. Am J Emerg Med 2017; 35:1617-1623. [DOI: 10.1016/j.ajem.2017.04.077] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 04/17/2017] [Accepted: 04/30/2017] [Indexed: 01/31/2023] Open
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23
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Martinell L, Herlitz J, Karlsson T, Nielsen N, Rylander C. Mild induced hypothermia and survival after out-of-hospital cardiac arrest. Am J Emerg Med 2017; 35:1595-1600. [DOI: 10.1016/j.ajem.2017.04.071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 04/24/2017] [Accepted: 04/26/2017] [Indexed: 01/09/2023] Open
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Figueroa SA, Blissitt PA, Livesay S, Wavra T, Guanci MM. Clinical Q & A: Translating Therapeutic Temperature Management from Theory to Practice. Ther Hypothermia Temp Manag 2017; 7:231-234. [PMID: 29058528 DOI: 10.1089/ther.2017.29037.mkb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Stephen A Figueroa
- 2 Division of Neurocritical Care, The University of Texas Southwestern Medical Center , Dallas, Texas
| | - Patricia A Blissitt
- 3 Harborview Medical Center and Swedish Medical Center, Clinical Faculty, University of Washington School of Nursing , Seattle, Washington
| | - Sarah Livesay
- 4 College of Nursing, Rush University , Chicago, Illinois
| | - Teresa Wavra
- 5 Cardiovascular CNS, Mission Hospital , Mission Viejo, California
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Madden LK, Hill M, May TL, Human T, Guanci MM, Jacobi J, Moreda MV, Badjatia N. The Implementation of Targeted Temperature Management: An Evidence-Based Guideline from the Neurocritical Care Society. Neurocrit Care 2017; 27:468-487. [DOI: 10.1007/s12028-017-0469-5] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Aléx J, Uppstu T, Saveman BI. The opinions of ambulance personnel regarding using a heated mattress for patients being cared for in a cold climate - An intervention study in ambulance care. Int J Circumpolar Health 2017; 76:1379305. [PMID: 28990464 PMCID: PMC5645772 DOI: 10.1080/22423982.2017.1379305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The purpose of the study was to describe the opinions of ambulance personnel regarding differences between using a heated mattress and a standard ambulance mattress. This study was an intervention study with pre- and post-evaluation. Evaluations of the opinions of personnel regarding the standard unheated mattress were conducted initially. After the intervention with new heated mattresses, follow-up evaluations were conducted. Ambulance personnel (n=64) from an ambulance station in northern Sweden took part in the study, which ran from October 2014 until February 2016. There were differences in opinions regarding the standard unheated mattress and the new heated mattress. The evaluation of the proxy ratings by the personnel showed that the heated mattress was warmer than the standard mattress, more pleasant to lie on and that patients were happier and more relaxed than when the standard mattress was used. The ambulance personnel in this study rated the experience of working with the heated mattress as very positive and proxy rated that it had a good effect on patient comfort. A heated mattress can be recommended for patients in ambulance care, even if more research is needed to receive sufficient evidence.
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Affiliation(s)
- Jonas Aléx
- a Department of Nursing and affiliated with the Arctic Research Centre at Umeå University, Research fields: Prehospital emergency care , Umeå University , Umeå , Sweden
| | - Tom Uppstu
- b Department of Nursing , Umeå University , Umeå , Sweden
| | - Britt-Inger Saveman
- a Department of Nursing and affiliated with the Arctic Research Centre at Umeå University, Research fields: Prehospital emergency care , Umeå University , Umeå , Sweden
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Wada T. Coagulofibrinolytic Changes in Patients with Post-cardiac Arrest Syndrome. Front Med (Lausanne) 2017; 4:156. [PMID: 29034235 PMCID: PMC5626829 DOI: 10.3389/fmed.2017.00156] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 09/11/2017] [Indexed: 01/08/2023] Open
Abstract
Whole-body ischemia and reperfusion due to cardiac arrest and subsequent return of spontaneous circulation constitute post-cardiac arrest syndrome (PCAS), which consists of four syndromes including systemic ischemia/reperfusion responses and post-cardiac arrest brain injury. The major pathophysiologies underlying systemic ischemia/reperfusion responses are systemic inflammatory response syndrome and increased coagulation, leading to disseminated intravascular coagulation (DIC), which clinically manifests as obstruction of microcirculation and multiple organ dysfunction. In particular, thrombotic occlusion in the brain due to DIC, referred to as the "no-reflow phenomenon," may be deeply involved in post-cardiac arrest brain injury, which is the leading cause of mortality in patients with PCAS. Coagulofibrinolytic changes in patients with PCAS are characterized by tissue factor-dependent coagulation, which is accelerated by impaired anticoagulant mechanisms, including antithrombin, protein C, thrombomodulin, and tissue factor pathway inhibitor. Damage-associated molecular patterns (DAMPs) accelerate not only tissue factor-dependent coagulation but also the factor XII- and factor XI-dependent activation of coagulation. Inflammatory cytokines are also involved in these changes via the expression of tissue factor on endothelial cells and monocytes, the inhibition of anticoagulant systems, and the release of neutrophil elastase from neutrophils activated by inflammatory cytokines. Hyperfibrinolysis in the early phase of PCAS is followed by inadequate endogenous fibrinolysis and fibrinolytic shutdown by plasminogen activator inhibitor-1. Moreover, cell-free DNA, which is also a DAMP, plays a pivotal role in the inhibition of fibrinolysis. DIC diagnosis criteria or fibrinolysis markers, including d-dimer and fibrin/fibrinogen degradation products, which are commonly tested in patients and easily accessible, can be used to predict the mortality or neurological outcome of PCAS patients with high accuracy. A number of studies have explored therapy for this unique pathophysiology since the first report on "no-reflow phenomenon" was published roughly 50 years ago. However, the optimum therapeutic strategy focusing on the coagulofibrinolytic changes in cardiac arrest or PCAS patients has not yet been established. The elucidation of more precise pathomechanisms of coagulofibrinolytic changes in PCAS may aid in the development of novel therapeutic targets, leading to an improvement in the outcomes of PCAS patients.
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Affiliation(s)
- Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Prolonged TTM – enhanced hypocoagulation and bleeding? Resuscitation 2017; 118:A3-A4. [DOI: 10.1016/j.resuscitation.2017.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 07/01/2017] [Indexed: 11/19/2022]
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29
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Jeppesen AN, Hvas AM, Grejs AM, Duez C, Ilkjær S, Kirkegaard H. Platelet aggregation during targeted temperature management after out-of-hospital cardiac arrest: A randomised clinical trial. Platelets 2017; 29:504-511. [DOI: 10.1080/09537104.2017.1336213] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Anni Nørgaard Jeppesen
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus N, Denmark
- Research Centre for Emergency Medicine, Aarhus University Hospital, Aarhus C, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
- Centre for Haemophilia and Thrombosis, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus N, Denmark
| | - Anders Morten Grejs
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus N, Denmark
- Research Centre for Emergency Medicine, Aarhus University Hospital, Aarhus C, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Christophe Duez
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus N, Denmark
- Research Centre for Emergency Medicine, Aarhus University Hospital, Aarhus C, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Susanne Ilkjær
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Hans Kirkegaard
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus N, Denmark
- Research Centre for Emergency Medicine, Aarhus University Hospital, Aarhus C, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
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Trąbka-Zawicki A, Tomala M, Zeliaś A, Paszek E, Zajdel W, Stępień E, Żmudka K. Adaptation of global hemostasis to therapeutic hypothermia in patients with out-of-hospital cardiac arrest: Thromboelastography study. Cardiol J 2017; 26:77-86. [PMID: 28695976 DOI: 10.5603/cj.a2017.0080] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 05/11/2017] [Accepted: 05/21/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The use of mild therapeutic hypothermia (MTH) in patients after out-of-hospital cardiac arrest (OHCA) who are undergoing primary percutaneous coronary intervention (pPCI) can protect patients from thromboembolic complications. The aim of the study was to evaluate the adaptive mecha- nisms of the coagulation system in MTH-treated comatose OHCA survivors. METHODS Twenty one comatose OHCA survivors with acute coronary syndrome undergoing imme- diate pPCI were treated with MTH. Quantitative and qualitative analyses of physical clot properties were performed using thromboelastography (TEG). Two analysis time points were proposed: 1) during MTH with in vitro rewarming conditions (37°C) and 2) after restoration of normothermia (NT) under normal (37°C) and in vitro cooling conditions (32°C). RESULTS During MTH compared to NT, reaction time (R) was lengthened, clot kinetic parameter (a) was significantly reduced, but no effect on clot strength (MA) was observed. Finally, the coagulation index (CI) was significantly reduced with clot fibrinolysis attenuated during MTH. The clot lysis time (CLT) was shortened, and clot stability (LY60) was lower compared with those values during NT. In vitro cooling generally influenced clot kinetics and reduced clot stability after treatment. CONCLUSIONS Thromboelastography is a useful method for evaluation of coagulation system dysfunc- tion in OHCA survivors undergoing MTH. Coagulation impairment in hypothermia was associated with a reduced rate of clot formation, increased weakness of clot strength, and disturbances of fibrinoly- sis. Blood sample analyses performed at 32°C during MTH, instead of the standard 37°C, seems to enhance the accuracy of the evaluation of coagulation impairment in hypothermia.
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Affiliation(s)
- Aleksander Trąbka-Zawicki
- Department of Interventional Cardiology, Jagiellonian University, John Paul II Hospital, Krakow, Poland.
| | - Marek Tomala
- Department of Interventional Cardiology, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Aleksander Zeliaś
- Department of Interventional Cardiology, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Elżbieta Paszek
- Department of Interventional Cardiology, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Wojciech Zajdel
- Department of Interventional Cardiology, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Ewa Stępień
- Department of Medical Physics, Marian Smoluchowski Institute of Physiscs, Faculty of Physics, Astronomy, and Applied Computer, Jagiellonian University, Krakow, Poland
| | - Krzysztof Żmudka
- Department of Interventional Cardiology, Jagiellonian University, John Paul II Hospital, Krakow, Poland
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Jeppesen AN, Hvas AM, Duez CHV, Grejs AM, Ilkjær S, Kirkegaard H. Prolonged targeted temperature management compromises thrombin generation: A randomised clinical trial. Resuscitation 2017; 118:126-132. [PMID: 28602694 DOI: 10.1016/j.resuscitation.2017.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 05/26/2017] [Accepted: 06/05/2017] [Indexed: 11/16/2022]
Abstract
AIM To investigate whether prolonged compared with standard duration of targeted temperature management (TTM) compromises coagulation. METHODS Comatose survivors after out-of-hospital cardiac arrest (n=82) were randomised to standard (24h) or prolonged (48h) duration of TTM at 33±1°C. Blood samples were drawn 22, 46 and 70h after attaining the target temperature. Samples were analysed for rotational thromboelastometry (ROTEM® (EXTEM®, INTEM®, FIBTEM® and HEPTEM®)) and thrombin generation using the Calibrated Automated Thrombogram® assay. RESULTS With the 22-h sample, we revealed no difference between groups in the ROTEM® and thrombin generation results beside a slightly higher EXTEM® and INTEM® maximum velocity in the prolonged group (p-values≤0.04). With the 46-h sample, ROTEM® showed no differences when using EXTEM®; however, 11% (p<0.01) longer clotting time and 12% (p<0.01) longer time to maximum velocity were evident in the prolonged group than in the standard group when using INTEM®. The prolonged group had reduced thrombin generation compared with the standard group as indicated by 30% longer lag time (p=0.04), 106nM decreased peak concentration (p<0.001), 36% longer time to peak (p=0.01) and 411 nM*minute decreased endogenous thrombin potential (p<0.001). With the 70-h sample, no differences in ROTEM® results were found between groups. However, the prolonged group had reduced thrombin generation indicated by longer lag time, decreased peak concentration and longer time to peak (all p-values≤0.02) compared with the standard group. CONCLUSION Prolonged TTM in post-cardiac arrest patients impairs thrombin generation. ClinicalTrials.gov identifier: NCT02258360.
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Affiliation(s)
- Anni Nørgaard Jeppesen
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Research Centre for Emergency Medicine, Aarhus University Hospital, Nørrebrogade 44, Building 30, 8000 Aarhus C, Denmark.
| | - Anne-Mette Hvas
- Centre for Haemophilia and Thrombosis, Department of Clinical Biochemistry, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Christophe Henri Valdemar Duez
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Research Centre for Emergency Medicine, Aarhus University Hospital, Nørrebrogade 44, Building 30, 8000 Aarhus C, Denmark
| | - Anders Morten Grejs
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Research Centre for Emergency Medicine, Aarhus University Hospital, Nørrebrogade 44, Building 30, 8000 Aarhus C, Denmark
| | - Susanne Ilkjær
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Hans Kirkegaard
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Research Centre for Emergency Medicine, Aarhus University Hospital, Nørrebrogade 44, Building 30, 8000 Aarhus C, Denmark; Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
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Ratcovich H, Sadjadieh G, Andersson H, Frydland M, Wiberg S, Dridi N, Kjaergaard J, Holmvang L. The effect of TIcagrelor administered through a nasogastric tube to COMAtose patients undergoing acute percutaneous coronary intervention: the TICOMA study. EUROINTERVENTION 2017; 12:1782-1788. [DOI: 10.4244/eij-d-16-00398] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Kashiura M, Sugiyama K, Tanabe T, Akashi A, Hamabe Y. Effect of ultrasonography and fluoroscopic guidance on the incidence of complications of cannulation in extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a retrospective observational study. BMC Anesthesiol 2017; 17:4. [PMID: 28125963 PMCID: PMC5267374 DOI: 10.1186/s12871-016-0293-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 12/13/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It remains unclear which cannulation method is best in cases of extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest. We assessed the effect of ultrasound- and fluoroscopy-guided percutaneous cannulation on complication incidence, compared with that using only ultrasound guidance. METHODS This single-center retrospective observational study was conducted between February 2011 and December 2015. In the comparison group, cannulation was performed percutaneously using only ultrasound guidance. In the exposure group, cannulation was performed percutaneously using fluoroscopy and ultrasound guidance. The primary outcome assessed was whether complications were associated with cannulation. The secondary outcome assessed was the duration from hospital arrival to extracorporeal circulation start. In addition to univariate analysis, multivariate logistic-regression analysis for cannulation complications was performed to adjust for several presumed confounders. RESULTS Of the patients who underwent ECPR, 73 were eligible; the comparison group included 50 cases and the exposure group included 23 cases. Univariate analysis showed that the complication incidence of the exposure group was significantly lower than that of the comparison group (8.7 vs. 36.0%, p = 0.022). Duration from hospital arrival to extracorporeal circulation start was almost the same in both groups (median, 17.0 min vs. 17.0 min, p = 0.92). After multivariate logistic regression analysis, cannulation using fluoroscopy and ultrasound was independently associated with a lower complication incidence (adjusted odds ratio, 0.14; p = 0.024). CONCLUSIONS Ultrasound- and fluoroscopy-guided cannulation may reduce the complication incidence of cannulation without delaying extracorporeal circulation start.
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Affiliation(s)
- Masahiro Kashiura
- Emergency and Critical Care Center, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-ku, Tokyo, 130-8575, Japan.
| | - Kazuhiro Sugiyama
- Emergency and Critical Care Center, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-ku, Tokyo, 130-8575, Japan
| | - Takahiro Tanabe
- Emergency and Critical Care Center, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-ku, Tokyo, 130-8575, Japan
| | - Akiko Akashi
- Emergency and Critical Care Center, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-ku, Tokyo, 130-8575, Japan
| | - Yuichi Hamabe
- Emergency and Critical Care Center, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-ku, Tokyo, 130-8575, Japan
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Exam 4 Questions. ABSOLUTE NEUROCRITICAL CARE REVIEW 2017. [PMCID: PMC7122514 DOI: 10.1007/978-3-319-64632-9_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A 73-year-old male with a history of hypertension and hyperlipidemia is currently in the stroke unit after suffering a right middle cerebral artery infarct. His symptoms started 2 h prior to arrival at the hospital, and tPA was administered. The patient is plegic on the left side and with mild dysarthria, but is otherwise neurologically intact. His labwork is within normal limits. Which of the following describes the optimal deep venous thrombosis (DVT) prophylaxis regimen for this patient?Wait 6 h post tPA, then administer unfractionated heparin (UFH) along with intermittent pneumatic compression (IPC) Wait 24 h post tPA, then administer UFH along with IPC Wait 6 h post tPA, then administer low molecular weight heparin (LMWH) along with IPC Wait 24 h post tPA, then administer LMWH along with IPC IPC only for the first 72 h, then LMWH or UFH after obtaining follow-up imaging
All of the following causes of acute encephalitis have the matching characteristic radiological features except:Autoimmune limbic encephalitis: T2/FLAIR hyperintensity in the mesial temporal lobes Cytomegalovirus: T2/FLAIR hyperintensity in the subependymal white matter JC virus: T2/FLAIR hyperintensity in the parieto-occipital lobes and corpus callosum Herpes simplex virus type 1: restricted diffusion in frontal/temporal lobes and insular cortex Varicella zoster: T2/FLAIR hyperintensity in the brainstem
Which of the following categorizations is most accurate regarding acute respiratory distress syndrome (ARDS) in the setting of subarachnoid hemorrhage (SAH)?Non-neurogenic, non-cardiogenic Neurogenic, non-cardiogenic Neurogenic, cardiogenic Non-neurogenic, cardiogenic None of the above accurately reflect ARDS in SAH
A 52-year-old female is admitted to the ICU with a Hunt-Hess 1, modified Fisher 2 subarachnoid hemorrhage. Her past medical history is significant for hypertension, diabetes mellitus, and chronic renal insufficiency. She undergoes craniotomy for surgical clipping of an anterior cerebral artery aneurysm, and does not experience any additional complications. Two weeks later, she begins complaining of left calf pain, and a lower extremity sonogram demonstrated a proximal deep venous thrombosis (DVT). The patient weighs 60 kg. Her laboratory values are as follows: sodium 142 mEq/L, potassium 3.4 mEq/L, carbon dioxide 18 mEq/L, blood urea nitrogen (BUN) 70 mg/dL, and serum creatinine 2.5 mg/dL. What would be the optimal treatment for this patient’s proximal DVT?Unfractionated heparin infusion for at least 5 days concomitantly with warfarin therapy Low molecular weight heparin 60 mg twice a day for at least 5 days concomitantly with warfarin therapy Fondaparinux 7.5 mg daily for 5 days followed by warfarin therapy Apixaban 10 mg twice daily for 7 days followed by 5 mg twice daily Rivaroxaban 15 mg twice daily for 21 days followed by 20 mg once daily
All of the following are currently implicated in uremic encephalopathy except:Derangements in cerebral metabolism Alterations in the blood-brain barrier Accumulation of circulating toxins Imbalance of endogenous neurotransmitters Recurrent lobar hemorrhages
A 70-year-old female is hospitalized with a recent ischemic infarct. As part of stroke core measures, you obtain a hemoglobin A1c of 10.0. What is an approximate estimation of this patient’s average blood glucose level over the last several months?70 mg/dL 100 mg/dL 130 mg/dL 190 mg/dL 240 mg/dL
A 28-year-old female with no known past medical history is in the ICU in status epilepticus, with anti-N-methyl D-aspartate (NMDA) receptor antibodies isolated in the cerebrospinal fluid. Which of the following is most likely to identify the root cause of her illness?Transvaginal ultrasound Contrast-enhanced CT of the chest Contrast-enhanced CT of the brain Virtual colonography Thorough examination of the skin, particularly in sun-exposed areas
A 17-year-old male with no significant past medical history collapses during a high school football game, and goes into cardiac arrest. He did not have any complaints earlier in the day. The patient is brought to a nearby hospital, where is he resuscitated, intubated, and transferred to the ICU for further management. The patient is currently undergoing therapeutic hypothermia, and a work-up is underway to determine the cause of his sudden collapse. Which of the following is the most likely diagnosis?Rupture of a previously undiagnosed cerebral aneurysm Hypertrophic cardiomyopathy Commotio cordis Severe hyponatremia and cerebral edema Brugada syndrome
A 31-year-old female at 38 weeks gestation is currently hospitalized for the treatment of preeclampsia. Due to her medical condition, her obstetrician is currently considering induced labor. At which point will this patient no longer be at risk for developing frank seizure activity as a result of her condition?48 h postpartum 1 week after delivery 2 weeks after delivery 4 weeks after delivery 6 weeks after delivery
A 38-year-old male with no prior medical history presents to the emergency department with fever and severe headaches for several days. A CT scan of the brain is unremarkable, and the results of a lumbar puncture are pending. What is the most appropriate empiric antimicrobial regimen at this time?Cefazolin and vancomycin Ceftriaxone and vancomycin Ceftriaxone, vancomycin and ampicillin Piperacillin/tazobactam and vancomycin Meropenem and vancomycin
The majority of intramedullary spinal cord neoplasms are:Astrocytomas Meningiomas Metastatic lesions Ependymomas Hemangioblastomas
Which of the following derived parameter formulas is correct?Cardiac index = cardiac output x body surface area Stroke volume = cardiac output/heart rate Systemic vascular resistance = 80 × (mean arterial pressure/cardiac output) Pulmonary vascular resistance = 80 × (mean pulmonary artery pressure/cardiac output) All of the above are correct
A 23-year-old female marathon runner is currently in the ICU after suffering from heat stroke following an outdoor run on a particularly hot summer day. She was initially delirious in the emergency department, but progressed to coma and respiratory failure requiring mechanical ventilation. Her oral temperature is 42.1 °C. Which of the following would be most effective in reducing this patient’s severe hyperthermia?Regularly scheduled alternating acetaminophen and ibuprofen Spraying room temperature water on the patient, followed by fanning Ice water immersion Dantrolene sodium, 2.5 mg/kg Application of ice packs to the groin and axilla
Hyperinsulinemia-euglycemia (HIE) therapy may be useful for toxicity related to which of the following?Tricyclic antidepressants Calcium channel blockers Aspirin Digoxin Lithium
A 71-year-old female with a history of alcohol abuse is currently intubated in the ICU following a catastrophic spontaneous left basal ganglia hemorrhage with resultant herniation. You have just declared her brain dead. The patient’s family agrees to make her an organ donor, and the organ donation coordinator requests you initiate levothyroxine therapy. Which of the following benefits would be expected with this treatment?Increase the number of solid organs available for transplant Eliminate the need for hepatic biopsy prior to liver transplant Eliminate the need for cardiac catheterization prior to heart transplant Eliminate the need for bronchoscopy prior to lung transplant Reduce the need for supplementation of sodium, potassium, calcium, and magnesium
Which of the following is not an element of the Full Outline of Unresponsiveness (FOUR) score?Eye opening Respiratory function Brainstem reflexes Motor response Verbal response
A 23-year-old female is currently in the ICU with status asthmaticus. She was initially on noninvasive positive pressure ventilation, with an arterial blood gas (ABG) as follows: pH 7.13, pCO2 60 mmHg, PaO2 is 61 mmHg, HCO3 24 mmol/L, and oxygen saturation of 90%. She is given continuous inhaled albuterol, intravenous steroids, and magnesium sulfate. She subsequently becomes more lethargic and is intubated, with settings as follows: volume assist-control, rate of 12 breaths/min, tidal volume of 500 cc, PEEP of 5 cm H2O, and FiO2 of 50%. Peak airway pressure is 50 cm H2O and plateau pressure is 15 cm H2O. A stat portable chest x-ray shows hyperinflation with no pneumothorax. A repeat ABG after 30 min of invasive ventilation shows the following: pH of 7.24, pCO2 49 mmHg, PaO2 71 mmHg, HCO3 is 25 mmol/L. Which of the following should be performed next?Increase rate to 16 Increase tidal volume to 600 cc Initiate bicarbonate infusion Switch to pressure assist-control Maintain current settings
Which of the following mechanisms is implicated in super-refractory status epilepticus?Influx of proinflammatory molecules Upregulation of NMDA receptors Upregulation of molecular transport molecules Downregulation of GABA receptors All of the above
A 85-year-old male with a history nephrolithiasis, mild dementia, and alcohol abuse presented to the emergency department after a fall from standing, and was found to a right holohemispheric subdural hematoma. His clot was evacuated successfully, in spite of his oozing diathesis in the operating room (INR on arrival was 1.4 with a platelet count of 88 × 103/μL). His serum transaminases are twice the normal value, and he has had refractory chronic hyponatremia. He has had three convulsions during this week of hospitalization, in spite of levetiracetam therapy at 1.5 g twice a day. Over the past 24 h, he has had a marked increase in agitation. He has also just had a 5-s run of non-sustained ventricular tachycardia, and his systolic blood pressure is now 85 mmHg. You are considering discontinuing his levetiracetam and starting a new agent. Which of the following would be the best choice in this scenario?Carbamazepine Phenytoin Valproate Lacosamide Topiramate
A 65-year-old male with a history of COPD on rescue albuterol and ipratropium is diagnosed with myasthenia gravis, and started on an acetylcholinesterase inhibitor. He returns several days later complaining of increased salivation and worsening bronchial secretions in the absence of fevers, purulent sputum, or increasing dyspnea. These symptoms are not relieved by use of his albuterol. On exam, he has slightly decreased air movement throughout both lung fields without any clear wheezing, no focal rales, and a normal inspiratory to expiratory ratio. Which treatment option is most likely to be beneficial?Increase frequency of short-acting ß2 agonist use Add a standing long-acting inhaled ß2 agonist Add glycopyrrolate as needed Add inhaled corticosteroids Add oral systemic corticosteroids
Regarding states of impaired consciousness, which of the following statements regarding arousal and awareness is correct?Coma: intact arousal, but impaired awareness Minimally conscious state: impaired arousal and impaired awareness Persistent vegetative state: intact arousal, but impaired awareness Locked-in state: intact arousal, but impaired awareness All of the above are correct
A 62-year-old female is currently in the ICU following craniotomy for clipping of a cerebral aneurysm. Postoperatively, she is noted to have an oxygen saturation of 92% on 50% non-rebreather face mask, and her respiratory rate is 32 breaths/min. She denies chest pain. Her blood pressure is 96/72 mmHg and heart rate is 120 beats/min. Nimodipine has been held according to blood pressure parameters. A portable chest x-ray shows hazy opacities bilaterally, and bedside echocardiogram shows decreased left ventricular systolic function with apical, septal, lateral, anterior, anteroseptal and inferolateral wall akinesis, along with apical ballooning. Which of the following should be performed next?Intubate the patient and begin mechanical ventilation Call urgent cardiology consult for cardiac catheterization Start noninvasive positive airway pressure ventilation Administer broad spectrum antibiotics Administer albuterol and systemic corticosteroids
Which of the following is the most common etiology of acute spinal cord ischemia and infarction?Atherosclerotic disease Rupture of an abdominal aortic aneurysm Degenerative spine disease Cardioembolic events Systemic hypotension in the setting of other disease processes
A 62-year-old female with a history of coronary artery disease has just been admitted to the ICU with a left-sided spontaneous basal ganglia hemorrhage. The patient takes 325 mg of aspirin daily at home, and you are considering platelet transfusion. Which of the following has been demonstrated regarding platelet transfusion in this setting?Improved chances of survival to hospital discharge Decreased hospital length-of-stay Improved chances of survival at 3 months Improved modified Rankin scale at 3 months None of the above
Which of the following therapies has been shown to decrease the incidence of delayed cerebral ischemia (DCI) in the setting of subarachnoid hemorrhage (SAH)?Atorvastatin Magnesium Methylprednisolone Nicardipine None of the above
A 70-year-old male with a history of diabetes, hypertension, and cigarette smoking (one pack per day for the last 40 years) is currently in the ICU with a COPD exacerbation. This is his third exacerbation this year, and was discharged from the hospital only 3 weeks prior. On your examination, he is alert, his breathing is labored, and he has rales at the right lung base. His vital signs are as follows: blood pressure 90/60 mmHg, heart rate 120 beats per minute, respirations 28 per minute, and temperature 38.3 °C. His oxygen saturation on 50% face mask is 93%, and his most recent PCO2 is 55 mmHg. Labs are notable for the following: white blood cell count 14.4 × 109/L with 90% neutrophils, blood urea nitrogen (BUN) 30 mg/dL, serum creatinine 1.2 mg/dL, and glucose 240 mg/dL. Ketones are negative. He is currently on noninvasive positive pressure ventilation at 10/5 cm H2O and 50% FiO2, and broad spectrum antibiotics have been administered. An hour later, the nurse pages you because his heart rate is now 140 beats per minute and irregular, blood pressure is 85 systolic, oxygen saturation is 85%, and he is minimally responsive. You now hear bilateral rales, most prominently in the right lung base, and scattered wheezes. Which of the following should be performed next?Increase inspiratory pressure to 15 and FiO2 to 100% Start a continuous diltiazem infusion and give intravenous furosemide Start a continuous phenylephrine infusion targeting a mean arterial pressure (MAP) > 65 Give 125 mg of solumedrol and administer albuterol via nebulizer Intubate the patient and initiate mechanical ventilation
A 57-year-old male with a history of epilepsy is currently in the stroke unit following a large right middle cerebral artery infarction. A nasogastric tube has been inserted, and 24 h continuous enteral feeds have been initiated. The patient is currently on 100 mg of phenytoin every 8 h for seizure prophylaxis. Which of the following measures should be taken to prevent the patient from developing subtherapeutic phenytoin levels?Change to 18 h tube feeds, and only administer phenytoin at night Change to 18 h tube feeds, and only administer phenytoin twice daily Switch from standard to hydrolyzed tube feeds Switch from standard to glycemic control tube feeds Hold tube feeds for 2 h before and after phenytoin administration
A 37-year-old female presents to the emergency department with approximately 2 weeks of progressively worsening clumsiness and drastic mood swings. Her past medical history is significant only for Crohn’s disease, for which she takes both natalizumab and infliximab. A contrast-enhanced CT scan of her head is performed, revealing hypodense, non-enhancing lesions in the cortical white matter of the frontal and parietal lobes. Despite treatment, the patient expires 1 month later. Which of the following is true regarding the most likely diagnosis?The diagnosis may be confirmed via CSF analysis The pathologic process spares oligodendrocytes It is a prion-based disease The condition is universally fatal despite treatment All of the above
A 58-year-old female presents to the emergency department with dry cough, fever and rapidly progressive dyspnea over 1 week. She has a history of rheumatoid arthritis (RA) and is maintained on weekly methotrexate and daily prednisone (which was increased to 30 mg starting 1 month ago for an acute flare). She takes no other medications. Her vital signs are as follows: blood pressure 100/70 mmHg, heart rate 110 beats/min, respiratory rate 20 breaths/min, and temperature 38.0 °C. In the ED she develops progressive hypoxemia with oxygen saturation 92% on 100% nonrebreather, and is increasingly diaphoretic. She is emergently intubated, and a chest x-ray post intubation shows extensive bilateral lung opacities. Which of the following should be administered at this time?Ceftriaxone and azithromycin Vancomycin and piperacillin-tazobactam Vancomycin, cefepime, and fluconzole Ceftriaxone, levofloxacin, and trimethoprim-sulfamethoxazole Tigecycline only
A 45-year-old woman undergoes uncomplicated transsphenoidal resection of a pituitary macroadenoma. She appears well hydrated and is not complaining of excessive thirst. Post-operatively, she is noted to have increased urine output. Serum sodium is 137 mEq/L, and serum osmolarity is 275 mOsm/kg. What is the most likely cause of her polyuria?Syndrome of inappropriate antidiuretic hormone Diabetes insipidus Cerebral salt wasting Fluid mobilization All of the above are equally likely
A 36-year-old female with a recent lumbar puncture to rule out subarachnoid hemorrhage is now complaining of a severe headache unlike anything she has experienced previously. She reports her headache is worse when standing, and better upon lying flat. She is otherwise neurologically intact. All of the following medications may be beneficial in this scenario except:Acetaminophen Ibuprofen Caffeine Aminophylline Methylprednisolone
Which of the following is the most common overall cause of acute myocardial infarction?Coronary dissection Plaque rupture Imbalance between oxygen demand and supply across a fixed obstruction Coronary vasospasm Ischemia related to hypotension and decreased perfusion
A 78-year-old male is in the ICU recovering from sepsis and pneumonia. He was just recently extubated after 2 days of mechanical ventilation and sedation with a fentanyl infusion. Over the ensuing days, he develops worsening abdominal distention, poor bowel sounds, and no stool output. CT scan reveals significant colonic distention, but no mass or obstruction. Records demonstrate a normal routine colonoscopy performed 6 weeks ago. You have appropriately hydrated the patient, corrected any electrolyte abnormalities, placed a rectal tube, withheld all opiates, and given intravenous erythromycin, but to no avail. Abdominal x-rays continue to demonstrate marked cecal dilatation greater than 12 cm in diameter. What is the next best appropriate therapy for this patient?Neostigmine Naloxone Metoclopromide Surgical consultation for hemicolectomy Endoscopic percutaneous cecostomy tube placement
Which of the following is the most common cerebral vascular malformation in the general population?AV malformation Dural AV fistula Developmental venous anomaly Cavernous malformation Vein of Galen malformation
A 49-year-old female with a history of acute lymphoblastic leukemia and recent subcutaneous cerebrospinal fluid (CSF) reservoir placement presents to the emergency department with fever, chills, and increased confusion for the past 3 days. Her CSF reservoir was last accessed 1 week ago. A thorough work-up reveals no other obvious infectious source, and there is concern for CSF reservoir-associated meningitis. Which of the following is the most likely causative organism?Coagulase-negative staphylococci Propionobacterium acnes Methicillin-resistant Staphylococcus aureus Klebsiella pneumoniae Neisseria meningitidis
A 47-year-old woman presents to the emergency department with headache, nausea, and vomiting. Non-contrast head CT is performed, revealing subarachnoid blood in the right Sylvian fissure, and conventional angiography reveals the presents of a large right-sided MCA aneurysm. The patient undergoes successful surgical clipping of her aneurysm, and is being observed in the ICU. On admission, the patient’s serum sodium was 142 mEq/L and the hematocrit was 37%; by the seventh post-operative day, the serum sodium is 127 mEq/L and the hematocrit is 44%. Bedside ultrasonography demonstrates an IVC diameter of approximately 0.9 cm. Which of the following interventions would be least reasonable at this time?Fludrocortisone, 0.2 mg twice a day 2% hypertonic saline, infused peripherally 3% hypertonic saline, infused centrally Sodium chloride oral tablets 1500 mL daily fluid restriction
Which of the following is true regarding central (non-infectious) fever?Less common in subarachnoid hemorrhage More common versus infectious fever Earlier onset versus infectious fever Easier to confirm versus infectious fever All of the above
Flaccid paralysis is most commonly associated with which of the following forms of encephalitis?West Nile Varicella zoster Rabies Herpes simplex Epstein-Barr
Which of the following would not be considered appropriate therapy for heparin-induced thrombocytopenia (HIT)?Discontinuation of heparin products alone Danaparoid Fondaparinux Argatroban All of the above are acceptable treatment options
A 45-year-old male with severe blunt traumatic brain injury (TBI) from a motor vehicle collision suffered a ventricular fibrillation cardiac arrest at the time of injury with return of spontaneous circulation (ROSC) in the field after endotracheal intubation and one dose of epinephrine. On arrival to the emergency department, no regional wall motion abnormalities were noted on surface echocardiography and no ST segment changes were seen on the presenting EKG. Head CT revealed cerebral contusions but no extra-axial mass lesions. The patient is now in the ICU and found to be comatose without sedation. Mild therapeutic hypothermia to 33° is being considered in the management of this post-arrest patient. Which of the following statements is true?Mild therapeutic hypothermia is contraindicated due to the risk of induced epilepsy Mild therapeutic hypothermia is contraindicated with any intracranial pathology on CT imaging Mild therapeutic hypothermia does not induce a clinically significant coagulopathy Patients who have sustained ROSC after an arrest associated with TBI do not benefit from therapeutic hypothermia Endovascular cooling is superior to surface cooling in young patients with ROSC
A 35-year-old male is in the intensive care unit following resection of a large right-sided meningioma. He is currently intubated and sedated on a continuous fentanyl infusion. The nurse calls you to the bedside due to concerns over “unusual ventilator waveforms”. Upon arrival, you note the following (see Image 1). What is the best way to describe this phenomenon?Reverse triggering Double triggering Breath stacking Missed triggering None of the above; normal ventilator waveforms are present
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Safety of glycoprotein IIb/IIIa inhibitors in patients under therapeutic hypothermia admitted for an acute coronary syndrome. Resuscitation 2016; 106:108-12. [DOI: 10.1016/j.resuscitation.2016.06.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 06/15/2016] [Accepted: 06/28/2016] [Indexed: 01/01/2023]
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Nolan JP, Ornato JP, Parr MJA, Perkins GD, Soar J. Resuscitation highlights in 2015. Resuscitation 2016; 100:A1-8. [PMID: 26803062 DOI: 10.1016/j.resuscitation.2016.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 01/13/2016] [Indexed: 12/29/2022]
Affiliation(s)
- J P Nolan
- School of Clinical Sciences, University of Bristol, UK; Royal United Hospital, Bath, UK.
| | - J P Ornato
- Department of Emergency Medicine, Virginia Commonwealth University, Richmond, VA, USA.
| | - M J A Parr
- University of New South Wales and Macquarie University, Sydney, Australia.
| | - G D Perkins
- University of Warwick, Warwick Medical School and Heart of England NHS Foundation Trust, Coventry CV4 7AL, UK.
| | - J Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB, UK.
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