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Chun MK, Park JS, Han J, Jhang WK, Kim DH. The association between initial post-resuscitation diastolic blood pressure and survival after pediatric cardiac arrest: a retrospective study. BMC Pediatr 2024; 24:563. [PMID: 39232714 PMCID: PMC11373354 DOI: 10.1186/s12887-024-05037-x] [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: 04/11/2024] [Accepted: 08/27/2024] [Indexed: 09/06/2024] Open
Abstract
BACKGROUND Limited research has analyzed the association between diastolic blood pressure (DBP) and survival after pediatric cardiopulmonary resuscitation (CPR). This study aimed to explore the association between post-resuscitation diastolic blood pressure and survival in pediatric patients who underwent CPR. METHOD This retrospective single-center study included pediatric patients admitted to the pediatric intensive care unit of Asan Medical Center between January 2016 to November 2022. Patients undergoing extracorporeal CPR and those with unavailable data were excluded. The primary endpoint was survival to ICU discharge. RESULTS A total of 106 patients were included, with 67 (63.2%) achieving survival to ICU discharge. Multivariate logistic regression analysis identified DBP within 1 h after ROSC as the sole significant variable (p = 0.002, aOR, 1.043; 95% CI, 1.016-1.070). Additionally, DBP within 1 h demonstrated an area under the ROC curve of 0.7 (0.592-0.809) for survival to ICU discharge, along with mean blood pressure within the same timeframe. CONCLUSION Our study highlights the importance of DBP within 1-hour post-ROSC as a significant prognostic factor for survival to ICU discharge. However, further validation through further prospective large-scale studies is warranted to confirm the appropriate post-resuscitation DBP of pediatric patients.
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Affiliation(s)
- Min Kyo Chun
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jun Sung Park
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jeeho Han
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Won Kyoung Jhang
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Da Hyun Kim
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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Karlsen H, Strand-Amundsen RJ, Skåre C, Eriksen M, Skulberg VM, Sunde K, Tønnessen TI, Olasveengen TM. Cerebral perfusion and metabolism with mild hypercapnia vs. normocapnia in a porcine post cardiac arrest model with and without targeted temperature management. Resusc Plus 2024; 18:100604. [PMID: 38510376 PMCID: PMC10950799 DOI: 10.1016/j.resplu.2024.100604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 02/15/2024] [Accepted: 03/03/2024] [Indexed: 03/22/2024] Open
Abstract
Aim To determine whether targeting mild hypercapnia (PaCO2 7 kPa) would yield improved cerebral blood flow and metabolism compared to normocapnia (PaCO2 5 kPa) with and without targeted temperature management to 33 °C (TTM33) in a porcine post-cardiac arrest model. Methods 39 pigs were resuscitated after 10 minutes of cardiac arrest using cardiopulmonary bypass and randomised to TTM33 or no-TTM, and hypercapnia or normocapnia. TTM33 was managed with intravasal cooling. Animals were stabilized for 30 minutes followed by a two-hour intervention period. Hemodynamic parameters were measured continuously, and neuromonitoring included intracranial pressure (ICP), pressure reactivity index, cerebral blood flow, brain-tissue pCO2 and microdialysis. Measurements are reported as proportion of baseline, and areas under the curve during the 120 min intervention period were compared. Results Hypercapnia increased cerebral flow in both TTM33 and no-TTM groups, but also increased ICP (199% vs. 183% of baseline, p = 0.018) and reduced cerebral perfusion pressure (70% vs. 84% of baseline, p < 0.001) in no-TTM animals. Cerebral lactate (196% vs. 297% of baseline, p < 0.001), pyruvate (118% vs. 152% of baseline, p < 0.001), glycerol and lactate/pyruvate ratios were lower with hypercapnia in the TTM33 group, but only pyruvate (133% vs. 150% of baseline, p = 0.002) was lower with hypercapnia among no-TTM animals. Conclusion In this porcine post-arrest model, hypercapnia led to increased cerebral flow both with and without hypothermia, but also increased ICP and reduced cerebral perfusion pressure in no-TTM animals. The effects of hypercapnia were different with and without TTM.(Institutional protocol number: FOTS, id 14931).
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Affiliation(s)
- Hilde Karlsen
- Department of Research and Development and Institute for Experimental Medical Research, Oslo University Hospital, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Christiane Skåre
- Department of Anesthesia and Intensive Care Medicine, Oslo University Hospital, Oslo, Norway
- University of Oslo, Oslo, Norway
| | - Morten Eriksen
- Institute for Experimental Medical Research, Oslo University Hospital, Oslo, Norway
| | - Vidar M Skulberg
- Institute for Experimental Medical Research, Oslo University Hospital, Oslo, Norway
| | - Kjetil Sunde
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Anesthesia and Intensive Care Medicine, Oslo University Hospital, Oslo, Norway
| | - Tor Inge Tønnessen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Anesthesia and Intensive Care Medicine, Oslo University Hospital, Oslo, Norway
| | - Theresa M Olasveengen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Anesthesia and Intensive Care Medicine, Oslo University Hospital, Oslo, Norway
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Jung YH, Lee HY, Lee BK, Choi BK, Kim TH, Kim JW, Kim HC, Kim HJ, Jeung KW. Feasibility of Magnetic Resonance-Based Conductivity Imaging as a Tool to Estimate the Severity of Hypoxic-Ischemic Brain Injury in the First Hours After Cardiac Arrest. Neurocrit Care 2024; 40:538-550. [PMID: 37353670 DOI: 10.1007/s12028-023-01776-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 06/05/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Early identification of the severity of hypoxic-ischemic brain injury (HIBI) after cardiac arrest can be used to help plan appropriate subsequent therapy. We evaluated whether conductivity of cerebral tissue measured using magnetic resonance-based conductivity imaging (MRCI), which provides contrast derived from the concentration and mobility of ions within the imaged tissue, can reflect the severity of HIBI in the early hours after cardiac arrest. METHODS Fourteen minipigs were resuscitated after 5 min or 12 min of untreated cardiac arrest. MRCI was performed at baseline and at 1 h and 3.5 h after return of spontaneous circulation (ROSC). RESULTS In both groups, the conductivity of cerebral tissue significantly increased at 1 h after ROSC compared with that at baseline (P = 0.031 and 0.016 in the 5-min and 12-min groups, respectively). The increase was greater in the 12-min group, resulting in significantly higher conductivity values in the 12-min group (P = 0.030). At 3.5 h after ROSC, the conductivity of cerebral tissue in the 12-min group remained increased (P = 0.022), whereas that in the 5-min group returned to its baseline level. CONCLUSIONS The conductivity of cerebral tissue was increased in the first hours after ROSC, and the increase was more prominent and lasted longer in the 12-min group than in the 5-min group. Our findings suggest the promising potential of MRCI as a tool to estimate the severity of HIBI in the early hours after cardiac arrest.
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Affiliation(s)
- Yong Hun Jung
- Department of Emergency Medicine, Chonnam National University Hospital, 42 Jebong-ro, Donggu, Gwangju, 61469, Republic of Korea
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Hyoung Youn Lee
- Trauma Center, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Hospital, 42 Jebong-ro, Donggu, Gwangju, 61469, Republic of Korea
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Bup Kyung Choi
- Medical Science Research Institute, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Tae-Hoon Kim
- Medical Convergence Research Center, Wonkwang University, Iksan, Republic of Korea
| | - Jin Woong Kim
- Department of Radiology, Chosun University Hospital, Gwangju, Republic of Korea
| | - Hyun Chul Kim
- Department of Radiology, Chosun University Hospital, Gwangju, Republic of Korea
| | - Hyung Joong Kim
- Medical Science Research Institute, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Kyung Woon Jeung
- Department of Emergency Medicine, Chonnam National University Hospital, 42 Jebong-ro, Donggu, Gwangju, 61469, Republic of Korea.
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea.
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Gu Q, Yang S, Fei D, Lu Y, Yu H. A nomogram for predicting sepsis-associated delirium: a retrospective study in MIMIC III. BMC Med Inform Decis Mak 2023; 23:184. [PMID: 37715189 PMCID: PMC10503010 DOI: 10.1186/s12911-023-02282-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 09/02/2023] [Indexed: 09/17/2023] Open
Abstract
OBJECTIVE To develop a nomogram for predicting the occurrence of sepsis-associated delirium (SAD). MATERIALS AND METHODS Data from a total of 642 patients were retrieved from the Medical Information Mart for Intensive Care (MIMIC III) database to build a prediction model. Multivariate logistic regression was performed to identify independent predictors and establish a nomogram to predict the occurrence of SAD. The performance of the nomogram was assessed in terms of discrimination and calibration by bootstrapping with 1000 resamples. RESULTS Multivariate logistic regression identified 4 independent predictors for patients with SAD, including Sepsis-related Organ Failure Assessment(SOFA) (p = 0.004; OR: 1.131; 95% CI 1.040 to 1.231), mechanical ventilation (P < 0.001; OR: 3.710; 95% CI 2.452 to 5.676), phosphate (P = 0.047; OR: 1.165; 95% CI 1.003 to 1.358), and lactate (P = 0.023; OR: 1.135; 95% CI 1.021 to 1.270) within 24 h of intensive care unit (ICU) admission. The area under the curve (AUC) of the predictive model was 0.742 in the training set and 0.713 in the validation set. The Hosmer - Lemeshow test showed that the model was a good fit (p = 0.471). The calibration curve of the predictive model was close to the ideal curve in both the training and validation sets. The DCA curve also showed that the predictive nomogram was clinically useful. CONCLUSION We constructed a nomogram for the personalized prediction of delirium in sepsis patients, which had satisfactory performance and clinical utility and thus could help clinicians identify patients with SAD in a timely manner, perform early intervention, and improve their neurological outcomes.
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Affiliation(s)
- Qiong Gu
- Department of Emergency Medicine, The First Hospital of Jiaxing/Affiliated Hospital of Jiaxing University, Jiaxing, 314001, China
| | - Shucong Yang
- Department of Emergency Medicine, The First Hospital of Jiaxing/Affiliated Hospital of Jiaxing University, Jiaxing, 314001, China
| | - DanTing Fei
- Department of Emergency Medicine, The First Hospital of Jiaxing/Affiliated Hospital of Jiaxing University, Jiaxing, 314001, China
| | - Yuting Lu
- Department of Emergency Medicine, The First Hospital of Jiaxing/Affiliated Hospital of Jiaxing University, Jiaxing, 314001, China
| | - Huijie Yu
- Department of Emergency Medicine, The First Hospital of Jiaxing/Affiliated Hospital of Jiaxing University, Jiaxing, 314001, China.
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Mølstrøm S, Nielsen TH, Nordstrøm CH, Forsse A, Møller S, Venø S, Mamaev D, Tencer T, Theódórsdóttir Á, Krøigård T, Møller J, Hassager C, Kjærgaard J, Schmidt H, Toft P. A randomized, double-blind trial comparing the effect of two blood pressure targets on global brain metabolism after out-of-hospital cardiac arrest. Crit Care 2023; 27:73. [PMID: 36823636 PMCID: PMC9951410 DOI: 10.1186/s13054-023-04376-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/20/2023] [Indexed: 02/25/2023] Open
Abstract
PURPOSE This study aimed to assess the effect of different blood pressure levels on global cerebral metabolism in comatose patients resuscitated from out-of-hospital cardiac arrest (OHCA). METHODS In a double-blinded trial, we randomly assigned 60 comatose patients following OHCA to low (63 mmHg) or high (77 mmHg) mean arterial blood pressure (MAP). The trial was a sub-study in the Blood Pressure and Oxygenation Targets after Out-of-Hospital Cardiac Arrest-trial (BOX). Global cerebral metabolism utilizing jugular bulb microdialysis (JBM) and cerebral oxygenation (rSO2) was monitored continuously for 96 h. The lactate-to-pyruvate (LP) ratio is a marker of cellular redox status and increases during deficient oxygen delivery (ischemia, hypoxia) and mitochondrial dysfunction. The primary outcome was to compare time-averaged means of cerebral energy metabolites between MAP groups during post-resuscitation care. Secondary outcomes included metabolic patterns of cerebral ischemia, rSO2, plasma neuron-specific enolase level at 48 h and neurological outcome at hospital discharge (cerebral performance category). RESULTS We found a clear separation in MAP between the groups (15 mmHg, p < 0.001). Cerebral biochemical variables were not significantly different between MAP groups (LPR low MAP 19 (16-31) vs. high MAP 23 (16-33), p = 0.64). However, the LP ratio remained high (> 16) in both groups during the first 30 h. During the first 24 h, cerebral lactate > 2.5 mM, pyruvate levels > 110 µM, LP ratio > 30, and glycerol > 260 µM were highly predictive for poor neurological outcome and death with AUC 0.80. The median (IQR) rSO2 during the first 48 h was 69.5% (62.0-75.0%) in the low MAP group and 69.0% (61.3-75.5%) in the high MAP group, p = 0.16. CONCLUSIONS Among comatose patients resuscitated from OHCA, targeting a higher MAP 180 min after ROSC did not significantly improve cerebral energy metabolism within 96 h of post-resuscitation care. Patients with a poor clinical outcome exhibited significantly worse biochemical patterns, probably illustrating that insufficient tissue oxygenation and recirculation during the initial hours after ROSC were essential factors determining neurological outcome.
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Affiliation(s)
- Simon Mølstrøm
- Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense, Denmark.
| | - Troels Halfeld Nielsen
- grid.7143.10000 0004 0512 5013Department of Neurosurgery, Odense University Hospital, Odense, Denmark
| | - Carl-Henrik Nordstrøm
- grid.7143.10000 0004 0512 5013Department of Neurosurgery, Odense University Hospital, Odense, Denmark
| | - Axel Forsse
- grid.4973.90000 0004 0646 7373Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Søren Møller
- grid.7143.10000 0004 0512 5013OPEN, Open Patient Data Explorative Network, Odense University Hospital, Odense, Denmark ,grid.10825.3e0000 0001 0728 0170Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Søren Venø
- grid.7143.10000 0004 0512 5013Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Dmitry Mamaev
- grid.7143.10000 0004 0512 5013Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Tomas Tencer
- grid.7143.10000 0004 0512 5013Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Ásta Theódórsdóttir
- grid.7143.10000 0004 0512 5013Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Thomas Krøigård
- grid.7143.10000 0004 0512 5013Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Jacob Møller
- grid.4973.90000 0004 0646 7373The Heart Centre, Copenhagen University Hospital, Copenhagen, Denmark ,grid.7143.10000 0004 0512 5013Department of Cardiology, Odense University Hospital, Odense, Denmark ,grid.10825.3e0000 0001 0728 0170Department of Clinical Medicine, University of Southern, Odense, Denmark
| | - Christian Hassager
- grid.4973.90000 0004 0646 7373The Heart Centre, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jesper Kjærgaard
- grid.4973.90000 0004 0646 7373The Heart Centre, Copenhagen University Hospital, Copenhagen, Denmark
| | - Henrik Schmidt
- grid.7143.10000 0004 0512 5013Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Palle Toft
- grid.7143.10000 0004 0512 5013Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
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Vammen L, Johannsen CM, Magnussen A, Povlsen A, Petersen SR, Azizi A, Pedersen M, Korshøj AR, Ringgaard S, Løfgren B, Andersen LW, Granfeldt A. Cerebral monitoring in a pig model of cardiac arrest with 48 h of intensive care. Intensive Care Med Exp 2022; 10:45. [PMID: 36284020 PMCID: PMC9596181 DOI: 10.1186/s40635-022-00475-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 10/17/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Neurological injury is the primary cause of death after out-of-hospital cardiac arrest. There is a lack of studies investigating cerebral injury beyond the immediate post-resuscitation phase in a controlled cardiac arrest experimental setting. METHODS The aim of this study was to investigate temporal changes in measures of cerebral injury and metabolism in a cardiac arrest pig model with clinically relevant post-cardiac arrest intensive care. A cardiac arrest group (n = 11) underwent 7 min of no-flow and was compared with a sham group (n = 6). Pigs underwent intensive care with 24 h of hypothermia at 33 °C. Blood markers of cerebral injury, cerebral microdialysis, and intracranial pressure (ICP) were measured. After 48 h, pigs underwent a cerebral MRI scan. Data are presented as median [25th; 75th percentiles]. RESULTS Return of spontaneous circulation was achieved in 7/11 pigs. Time to ROSC was 4.4 min [4.2; 10.9]. Both NSE and NfL increased over time (p < 0.001), and were higher in the cardiac arrest group at 48 h (NSE 4.2 µg/L [2.4; 6.1] vs 0.9 [0.7; 0.9], p < 0.001; NfL 63 ng/L [35; 232] vs 29 [21; 34], p = 0.02). There was no difference in ICP at 48 h (17 mmHg [14; 24] vs 18 [13; 20], p = 0.44). The cerebral lactate/pyruvate ratio had secondary surges in 3/7 cardiac arrest pigs after successful resuscitation. Apparent diffusion coefficient was lower in the cardiac arrest group in white matter cortex (689 × 10-6 mm2/s [524; 765] vs 800 [799; 815], p = 0.04) and hippocampus (854 [834; 910] vs 1049 [964; 1180], p = 0.03). N-Acetylaspartate was lower on MR spectroscopy in the cardiac arrest group (- 17.2 log [- 17.4; - 17.0] vs - 16.9 [- 16.9; - 16.9], p = 0.03). CONCLUSIONS We have developed a clinically relevant cardiac arrest pig model that displays cerebral injury as marked by NSE and NfL elevations, signs of cerebral oedema, and reduced neuron viability. Overall, the burden of elevated ICP was low in the cardiac arrest group. A subset of pigs undergoing cardiac arrest had persisting metabolic disturbances after successful resuscitation.
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Affiliation(s)
- Lauge Vammen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Palle Juul Jensens Blvd. 99 G304, 8200, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Cecilie Munch Johannsen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Palle Juul Jensens Blvd. 99 G304, 8200, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Andreas Magnussen
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Amalie Povlsen
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
- Department of Cardiothoracic Anesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Arezo Azizi
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Michael Pedersen
- Comparative Medicine Laboratory, Aarhus University, Aarhus N, Denmark
| | - Anders Rosendal Korshøj
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
- Department of Neurosurgery, Aarhus University Hospital, Aarhus N, Denmark
| | | | - Bo Løfgren
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus N, Denmark
- Department of Medicine, Randers Regional Hospital, Randers, Denmark
| | - Lars W Andersen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Palle Juul Jensens Blvd. 99 G304, 8200, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
- Prehospital Emergency Medical Services, Central Denmark Region, Aarhus N, Denmark
| | - Asger Granfeldt
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Palle Juul Jensens Blvd. 99 G304, 8200, Aarhus N, Denmark.
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark.
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Lu Y, Shen R, Lin W, Zhou X, Hu J, Zhang Q. Association between blood pressure variability and clinical outcomes after successful recanalization in patients with large vessel occlusion stroke after mechanical thrombectomy. Front Neurol 2022; 13:967395. [PMID: 36034274 PMCID: PMC9399916 DOI: 10.3389/fneur.2022.967395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 07/18/2022] [Indexed: 11/24/2022] Open
Abstract
Objective Nearly half of patients who undergo mechanical thrombectomy (MT) do not experience a favorable outcome. The association between blood pressure fluctuation and clinical outcomes after successful MT is controversial. We evaluated the influence of blood pressure variability (BPV) on the clinical outcomes of stroke patients with large vessel occlusion (LVO) who underwent successful recanalization after MT. Methods Patients with anterior circulation LVO stroke who underwent successful emergency MT (modified Thrombolysis in Cerebral Infarction, mTICI ≥ 2b) at the Shanghai Tenth People's Hospital of Tongji University from 2017 to 2021 were enrolled. Multivariate logistic models were used to investigate the association between BPV (mean arterial pressure [MAP] assessed using the standard deviation [SD]) and clinical outcomes. The primary outcome was 90-day modified Rankin Scale scores (mRS), and the secondary outcomes were 30-day mortality and symptomatic intracranial hemorrhage (sICH). Results A total of 458 patients (56.8% men), with a mean age of 72 ± 1 years, were enrolled. Among them, 207 (45.2%) patients had unfavorable functional outcomes (mRS score 3–6) at 90 days, 61 (13.3%) patients died within 30 days, and 20 (4.4%) patients had sICH. In a fully adjusted model, BPV was associated with a higher risk of a 90-day mRS score of 3–6 (P = 0.04), 30-day mortality (P < 0.01), and sICH (P < 0.01). A significant interaction between MAP SD and rescue futile recanalization treatment was observed (P < 0.01). Conclusions Among patients with LVO stroke who underwent successful recanalization, higher BPV was associated with worse functional outcomes, especially in those who underwent rescue treatment.
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Affiliation(s)
- You Lu
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Rui Shen
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wenjian Lin
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiaoyu Zhou
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jian Hu
- Department of Radiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
- Jian Hu
| | - Quanbin Zhang
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
- *Correspondence: Quanbin Zhang
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Nordström CH, Forsse A, Jakobsen RP, Mölström S, Nielsen TH, Toft P, Ungerstedt U. Bedside interpretation of cerebral energy metabolism utilizing microdialysis in neurosurgical and general intensive care. Front Neurol 2022; 13:968288. [PMID: 36034291 PMCID: PMC9399721 DOI: 10.3389/fneur.2022.968288] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/11/2022] [Indexed: 12/02/2022] Open
Abstract
The microdialysis technique was initially developed for monitoring neurotransmitters in animals. In 1995 the technique was adopted to clinical use and bedside enzymatic analysis of glucose, pyruvate, lactate, glutamate and glycerol. Under clinical conditions microdialysis has also been used for studying cytokines, protein biomarkers, multiplex proteomic and metabolomic analyses as well as for pharmacokinetic studies and evaluation of blood-brain barrier function. This review focuses on the variables directly related to cerebral energy metabolism and the possibilities and limitations of microdialysis during routine neurosurgical and general intensive care. Our knowledge of cerebral energy metabolism is to a large extent based on animal experiments performed more than 40 years ago. However, the different biochemical information obtained from various techniques should be recognized. The basic animal studies analyzed brain tissue homogenates while the microdialysis technique reflects the variables in a narrow zone of interstitial fluid surrounding the probe. Besides the difference of the volume investigated, the levels of the biochemical variables differ in different compartments. During bedside microdialysis cerebral energy metabolism is primarily reflected in measured levels of glucose, lactate and pyruvate and the lactate to pyruvate (LP) ratio. The LP ratio reflects cytoplasmatic redox-state which increases instantaneously during insufficient aerobic energy metabolism. Cerebral ischemia is characterized by a marked increase in intracerebral LP ratio at simultaneous decreases in intracerebral levels of pyruvate and glucose. Mitochondrial dysfunction is characterized by a moderate increase in LP ratio at a very marked increase in cerebral lactate and normal or elevated levels of pyruvate and glucose. The patterns are of importance in particular for interpretations in transient cerebral ischemia. A new technique for evaluating global cerebral energy metabolism by microdialysis of the draining cerebral venous blood is discussed. In experimental studies it has been shown that pronounced global cerebral ischemia is reflected in venous cerebral blood. Jugular bulb microdialysis has been investigated in patients suffering from subarachnoid hemorrhage, during cardiopulmonary bypass and resuscitation after out of hospital cardiac arrest. Preliminary results indicate that the new technique may give valuable information of cerebral energy metabolism in clinical conditions when insertion of an intracerebral catheter is contraindicated.
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Affiliation(s)
- Carl-Henrik Nordström
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
- *Correspondence: Carl-Henrik Nordström
| | - Axel Forsse
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
| | - Rasmus Peter Jakobsen
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Simon Mölström
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | | | - Palle Toft
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Urban Ungerstedt
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
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Chi CY, Tsai MS, Kuo LK, Hsu HH, Huang WC, Lai CH, Chang HCH, Tsai CL, Huang CH. Post-resuscitation diastolic blood pressure is a prognostic factor for outcomes of cardiac arrest patients: a multicenter retrospective registry-based analysis. J Intensive Care 2022; 10:39. [PMID: 35933429 PMCID: PMC9356498 DOI: 10.1186/s40560-022-00631-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 07/30/2022] [Indexed: 12/03/2022] Open
Abstract
Background Post-resuscitation hemodynamic level is associated with outcomes. This study was conducted to investigate if post-resuscitation diastolic blood pressure (DBP) is a favorable prognostic factor. Methods Using TaIwan Network of Targeted Temperature ManagEment for CARDiac Arrest (TIMECARD) registry, we recruited adult patients who received targeted temperature management in nine medical centers between January 2014 and September 2019. After excluding patients with extracorporeal circulation support, 448 patients were analyzed. The first measured, single-point blood pressure after resuscitation was used for analysis. Study endpoints were survival to discharge and discharge with favorable neurologic outcomes (CPC 1–2). Multivariate analysis, area under the receiver operating characteristic curve (AUC), and generalized additive model (GAM) were used for analysis. Results Among the 448 patients, 182 (40.7%) patients survived, and 89 (19.9%) patients had CPC 1–2. In the multivariate analysis, DBP > 70 mmHg was an independent factor for survival (adjusted odds ratio [aOR] 2.16, 95% confidence interval [CI, 1.41–3.31]) and > 80 mmHg was an independent factor for CPC 1–2 (aOR 2.04, 95% CI [1.14–3.66]). GAM confirmed that DBP > 80 mmHg was associated with a higher likelihood of CPC 1–2. In the exploratory analysis, patients with DBP > 80 mmHg had a significantly higher prevalence of cardiogenic cardiac arrest (p = 0.015) and initial shockable rhythm (p = 0.045). Conclusion We found that DBP after resuscitation can predict outcomes, as a higher DBP level correlated with cardiogenic cardiac arrest.
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Affiliation(s)
- Chien-Yu Chi
- Department of Emergency Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin, Taiwan.,Graduate Institute of Clinical Medicine, Medical College, National Taiwan University, Taipei, Taiwan
| | - Min-Shan Tsai
- Department of Emergency Medicine, National Taiwan University Hospital, #7, Chung-Shan South Road, Taipei, 100, Taiwan
| | - Li-Kuo Kuo
- Department of Critical Care Medicine, MacKay Memorial Hospital, Taipei branch, Taiwan
| | - Hsin-Hui Hsu
- Department of Critical Care Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Wei-Chun Huang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chih-Hung Lai
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Herman Chih-Heng Chang
- Department of Emergency and Critical Care Medicine, Fu-Jen Catholic University Hospital, New Taipei City, Taiwan
| | - Chu-Lin Tsai
- Department of Emergency Medicine, National Taiwan University Hospital, #7, Chung-Shan South Road, Taipei, 100, Taiwan
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Hospital, #7, Chung-Shan South Road, Taipei, 100, Taiwan.
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Grand J, Hassager C, Schmidt H, Møller JE, Mølstrøm S, Nyholm B, Kjaergaard J. Hemodynamic evaluation by serial right heart catheterizations after cardiac arrest; protocol of a sub-study from the Blood Pressure and Oxygenation Targets after Out-of-Hospital Cardiac Arrest-trial (BOX). Resusc Plus 2021; 8:100188. [PMID: 34950913 PMCID: PMC8671111 DOI: 10.1016/j.resplu.2021.100188] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/20/2021] [Accepted: 11/22/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Neurological injury and mortality remain high in comatose patients resuscitated from out-of-hospital cardiac arrest (OHCA). Hypotension and hypoxia during post-resuscitation care have been associated with poor outcome, but the optimal oxygenation- and blood pressure-targets are unknown. The impact of different doses of norepinephrine on advanced hemodynamic after OHCA and the impact of different oxygenation-targets on pulmonary circulation and resistance (PVR), are unknown. The aims of this substudy of the "Blood pressure and oxygenations targets after out-of-hospital cardiac arrest (BOX)"-trial are to investigate the effect of two different MAP- and oxygenation-targets on advanced systemic and pulmonary hemodynamics measured by pulmonary artery catheters (PAC). METHODS The BOX-trial is an investigator-initiated, randomized, controlled study comparing targeted MAP of 63 mmHg vs 77 mmHg (double-blinded intervention) and 9-10 kPa versus PaO2 of 13-14 kPa oxygenation-targets (open-label). Per protocol, all patients will be monitored systematically with PACs. The primary endpoint of the hemodynamic-substudy is cardiac output for the MAP-intervention, and PVR for the oxygenation-intervention. For both endpoints, the difference within 48 h between groups are assessed. Secondary endpoints are pulmonary capillary wedge pressure and pulmonary arterial pressure and association between advanced hemodynamic variables and mortality and biomarkers of inflammation and brain injury. DISCUSSION In the BOX-trial, patients will be randomly allocated to two levels of MAP and oxygenation, which are central parts of post-resuscitation care and where evidence is sparse. The advanced-hemodynamic substudy will give valuable knowledge of the hemodynamic consequences of changing blood pressure and oxygen-levels of the critical cardiac patient. It will be one of the largest clinical, prospective trials of advanced hemodynamics measured by serial PACs in consecutive comatose patients, resuscitated after OHCA. The randomized and placebo-controlled trialdesign of the MAP-intervention minimizes risk of selection bias and confounders. Furthermore, hemodynamic characteristics and associations with outcome will be investigated. TRIAL REGISTRATION ClinicalTrials.gov (ClinicalTrials.gov Identifier: NCT03141099). Registered March 30, 2017.
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Affiliation(s)
- Johannes Grand
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Henrik Schmidt
- Department of Anesthesiology and Intensive Care, Odense University Hospital, 5000 Odense C, Denmark
| | - Jacob E. Møller
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
- Department of Cardiology, Odense University Hospital, 5000 C Odense, Denmark
| | - Simon Mølstrøm
- Department of Cardiology, Odense University Hospital, 5000 C Odense, Denmark
| | - Benjamin Nyholm
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
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Grand J, Wiberg S, Kjaergaard J, Wanscher M, Hassager C. Increasing mean arterial pressure or cardiac output in comatose out-of-hospital cardiac arrest patients undergoing targeted temperature management: Effects on cerebral tissue oxygenation and systemic hemodynamics. Resuscitation 2021; 168:199-205. [PMID: 34461205 DOI: 10.1016/j.resuscitation.2021.08.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/19/2021] [Accepted: 08/20/2021] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Few data exist on the effects of increasing norepinephrine doses or increasing arterial CO2 (PaCO2) on hemodynamics and cerebral oxygenation in comatose out-of-hospital cardiac arrest (OHCA) patients. METHODS We prospectively studied 10 resuscitated OHCA-patients undergoing targeted temperature management (36C°). The trial consisted of 5 phases with 20 minutes steady state in-between: Phase 1-4 were increasing doses of norepinephrine to reach targets of mean arterial pressure (MAP). First 65, second 75, third 85, fourth 65 mmHg again. In the fifth phase, MAP was constant while PaCO2 was increased to 6.5-7.3 kPa to increase cardiac output. Primary outcome was cerebral near-infrared spectroscopy (NIRS). Secondary outcomes were hemodynamic variables from Swan-Ganz catheters and blood samples from the radial artery and jugular bulb. RESULTS To reach a MAP at 85 mmHg, norepinephrine was increased from 0.11 ± 0.02 to 0.18 ± 0.02 µg/kg/min (P < 0.001). Norepinephrine uptitration significantly increased systemic vascular resistance (SVR) and pulmonary vascular resistance, without affecting cardiac output, heart rate or cerebral oxygenation. Increasing PaCO2, resulted in a significant increase in cardiac output and cerebral NIRS, but arterial-venous cerebral oxygen-uptake decreased. Norepinephrine demand to keep MAP at 65 mmHg was unaffected by increasing PaCO2. CONCLUSIONS A short-term increase in MAP with norepinephrine in resuscitated comatose cardiac arrest-patients is associated with increased SVR and pulmonary vascular resistance without affecting cardiac output or cerebral NIRS. Increased cardiac output caused by an increase in PaCO2 increased cerebral NIRS, but not cerebral oxygen uptake.
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Affiliation(s)
- Johannes Grand
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark.
| | - Sebastian Wiberg
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Michael Wanscher
- Department of Cardiothoracic Anaesthesia 4142, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
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Skrifvars MB. Hunting high and low for the right blood pressure after cardiac arrest. Resuscitation 2021; 167:385-386. [PMID: 34363857 DOI: 10.1016/j.resuscitation.2021.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 07/22/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
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