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DiNardo JA. Nadir Temperature During Neonatal Cardiac Surgery and Neurologic Outcome. J Am Coll Cardiol 2024; 84:464-466. [PMID: 39048278 DOI: 10.1016/j.jacc.2024.05.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 05/01/2024] [Indexed: 07/27/2024]
Affiliation(s)
- James A DiNardo
- Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts, USA.
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Shuto T, Anai H, Wada T, Kawashima T, Mori K, Miyamoto S. Low-flow perfusion technique for shaggy aortic arch. Gen Thorac Cardiovasc Surg 2024; 72:439-446. [PMID: 37995016 DOI: 10.1007/s11748-023-01988-7] [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: 08/07/2023] [Accepted: 10/28/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND The most common complication of thoracic aortic disease with shaggy aorta is cerebral infarction. We have performed "low-flow perfusion" as a method of extracorporeal circulation to prevent cerebral embolism in patients with strong atherosclerotic lesions in the aortic arch. METHODS "Low-flow perfusion" is a method in which cardiopulmonary bypass is started by partial blood removal, approaching deep hypothermia while maintaining self-cardiac output. We compared the outcomes of 12 patients who underwent the "low-flow perfusion" method (Group L) with those of 12 who underwent normal extracorporeal circulation (Group N) during aortic arch surgery since 2019. RESULTS Group L consisted of 8 males with an average age of 73 years old, and Group N consisted of 6 males with an average age of 73 years old. The average time from the start of cooling to ventricular fibrillation was 9.5 min in Group L and 3.6 min in Group N (p < 0.01). The eardrum temperature when ventricular fibrillation was reached was 28.2 °C in Group L and 32.5 °C in Group N (p = 0.01). A blood flow analysis also revealed low wall shear stress on the lesser curvature of the aortic arch. CONCLUSION With this method, the intracranial temperature was sufficiently low at the time of ventricular fibrillation, and there was no need to increase the total pump flow. The low-flow perfusion method can prevent cerebral embolism by preventing atheroma destruction by the blood flow jet while maintaining the self-cardiac output during the cooling process.
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Affiliation(s)
- Takashi Shuto
- Department of Cardiovascular Surgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-Machi, Yufu-Shi, Oita, 879-5593, Japan.
| | - Hirofumi Anai
- Department of Cardiovascular Surgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-Machi, Yufu-Shi, Oita, 879-5593, Japan
| | - Tomoyuki Wada
- Department of Cardiovascular Surgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-Machi, Yufu-Shi, Oita, 879-5593, Japan
| | - Takayuki Kawashima
- Department of Cardiovascular Surgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-Machi, Yufu-Shi, Oita, 879-5593, Japan
| | - Kazuki Mori
- Department of Cardiovascular Surgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-Machi, Yufu-Shi, Oita, 879-5593, Japan
| | - Shinji Miyamoto
- Department of Cardiovascular Surgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-Machi, Yufu-Shi, Oita, 879-5593, Japan
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3
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Klüß C, Giesbrecht A, Rudloff M, von Dossow V, Sandica E, Gummert J. Practical training concept for perfusionists at the heart and diabetes center Nordrhein-Westfalen. Perfusion 2024:2676591241248539. [PMID: 38647438 DOI: 10.1177/02676591241248539] [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: 04/25/2024]
Abstract
BACKGROUND Increasing regulations and requirements of advisory bodies, in particular the Joint Federal Committee and the Medical Service of the health insurance funds, make it necessary to employ only demonstrably well-trained perfusionists. The minimum requirement for this staff is EBCP certification. Currently there is limited availability of such specialists on the German market. Therefore, the qualification of young people in this area is of central importance. The aim of this paper is to strengthen the training of perfusionists at our centre, to standardise the process and to provide the respective student with a "roadmap" to their internship. MATERIAL & METHODS The structure is based on a rough division of the 24 weeks of internship. This is described in detail in the following and is backed up with the learning objectives for the respective time periods. RESULTS At our centre, practical training has been standardized and clear responsibilities have been defined. Furthermore, as a centre of maximum care in the field of cardiac surgery, we can offer students the necessary number of perfusions in just six months to meet the requirements of the ECBP for practical training. According to this concept, 20 perfusionists have been successfully trained in the last 8 years. All of them have passed the exams and have been certified according to EBCP. CONCLUSION The aim of the practical semester is for the student to be in a position at the end of the semester to independently supervise simple cardiac surgery procedures with the aid of the Extra- Corporal Circulation (ECC) and to carry this out in accordance with the currently valid guidelines and directives (1-8) and the departmental procedural instructions based on them. Great emphasis is placed to the students becoming aware of their competence to act, knowing their limits and being able to assess when these limits have been reached and the involvement of experienced colleagues is necessary to ensure patient safety.
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Affiliation(s)
- Christian Klüß
- Heart and Diabetes Center NRW, Department of Clinical Perfusion, Bad Oeynhausen, Germany
| | - André Giesbrecht
- Heart and Diabetes Center NRW, Department of Clinical Perfusion, Bad Oeynhausen, Germany
| | - Markus Rudloff
- Heart and Diabetes Center NRW, Department of Clinical Perfusion, Bad Oeynhausen, Germany
| | - Vera von Dossow
- Heart and Diabetes Center NRW, Institute of Anaesthesiology and Pain Therapy, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Eugen Sandica
- Heart and Diabetes Center NRW, Department of Pediatric Cardiac Surgery and Congenital Heart Defects, Bad Oeynhausen, Germany
| | - Jan Gummert
- Heart and Diabetes Center NRW, Department of Thoracic and Cardiovascular Surgery, Ruhr University Bochum, Bad Oeynhausen, Germany
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Subedi A, Khanal K, Regmi A, Panday S, Yadav R, Nakarmi P, Shrestha E, Prasai P, McHenry R, Karki S. Hypothermic Cardiac Arrest: A Case Report of an Unexpected Survivor Using Air Medical Transportation in Nepal. Air Med J 2024; 43:171-173. [PMID: 38490783 DOI: 10.1016/j.amj.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 11/14/2023] [Accepted: 11/18/2023] [Indexed: 03/17/2024]
Abstract
This is a case of a 34-year-old man surviving hypothermic cardiac arrest with excellent neurologic recovery in Nepal. After 3 days without communication at an altitude of approximately 6,000 m, the patient was located in a crevasse and retrieved by a helicopter-supported search and rescue team. At first contact, he was reported to be breathing and shivering with appropriate pupillary response. The patient was then flown to a local teaching hospital where he was assessed on arrival and found to be in cardiac arrest with absence of spontaneous breathing and a central pulse and bilaterally fixed and dilated pupils. An electrocardiogram demonstrated asystole, and his core temperature was unrecordably low on the available device. After resuscitation and return of spontaneous circulation, the patient received a secondary helicopter transfer to a major hospital in the capital, Kathmandu, where his recovery continued. The report discusses the physiological basis of the relatively favorable outcomes observed in hypothermic cardiac arrest and highlights the operations and capability of helicopter emergency medical services in a country on the United Nations list of least developed nations.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Ryan McHenry
- Glasgow, Scottish Ambulance Service, Edinburgh, Scotland, UK.
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Flickinger KL, Weissman A, Elmer J, Coppler PJ, Guyette FX, Repine MJ, Dezfulian C, Hopkins D, Frisch A, Doshi AA, Rittenberger JC, Callaway CW. Metabolic Manipulation and Therapeutic Hypothermia. Ther Hypothermia Temp Manag 2024; 14:46-51. [PMID: 37405749 DOI: 10.1089/ther.2023.0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023] Open
Abstract
Hypothermia has multiple physiological effects, including decreasing metabolic rate and oxygen consumption (VO2). There are few human data about the magnitude of change in VO2 with decreases in core temperature. We aimed to quantify to magnitude of reduction in resting VO2 as we reduced core temperature in lightly sedated healthy individuals. After informed consent and physical screening, we cooled participants by rapidly infusing 20 mL/kg of cold (4°C) saline intravenously and placing surface cooling pads on the torso. We attempted to suppress shivering using a 1 mcg/kg intravenous bolus of dexmedetomidine followed by titrated infusion at 1.0 to 1.5 μg/(kg·h). We measured resting metabolic rate VO2 through indirect calorimetry at baseline (37°C) and at 36°C, 35°C, 34°C, and 33°C. Nine participants had mean age 30 (standard deviation 10) years and 7 (78%) were male. Baseline VO2 was 3.36 mL/(kg·min) (interquartile range 2.98-3.76) mL/(kg·min). VO2 was associated with core temperature and declined with each degree decrease in core temperature, unless shivering occurred. Over the entire range from 37°C to 33°C, median VO2 declined 0.7 mL/(kg·min) (20.8%) in the absence of shivering. The largest average decrease in VO2 per degree Celsius was by 0.46 mL/(kg·min) (13.7%) and occurred between 37°C and 36°C in the absence of shivering. After a participant developed shivering, core body temperature did not decrease further, and VO2 increased. In lightly sedated humans, metabolic rate decreases around 5.2% for each 1°C decrease in core temperature from 37°C to 33°C. Because the largest decrease in metabolic rate occurs between 37°C and 36°C, subclinical shivering or other homeostatic reflexes may be present at lower temperatures.
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Affiliation(s)
- Katharyn L Flickinger
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alexandra Weissman
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Critical Care, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Patrick J Coppler
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Melissa J Repine
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Cameron Dezfulian
- Department of Critical Care, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Critical Care, Baylor College of Medicine, Houston, Texas, USA
- Critical Care, Texas Children's Hospital, Houston, Texas, USA
| | - David Hopkins
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Adam Frisch
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ankur A Doshi
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jon C Rittenberger
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Occupational Therapy, University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, Pennsylvania, USA
- Department of Emergency Medicine, Guthrie Medical Group, Sayre, Pennsylvania, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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6
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Wang L, Zhong G, Lv X, Dong Y, Hou Y, Chen L. Clinical outcomes of mild versus moderate hypothermic circulatory arrest with antegrade cerebral perfusion in adult aortic arch surgery: A systematic review and meta-analysis. Perfusion 2024; 39:266-280. [PMID: 36476142 DOI: 10.1177/02676591221144169] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
OBJECTIVES In adult aortic arch surgery, moderate hypothermic circulatory arrest (HCA) with selective antegrade cerebral perfusion (SACP) (MoHACP) is widely used, but the application of mild HCA with SACP (MiHACP) is still controversial. This meta-analysis aimed to compare clinical outcomes using MiHACP or MoHACP. METHODS Studies comparing outcomes of MiHACP or MoHACP in adult aortic arch surgery were searched from four databases from inception through April 2022. Primary outcomes were postoperative permanent neurological deficit (PND), temporary neurological deficit (TND), and mortality. Secondary outcomes included other common complications. Meta-analysis was conducted using a random-effects model in all cases. RESULTS Eleven comparative studies were included, with 1555 patients in MiHACP group and 1499 patients in MoHACP group, and the mean HCA temperature were 29.4°C and 24.8°C, respectively. Postoperative PND, TND, mortality, paraplegia, dialysis, tracheotomy, reexploration for bleeding, and chest tube drainage volume were comparable in the two groups (p > 0.05). Ventilator time, intensive care unit and in-hospital length of stay were shorter in MiHACP group (p < 0.05). Outcomes were also comparable or had some benefits in MiHACP group when subgroup analyses were conducted according to hemiarch or total arch replacement, unilateral or bilateral SACP, HCA time, emergency aortic dissection surgery, and concomitant procedure. CONCLUSION The present meta-analysis showed acceptability of MiHACP in adult aortic arch surgery. Results need to be taken with caution as moderate risk of bias and very low quality of evidence were observed in this meta-analysis. Randomized controlled trials are needed for further analysis.
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Affiliation(s)
- Lei Wang
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, China
| | - Guodong Zhong
- Department of Pathology, the Second People's Hospital, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Xiaochai Lv
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, China
| | - Yi Dong
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, China
| | - Yanting Hou
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, China
| | - Liangwan Chen
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, China
- Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, China
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7
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Hughes GC, Chen EP, Browndyke JN, Szeto WY, DiMaio JM, Brinkman WT, Gaca JG, Blumenthal JA, Karhausen JA, Bisanar T, James ML, Yanez D, Li YJ, Mathew JP. Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest Trial (GOT ICE): A Randomized Clinical Trial Comparing Outcomes After Aortic Arch Surgery. Circulation 2024; 149:658-668. [PMID: 38084590 PMCID: PMC10922813 DOI: 10.1161/circulationaha.123.067022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 11/10/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND Deep hypothermia has been the standard for hypothermic circulatory arrest (HCA) during aortic arch surgery. However, centers worldwide have shifted toward lesser hypothermia with antegrade cerebral perfusion. This has been supported by retrospective data, but there has yet to be a multicenter, prospective randomized study comparing deep versus moderate hypothermia during HCA. METHODS This was a randomized single-blind trial (GOT ICE [Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest]) of patients undergoing arch surgery with HCA plus antegrade cerebral perfusion at 4 US referral aortic centers (August 2016-December 2021). Patients were randomized to 1 of 3 hypothermia groups: DP, deep (≤20.0 °C); LM, low-moderate (20.1-24.0 °C); and HM, high-moderate (24.1-28.0 °C). The primary outcome was composite global cognitive change score between baseline and 4 weeks postoperatively. Analysis followed the intention-to-treat principle to evaluate if: (1) LM noninferior to DP on global cognitive change score; (2) DP superior to HM. The secondary outcomes were domain-specific cognitive change scores, neuroimaging findings, quality of life, and adverse events. RESULTS A total of 308 patients consented; 282 met inclusion and were randomized. A total of 273 completed surgery, and 251 completed the 4-week follow-up (DP, 85 [34%]; LM, 80 [34%]; HM, 86 [34%]). Mean global cognitive change score from baseline to 4 weeks in the LM group was noninferior to the DP group; likewise, no significant difference was observed between DP and HM. Noninferiority of LM versus DP, and lack of difference between DP and HM, remained for domain-specific cognitive change scores, except structured verbal memory, with noninferiority of LM versus DP not established and structured verbal memory better preserved in DP versus HM (P = 0.036). There were no significant differences in structural or functional magnetic resonance imaging brain imaging between groups postoperatively. Regardless of temperature, patients who underwent HCA demonstrated significant reductions in cerebral gray matter volume, cortical thickness, and regional brain functional connectivity. Thirty-day in-hospital mortality, major morbidity, and quality of life were not different between groups. CONCLUSIONS This randomized multicenter study evaluating arch surgery HCA temperature strategies found low-moderate hypothermia noninferior to traditional deep hypothermia on global cognitive change 4 weeks after surgery, although in secondary analysis, structured verbal memory was better preserved in the deep group. The verbal memory differences in the low- and high-moderate groups and structural and functional connectivity reductions from baseline merit further investigation and suggest opportunities to further optimize brain perfusion during HCA. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02834065.
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Affiliation(s)
- G Chad Hughes
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery (G.C.H., E.P.C., J.G.G.), Duke University Medical Center, Durham, NC
| | - Edward P Chen
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery (G.C.H., E.P.C., J.G.G.), Duke University Medical Center, Durham, NC
| | - Jeffrey N Browndyke
- Department of Psychiatry & Behavioral Sciences, Division of Behavioral Medicine & Neurosciences (J.N.B., J.A.B.), Duke University Medical Center, Durham, NC
| | - Wilson Y Szeto
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia (W.Y.S.)
| | - J Michael DiMaio
- The Heart Hospital, Baylor Scott and White, Plano, TX (J.M.D., W.T.B.)
| | | | - Jeffrey G Gaca
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery (G.C.H., E.P.C., J.G.G.), Duke University Medical Center, Durham, NC
| | - James A Blumenthal
- Department of Psychiatry & Behavioral Sciences, Division of Behavioral Medicine & Neurosciences (J.N.B., J.A.B.), Duke University Medical Center, Durham, NC
| | - Jorn A Karhausen
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
| | - Tiffany Bisanar
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
| | - Michael L James
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
- Department of Neurology (M.L.J.), Duke University School of Medicine, Durham, NC
| | - David Yanez
- Department of Biostatistics and Bioinformatics (D.Y., Y.-J.L.), Duke University School of Medicine, Durham, NC
| | - Yi-Ju Li
- Department of Biostatistics and Bioinformatics (D.Y., Y.-J.L.), Duke University School of Medicine, Durham, NC
| | - Joseph P Mathew
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
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Rybar D. Deep Hypothermic Circulatory Arrest: A Brief History and Where It Is Going. J Cardiothorac Vasc Anesth 2024; 38:560-562. [PMID: 38228425 DOI: 10.1053/j.jvca.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 11/03/2023] [Indexed: 01/18/2024]
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9
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Qin X, Chen X, Zhao X, Yao L, Li B, Pan G, Xu J, Jiang R, Zhao Z, Liang Z, Guo X, Huang J, Li X. Evaluation of brain function in adult patent ductus arteriosus surgery: A multimodal monitoring approach. Curr Probl Cardiol 2024; 49:102334. [PMID: 38142948 DOI: 10.1016/j.cpcardiol.2023.102334] [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: 11/16/2023] [Revised: 12/04/2023] [Accepted: 12/12/2023] [Indexed: 12/26/2023]
Abstract
Adult patent ductus arteriosus (PDA) repair surgery often involves hypothermic cardiopulmonary bypass (CPB) and is associated with postoperative neurological complications. Our study evaluates brain function during PDA surgery using regional cerebral oxygen saturation (rSO2) and bispectral index (BIS) monitoring to mitigate these complications. Patients were categorized into moderate (26-31 ℃) and mild (32-35 ℃) hypothermia groups. Findings indicate a positive correlation between PDA diameter and pulmonary artery systolic blood pressure, and a strong correlation between delirium and average rSO2-AUC. The mild hypothermia group had longer extubation and hospitalization times. During CPB, rSO2 levels fluctuated significantly, and EEG analysis revealed changes in brain wave patterns. One case of nerve injury in the mild hypothermia group showed incomplete recovery after a year. Our results advocate for moderate hypothermia during CPB in adult PDA repair, suggesting that combined rSO2 and BIS monitoring can reduce neurological complications post-surgery.
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Affiliation(s)
- Xuewei Qin
- Department of Anesthesiology, Peking University International Hospital, Beijing 102206, China
| | - Xuanling Chen
- Department of Anesthesiology, Peking University International Hospital, Beijing 102206, China
| | - Xin Zhao
- Department of Anesthesiology, Peking University International Hospital, Beijing 102206, China
| | - Lan Yao
- Department of Anesthesiology, Peking University International Hospital, Beijing 102206, China.
| | - Bin Li
- Department of Cardiac Surgery, Peking University International Hospital, Beijing 102206, China
| | - Guangyu Pan
- Department of Cardiac Surgery, Peking University International Hospital, Beijing 102206, China
| | - Jianping Xu
- Department of Cardiac Surgery, Peking University International Hospital, Beijing 102206, China; Department of Cardiac Surgery, National Center for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Rui Jiang
- Department of Cardiac Surgery, National Center for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | | | | | - Xiangyang Guo
- Department of Anesthesiology, Peking University Third Hospital, Beijing 100191, China
| | - Jiapeng Huang
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY 40202, USA
| | - Xiaoli Li
- The State Key Laboratory of Cognitive Neuroscience and Learning & IDG/McGovern Institute for Brain Research, Beijing Normal University, Beijing 100875, China
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10
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Slovis JC, Bach A, Beaulieu F, Zuckerberg G, Topjian A, Kirschen MP. Neuromonitoring after Pediatric Cardiac Arrest: Cerebral Physiology and Injury Stratification. Neurocrit Care 2024; 40:99-115. [PMID: 37002474 PMCID: PMC10544744 DOI: 10.1007/s12028-023-01685-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 01/30/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Significant long-term neurologic disability occurs in survivors of pediatric cardiac arrest, primarily due to hypoxic-ischemic brain injury. Postresuscitation care focuses on preventing secondary injury and the pathophysiologic cascade that leads to neuronal cell death. These injury processes include reperfusion injury, perturbations in cerebral blood flow, disturbed oxygen metabolism, impaired autoregulation, cerebral edema, and hyperthermia. Postresuscitation care also focuses on early injury stratification to allow clinicians to identify patients who could benefit from neuroprotective interventions in clinical trials and enable targeted therapeutics. METHODS In this review, we provide an overview of postcardiac arrest pathophysiology, explore the role of neuromonitoring in understanding postcardiac arrest cerebral physiology, and summarize the evidence supporting the use of neuromonitoring devices to guide pediatric postcardiac arrest care. We provide an in-depth review of the neuromonitoring modalities that measure cerebral perfusion, oxygenation, and function, as well as neuroimaging, serum biomarkers, and the implications of targeted temperature management. RESULTS For each modality, we provide an in-depth review of its impact on treatment, its ability to stratify hypoxic-ischemic brain injury severity, and its role in neuroprognostication. CONCLUSION Potential therapeutic targets and future directions are discussed, with the hope that multimodality monitoring can shift postarrest care from a one-size-fits-all model to an individualized model that uses cerebrovascular physiology to reduce secondary brain injury, increase accuracy of neuroprognostication, and improve outcomes.
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Affiliation(s)
- Julia C Slovis
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA.
| | - Ashley Bach
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA
| | - Forrest Beaulieu
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA
| | - Gabe Zuckerberg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA
| | - Alexis Topjian
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA
| | - Matthew P Kirschen
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA
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11
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Savioli G, Ceresa IF, Bavestrello Piccini G, Gri N, Nardone A, La Russa R, Saviano A, Piccioni A, Ricevuti G, Esposito C. Hypothermia: Beyond the Narrative Review-The Point of View of Emergency Physicians and Medico-Legal Considerations. J Pers Med 2023; 13:1690. [PMID: 38138917 PMCID: PMC10745126 DOI: 10.3390/jpm13121690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/14/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023] Open
Abstract
Hypothermia is a widespread condition all over the world, with a high risk of mortality in pre-hospital and in-hospital settings when it is not promptly and adequately treated. In this review, we aim to describe the main specificities of the diagnosis and treatment of hypothermia through consideration of the physiological changes that occur in hypothermic patients. Hypothermia can occur due to unfavorable environmental conditions as well as internal causes, such as pathological states that result in reduced heat production, increased heat loss or ineffectiveness of the thermal regulation system. The consequences of hypothermia affect several systems in the body-the cardiovascular system, the central and peripheral nervous systems, the respiratory system, the endocrine system and the gastrointestinal system-but also kidney function, electrolyte balance and coagulation. Once hypothermia is recognized, prompt treatment, focused on restoring body temperature and supporting vital functions, is fundamental in order to avert preventable death. It is important to also denote the fact that CPR has specificities related to the unique profile of hypothermic patients.
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Affiliation(s)
- Gabriele Savioli
- Emergency Department, IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Iride Francesca Ceresa
- Emergency Department and Internal Medicine, Istituti Clinici di Pavia e Vigevano, Gruppo San Donato, 27029 Vigevano, Italy;
| | | | - Nicole Gri
- Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell’Ospedale Maggiore, 3, 20162 Milano, Italy
| | - Alba Nardone
- Emergency Department, Ospedale Civile, 27058 Voghera, Italy
| | - Raffaele La Russa
- Department of Clinical and Experimental Medicine, Section of Forensic Pathology, University of Foggia, 71122 Foggia, Italy
| | - Angela Saviano
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Roma, Italy; (A.S.); (A.P.)
| | - Andrea Piccioni
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Roma, Italy; (A.S.); (A.P.)
| | - Giovanni Ricevuti
- Department of Drug Science, University of Pavia, 27100 Pavia, Italy;
| | - Ciro Esposito
- Nephrology and Dialysis Unit, ICS Maugeri, University of Pavia, 27100 Pavia, Italy;
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12
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Lugnet V, McDonough M, Gordon L, Galindez M, Mena Reyes N, Sheets A, Zafren K, Paal P. Termination of Cardiopulmonary Resuscitation in Mountain Rescue: A Scoping Review and ICAR MedCom 2023 Recommendations. High Alt Med Biol 2023; 24:274-286. [PMID: 37733297 DOI: 10.1089/ham.2023.0068] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023] Open
Abstract
Lugnet, Viktor, Miles McDonough, Les Gordon, Mercedes Galindez, Nicolas Mena Reyes, Alison Sheets, Ken Zafren, and Peter Paal. Termination of cardiopulmonary resuscitation in mountain rescue: a scoping review and ICAR MedCom 2023 recommendations. High Alt Med Biol. 24:274-286, 2023. Background: In 2012, the International Commission for Mountain Emergency Medicine (ICAR MedCom) published recommendations for termination of cardiopulmonary resuscitation (CPR) in mountain rescue. New developments have necessitated an update. This is the 2023 update for termination of CPR in mountain rescue. Methods: For this scoping review, we searched the PubMed and Cochrane libraries, updated the recommendations, and obtained consensus approval within the writing group and the ICAR MedCom. Results: We screened a total of 9,102 articles, of which 120 articles met the inclusion criteria. We developed 17 recommendations graded according to the strength of recommendation and level of evidence. Conclusions: Most of the recommendations from 2012 are still valid. We made minor changes regarding the safety of rescuers and responses to primary or traumatic cardiac arrest. The criteria for termination of CPR remain unchanged. The principal changes include updated recommendations for mechanical chest compression, point of care ultrasound (POCUS), extracorporeal life support (ECLS) for hypothermia, the effects of water temperature in drowning, and the use of burial times in avalanche rescue.
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Affiliation(s)
- Viktor Lugnet
- International Commission for Mountain Emergency Medicine (ICAR MedCom), Kloten, Switzerland
- Department of Anesthesiology and Intensive Care, Östersund Hospital, Östersund, Sweden
- Swedish Mountain Guides Association (SBO), Gällivare, Sweden
| | - Miles McDonough
- International Commission for Mountain Emergency Medicine (ICAR MedCom), Kloten, Switzerland
- Department of Emergency Medicine, UCSF Fresno, Fresno, California, USA
| | - Les Gordon
- International Commission for Mountain Emergency Medicine (ICAR MedCom), Kloten, Switzerland
- Langdale Ambleside Mountain Rescue Team, Ambleside, United Kingdom
- Department of Anaesthesia, University Hospitals of Morecambe Bay Trust, Lancaster, United Kingdom
| | - Mercedes Galindez
- International Commission for Mountain Emergency Medicine (ICAR MedCom), Kloten, Switzerland
- Department of Internal Medicine, Hospital Zonal Ramón Carrillo, San Carlos de Bariloche, Argentina
- Comisión de Auxilio Club Andino Bariloche, San Carlos de Bariloche, Argentina
| | - Nicolas Mena Reyes
- International Commission for Mountain Emergency Medicine (ICAR MedCom), Kloten, Switzerland
- Department of Emergency Medicine, Sótero del Río Hospital, Santiago de Chile, Chile
- Grupo de Rescate Médico en Montaña (GREMM), Santiago, Chile
- Emegency Medicine Section, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alison Sheets
- International Commission for Mountain Emergency Medicine (ICAR MedCom), Kloten, Switzerland
- Emergency Medicine, Boulder Community Health, Boulder, Colorado, USA
- Wilderness Medicine Section, University of Colorado Health Sciences Center, Aurora, Colorado, USA
| | - Ken Zafren
- International Commission for Mountain Emergency Medicine (ICAR MedCom), Kloten, Switzerland
- Himalayan Rescue Association, Kathmandu, Nepal
- Department of Emergency Medicine, Stanford University Medical Center, Stanford, California, USA
- Alaska Native Medical Center, Anchorage, Alaska, USA
| | - Peter Paal
- International Commission for Mountain Emergency Medicine (ICAR MedCom), Kloten, Switzerland
- Department of Anaesthesiology and Intensive Care Medicine, St. John of God Hospital, Paracelsus Medical University, Salzburg, Austria
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Ghia S, Savadjian A, Shin D, Diluozzo G, Weiner MM, Bhatt HV. Hypothermic Circulatory Arrest in Adult Aortic Arch Surgery: A Review of Hypothermic Circulatory Arrest and its Anesthetic Implications. J Cardiothorac Vasc Anesth 2023; 37:2634-2645. [PMID: 37723023 DOI: 10.1053/j.jvca.2023.08.139] [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: 06/12/2023] [Revised: 08/11/2023] [Accepted: 08/20/2023] [Indexed: 09/20/2023]
Abstract
Diseases affecting the aortic arch often require surgical intervention. Hypothermic circulatory arrest (HCA) enables a safe approach during open aortic arch surgeries. Additionally, HCA provides neuroprotection by reducing cerebral metabolism and oxygen requirements. However, HCA comes with significant risks (eg, neurologic dysfunction, stroke, and coagulopathy), and the cardiac anesthesiologist must completely understand the surgical techniques, possible complications, and management strategies.
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Affiliation(s)
- Samit Ghia
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Andre Savadjian
- Department of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, NC
| | - DaWi Shin
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gabriele Diluozzo
- Department of Cardiovascular Surgery, Yale School of Medicine, Bridgeport, CT
| | - Menachem M Weiner
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Himani V Bhatt
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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14
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Fang YH, Zhang YJ, Zhen YN, Liu XP, Sun G, Han YX. Hyperlactatemia in patients undergoing pulmonary endarterectomy with deep hypothermic circulatory arrest: Risk factors and its effects on the outcome. Perfusion 2023:2676591231208984. [PMID: 38124315 DOI: 10.1177/02676591231208984] [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: 12/23/2023]
Abstract
INTRODUCTION To determine the risk factors of hyperlactatemia in pulmonary endarterectomy (PEA) surgery and assess whether elevated blood lactate levels are associated with adverse outcomes. METHODS In this retrospective observational study, a total of 111 consecutive patients who underwent PEA for chronic thromboembolic pulmonary hypertension at the XXX Hospital between December 2016 and January 2022 were included. We retrospectively evaluated arterial blood samples analyzed intraoperatively. The pre- and intraoperative risk factors for hyperlactatemia and the postoperative outcomes were recorded. RESULTS Lactate levels gradually increased during surgery. The optimal cut-off lactate level for major postoperative complications, calculated using receiver operating characteristic analysis, was 7.0 mmol/L. Deep hypothermic circulatory arrest (DHCA) duration, nadir hematocrit, and preoperative pulmonary vascular resistance were risk factors for lactate levels >7 mmol/L. Moreover, the intraoperative peak lactate level during PEA under DHCA was found to be a statistically significant predictor of major complications being associated with longer mechanical ventilation time (r = 0.294; p = .003) and intensive care unit length of stay (r = 0.327; p = .001). CONCLUSIONS Deep hypothermic circulatory arrest duration, nadir hematocrit, and preoperative pulmonary vascular resistance were associated with hyperlactatemia. Increased lactate levels were independent predictors of longer mechanical ventilation time, intensive care unit length of stay, and major complications.
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Affiliation(s)
- Ying-Hui Fang
- Department of Anesthesia, China-Japan Friendship Hospital, Beijing, China
| | - Ya-Jun Zhang
- Department of Anesthesia, China-Japan Friendship Hospital, Beijing, China
| | - Ya-Nan Zhen
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Xiao-Peng Liu
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Guang Sun
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Yong-Xin Han
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
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15
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Kalisz S, Stoll T, Bouazza FZ, Claus M, Malinverni S. Extracorporeal Life Support for Recurrent Hypothermic Cardiac Arrest: A Case Report. Cureus 2023; 15:e49684. [PMID: 38161851 PMCID: PMC10756991 DOI: 10.7759/cureus.49684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2023] [Indexed: 01/03/2024] Open
Abstract
Hypothermia-associated cardiac arrest (HACA) is a challenge for emergency physicians. Standard cardiopulmonary resuscitation (CPR) remains the primary intervention for the treatment of HACA, but extracorporeal life support (ECLS) may be needed as an adjunct to CPR. In this report, we present the case of an adult Asian patient who experienced two episodes of HACA at a two-year interval. In both episodes, the patient was treated with ECLS in addition to standard CPR. We discuss the fundamentals of HACA and how to safely and effectively incorporate ECLS into its management. No-flow time, age, comorbidities, and the cause of the cardiac arrest are criteria to consider when deciding on the duration of CPR and the intensity of the resources deployed. Hypothermia is a reversible cause of cardiac arrest, justifying prolonged CPR. According to the Hypothermia Outcome Prediction after ECLS (HOPE) score, active rewarming through ECLS is recommended. However, a history of cardiac arrest is rare and might be considered a severe comorbidity contraindicating ECLS use. Nevertheless, the indication is determined on a case-by-case basis.
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Affiliation(s)
- Simon Kalisz
- Emergency Department, CHU Saint-Pierre, Brussels, BEL
| | | | | | - Marc Claus
- Intensive Care Unit, CHU Saint-Pierre, Brussels, BEL
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16
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Tang T, Wu C, Liu J, Jian K, Liu W, Sheng W. Hypothermic Circulatory Arrest in Median Sternotomy Hemorrhage During Redo Aortic Surgery. Braz J Cardiovasc Surg 2023; 38:e20220164. [PMID: 37801053 PMCID: PMC10550102 DOI: 10.21470/1678-9741-2022-0164] [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: 04/09/2022] [Accepted: 03/16/2023] [Indexed: 10/07/2023] Open
Abstract
INTRODUCTION This study summarizes the clinical data of patients who developed sternotomy hemorrhage during redo aortic surgery and analyzes the clinical experience of using hypothermic circulatory arrest. METHODS We retrospectively analyzed the medical records of patients who developed sternotomy hemorrhage during redo aortic surgery from May 2018 to August 2021. General anesthesia with single-lumen tracheal intubation was used. Femoral artery, vein, and superior vena cava cannulation were used if cardiopulmonary bypass was required according to the situation, and right superior vein or apical cannulation was selected for left heart drainage. RESULTS A total of 11 patients were enrolled in this study, comprising nine males and two females, with an average age of 44.3±16.7 years. All cases were successfully completed without cerebrovascular complications or paraplegia. Two patients died during hospitalization, two patients died during the follow-up after discharge, and the remaining patients are recovering well. CONCLUSION The femoral-femoral bypass with hypothermic circulatory arrest technique is a safe and reliable method to use in cases of sternotomy hemorrhage during redo aortic surgery.
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Affiliation(s)
- Tiansheng Tang
- Department of Cardiovascular Surgery, The First Affiliated Hospital
of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu,
Anhui, People’s Republic of China
| | - Changjuan Wu
- Department of Pharmacy, Wannan Medical College, Wuhu, Anhui,
People’s Republic of China
| | - Jianshi Liu
- Department of Cardiovascular Surgery, DeltaHealth Hospital,
Shanghai, People’s Republic of China
| | - Kaitao Jian
- Department of Cardiovascular Surgery, DeltaHealth Hospital,
Shanghai, People’s Republic of China
| | - Wei Liu
- Department of Cardiovascular Surgery, DeltaHealth Hospital,
Shanghai, People’s Republic of China
| | - Weiyong Sheng
- Department of Cardiovascular Surgery, The First Affiliated Hospital
of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu,
Anhui, People’s Republic of China
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17
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Zhao Y, Zeng Z, Bao X, Wu M, Feng J, Jing Z, Feng R. TEVAR for aortic arch lesions combining physician-modified endograft and in-situ fenestration. INT ANGIOL 2023; 42:412-419. [PMID: 37962899 DOI: 10.23736/s0392-9590.23.05063-0] [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: 11/15/2023]
Abstract
BACKGROUND The aim of this retrospective study was to investigate the outcomes of combining physician-modified endograft (PMEG) and in-situ fenestration (ISF) for aortic arch repair. METHODS A retrospective analysis was performed in 12 patients with aortic arch pathologies who underwent thoracic endovascular aortic repair with PMEG and ISF between June 2019 and February 2020. RESULTS Revascularizations of supra-aortic arteries were successfully performed in 91.7% patients (11/12). One patient with aberrant right subclavian artery was unsuccessful because of tortuosity and sharp angle. One patient received endovascular exclusion by Viabahn due to artery injury of the femoral access. During the follow-up (mean 22.7 months), one patient underwent Bentall surgery because of retrograde type A aortic dissection, and one patient received coils embolization due to occurrence of a type I endoleak. In addition, one patient died of myocardial infarction 13 months after surgery. Results obtained after computed tomography angiography confirmed patency of all the supra-aortic arteries. CONCLUSIONS Combining PMEG and ISF could be a feasible option for aortic arch lesions in selected patients. Long-term durability concerns require further evaluation.
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Affiliation(s)
- Yuxi Zhao
- Department of Vascular Surgery, Shanghai General Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Zhaoxiang Zeng
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, Shanghai, China
| | - Xianhao Bao
- Department of Vascular Surgery, Shanghai General Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Mingwei Wu
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Jiaxuan Feng
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, Shanghai, China
| | - Zaiping Jing
- Department of Vascular Surgery, Changhai Hospital, Navy Medical University, Shanghai, China
| | - Rui Feng
- Department of Vascular Surgery, Shanghai General Hospital, Shanghai Jiaotong University, Shanghai, China -
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18
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Nielsen N, Friberg H. Changes in Practice of Controlled Hypothermia after Cardiac Arrest in the Past 20 Years: A Critical Care Perspective. Am J Respir Crit Care Med 2023; 207:1558-1564. [PMID: 37104654 DOI: 10.1164/rccm.202211-2142cp] [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: 11/22/2022] [Accepted: 04/26/2023] [Indexed: 04/29/2023] Open
Abstract
For 20 years, induced hypothermia and targeted temperature management have been recommended to mitigate brain injury and increase survival after cardiac arrest. On the basis of animal research and small clinical trials, the International Liaison Committee on Resuscitation strongly advocated hypothermia at 32-34 °C for 12-24 hours for comatose patients with out-of-hospital cardiac arrest with initial rhythm of ventricular fibrillation or nonperfusing ventricular tachycardia. The intervention was implemented worldwide. In the past decade, hypothermia and targeted temperature management have been investigated in larger clinical randomized trials focusing on target temperature depth, target temperature duration, prehospital versus in-hospital initiation, nonshockable rhythms, and in-hospital cardiac arrest. Systematic reviews suggest little or no effect of delivering the intervention on the basis of the summary of evidence, and the International Liaison Committee on Resuscitation today recommends only to treat fever and keep body temperature below 37.5 °C (weak recommendation, low-certainty evidence). Here we describe the evolution of temperature management for patients with cardiac arrest during the past 20 years and how the accrued evidence has influenced not only the recommendations but also the guideline process. We also discuss possible paths forward in this field, bringing up both whether fever management is at all beneficial for patients with cardiac arrest and which knowledge gaps future clinical trials in temperature management should address.
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Affiliation(s)
- Niklas Nielsen
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anesthesiology and Intensive Care, Helsingborg Hospital, Helsingborg, Sweden; and
| | - Hans Friberg
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anesthesiology and Intensive Care, Skåne University Hospital, Malmö, Sweden
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19
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Abdul-Rahman T, Lizano-Jubert I, Garg N, Tejerina-Marion E, Awais Bukhari SM, Luisa Ek A, Wireko AA, Mares AC, Sikora V, Gupta R. The Use of Cardioprotective Devices and Strategies in Patients Undergoing Percutaneous Procedures and Cardiac Surgery. Healthcare (Basel) 2023; 11:healthcare11081094. [PMID: 37107928 PMCID: PMC10137626 DOI: 10.3390/healthcare11081094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 02/28/2023] [Accepted: 04/06/2023] [Indexed: 04/29/2023] Open
Abstract
In the United States, about one million people are seen to visit the operating theater for cardiac surgery annually. However, nearly half of these visits result in complications such as renal, neurological, and cardiac injury of varying degrees. Historically, many mechanisms and approaches have been explored in attempts to reduce injuries associated with cardiac surgery and percutaneous procedures. Devices such as cardioplegia, mechanical circulatory support, and other methods have shown promising results in managing and preventing life-threatening cardiac-surgery-related outcomes such as heart failure and cardiogenic shock. Comparably, cardioprotective devices such as TandemHeart, Impella family devices, and venoarterial extracorporeal membrane oxygenation (VA-ECMO) have also been proven to show significant cardioprotection through mechanical support. However, their use as interventional agents in the prevention of hemodynamic changes due to cardiac surgery or percutaneous interventions has been correlated with adverse effects. This can lead to a rebound increased risk of mortality in high-risk patients who undergo cardiac surgery. Further research is necessary to delineate and stratify patients into appropriate cardioprotective device groups. Furthermore, the use of one device over another in terms of efficacy remains controversial and further research is necessary to assess device potential in different settings. Clinical research is also needed regarding novel strategies and targets, such as transcutaneous vagus stimulation and supersaturated oxygen therapy, aimed at reducing mortality among high-risk cardiac surgery patients. This review explores the recent advances regarding the use of cardioprotective devices in patients undergoing percutaneous procedures and cardiac surgery.
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Affiliation(s)
- Toufik Abdul-Rahman
- Medical Institute, Sumy State University, 40007 Sumy, Ukraine
- Department of Cardiology, Otto Von Guericke University of Magdeburg, 39120 Magdeburg, Germany
| | - Ileana Lizano-Jubert
- Centro de Investigación en Ciencias de la Salud (CICSA), FCS, Universidad Anáhuac Campus Norte, Huixquilucan 52786, Mexico
| | - Neil Garg
- Rowan-Virtua School of Osteopathic Medicine, One Medical Center Drive Stratford, Stratford, NJ 08084, USA
| | - Emilio Tejerina-Marion
- Centro de Investigación en Ciencias de la Salud (CICSA), FCS, Universidad Anáhuac Campus Norte, Huixquilucan 52786, Mexico
| | | | - Ana Luisa Ek
- Centro de Investigación en Ciencias de la Salud (CICSA), FCS, Universidad Anáhuac Campus Norte, Huixquilucan 52786, Mexico
| | - Andrew Awuah Wireko
- Medical Institute, Sumy State University, 40007 Sumy, Ukraine
- Department of Cardiology, Otto Von Guericke University of Magdeburg, 39120 Magdeburg, Germany
| | - Adriana C Mares
- Division of Cardiovascular Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX 79905, USA
| | - Vladyslav Sikora
- Medical Institute, Sumy State University, 40007 Sumy, Ukraine
- Department of Clinical and Experimental Medicine, University of Foggia, Via Napoli, 20, 71122 Foggia, Italy
| | - Rahul Gupta
- Department of Cardiology, Lehigh Valley Health Network, Allentown, PA 18103, USA
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20
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Cui Y, Liu X, Xiong J, Tan Z, Du L, Lin J. Cardiopulmonary bypass for total aortic arch replacement surgery: A review of three techniques. Front Cardiovasc Med 2023; 10:1109401. [PMID: 37063959 PMCID: PMC10098116 DOI: 10.3389/fcvm.2023.1109401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 03/09/2023] [Indexed: 03/31/2023] Open
Abstract
One treatment for acute type A aortic dissection is to replace the ascending aorta and aortic arch with a graft during circulatory arrest of the lower body, but this is associated with high mortality and morbidity. Maintaining the balance between oxygen supply and demand during circulatory arrest is the key to reducing morbidity and is the primary challenge during body perfusion. The aim of this review is to summarize current knowledge of body perfusion techniques and to predict future development of this field. We present three perfusion techniques based on deep hypothermic circulatory arrest (DHCA): DHCA alone, DHCA with selective cerebral perfusion, and DHCA with total body perfusion. DHCA was first developed to provide a clear surgical field, but it may contribute to stroke in 4%–15% of patients. Antegrade or retrograde cerebral perfusion can provide blood flow for the brain during circulatory arrest, and it is associated with much lower stroke incidence of 3%–9%. Antegrade cerebral perfusion may be better than retrograde perfusion during longer arrest. In theory, blood flow can be provided to all vital organs through total body perfusion, which can be implemented via either arterial or venous systems, or by combining retrograde inferior vena caval perfusion with antegrade cerebral perfusion. However, whether total body perfusion is better than other techniques require further investigation in large, multicenter studies. Current techniques for perfusion during circulatory arrest remain imperfect, and a technique that effectively perfuses the upper and lower body effectively during circulatory arrest is missing. Total body perfusion should be systematically compared against selective cerebral perfusion for improving outcomes after circulatory arrest.
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21
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Bessho R. Neuroprotection during Open Aortic Arch Surgery: Cerebral Perfusion Methods and Temperature. J NIPPON MED SCH 2023; 90:11-19. [PMID: 35644556 DOI: 10.1272/jnms.jnms.2023_90-103] [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: 11/19/2022]
Abstract
Neuroprotection is important in open aortic arch surgery because of the dependence of brain tissues on cerebral perfusion. Therefore, several techniques have been developed to reduce cerebral ischemia and improve outcomes in open aortic arch surgery. In this review, I describe various neuroprotective strategies, such as profound and deep hypothermic circulatory arrest, selective antegrade cerebral perfusion, retrograde cerebral perfusion, and lower body circulatory arrest; compare their advantages and disadvantages, and discuss their evolution and current status by reviewing relevant literature.
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Affiliation(s)
- Ryuzo Bessho
- Department of Cardiovascular Surgery, Nippon Medical School Chiba Hokusoh Hospital
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22
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Kacha AK, Hicks MH, Mahrous C, Dalton A, Ben-Jacob TK. Management of Intraoperative Cardiac Arrest. Anesthesiol Clin 2023; 41:103-119. [PMID: 36871994 DOI: 10.1016/j.anclin.2022.10.002] [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: 03/07/2023]
Abstract
Perioperative arrests are both uncommon and heterogeneous and have not been described or studied to the same extent as cardiac arrest in the community. These crises are usually witnessed, frequently anticipated, and involve a rescuer physician with knowledge of the patient's comorbidities and coexisting anesthetic or surgically related pathophysiology ultimately leading to better outcomes. This article reviews the most probable causes of intraoperative arrest and their management.
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Affiliation(s)
- Aalok K Kacha
- Department of Anesthesia and Critical Care, Section of Critical Care Medicine, University of Chicago, 5841 South Maryland Avenue, MC 4028, Chicago, IL 60637, USA; Department of Surgery, Section of Transplant Surgery, University of Chicago, 5841 South Maryland Avenue, MC 4028, Chicago, IL 60637, USA.
| | - Megan Henley Hicks
- Department of Anesthesiology, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, 1 Medical Center Boulevard, Winston-Salem, NC 27157, USA
| | - Christopher Mahrous
- Department of Anesthesiology, Cooper Medical School of Rowan University, One Cooper Plaza, Dorrance 2nd Floor, Camden, NJ 08103, USA
| | - Allison Dalton
- Department of Anesthesia and Critical Care, Section of Critical Care Medicine, University of Chicago, 5841 South Maryland Avenue, MC 4028, Chicago, IL 60637, USA
| | - Talia K Ben-Jacob
- Department of Anesthesiology, Division of Critical Care, Cooper Medical School of Rowan University, One Cooper Plaza, Dorrance 2nd Floor, Camden, NJ 08103, USA
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23
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Hughes GC. It Depends What the Definition of "Safe" Is. Ann Thorac Surg 2023; 115:394-395. [PMID: 35944703 DOI: 10.1016/j.athoracsur.2022.07.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 07/31/2022] [Indexed: 02/07/2023]
Affiliation(s)
- G Chad Hughes
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Box 3051 DUMC, Durham, NC 27710.
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24
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Orozco-Sevilla V, Etheridge G, Coselli JS. Thoracic Aortic Aneurysm Surgery: DON'T QUIT-JUST DO IT. AORTA (STAMFORD, CONN.) 2022; 10:155-161. [PMID: 36521806 PMCID: PMC9754878 DOI: 10.1055/s-0042-1750098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Surgical aortic repair has progressed from aneurysm ligation to homografts to Dacron grafts to totally endovascular interventions. These fields will continue to evolve, and new endovascular technology will be used in virtually every part of the aorta, eventually dominating this field of surgery. However, as surgeons, we must be cautious and not let go of our open-surgery skills, as they will always be the ultimate bailout solution.
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Affiliation(s)
- Vicente Orozco-Sevilla
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas,Department of Cardiovascular Surgery, CHI St. Luke's Health—Baylor St. Luke's Medical Center, Houston, Texas
| | - Ginger Etheridge
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Joseph S. Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas,Department of Cardiovascular Surgery, CHI St. Luke's Health—Baylor St. Luke's Medical Center, Houston, Texas,Address for correspondence Joseph S. Coselli, MD One Baylor PlazaBCM 390, Houston, TX 77030
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Pupovac SS, Hemli JM, Giammarino AT, Varrone M, Aminov A, Scheinerman SJ, Hartman AR, Brinster DR. Deep Versus Moderate Hypothermia in Acute Type A Aortic Dissection: A Propensity-Matched Analysis. Heart Lung Circ 2022; 31:1699-1705. [PMID: 36150951 DOI: 10.1016/j.hlc.2022.07.021] [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: 01/20/2022] [Revised: 07/15/2022] [Accepted: 07/30/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND The ideal temperature for hypothermic circulatory arrest (HCA) during acute type A aortic dissection (ATAAD) repair has yet to be determined. We examined the clinical impact of different degrees of hypothermia during dissection repair. METHODS Out of 240 cases of ATAAD between June 2014 and December 2019, 228 patients were divided into two groups according to lowest intraoperative temperature: moderate hypothermic circulatory arrest (MHCA) (20-28°C) versus deep hypothermic circulatory arrest (DHCA) (<20°C). From this, 74 pairs of propensity-matched patients were analysed with respect to operative data and short-term clinical outcomes. Independent predictors of a composite outcome of 30-day mortality and stroke were identified. RESULTS Mean lowest temperature was 25.5±3.9°C in the MHCA group versus 16.0±2.9°C in DHCA. Overall 30-day mortality of matched cohort was 11.5% (17 deaths), there were no significant different between matched groups. Cardiopulmonary bypass (CPB) times were longer in DHCA (221.0±69.9 vs 190.7±74.5 mins, p=0.01). Antegrade cerebral perfusion (ACP) during HCA predicted a lower composite risk of 30-day mortality and stroke (OR 0.38). Female sex (OR 4.71), lower extremity ischaemia at presentation (OR 3.07), and CPB >235 minutes (OR 2.47), all portended worse postoperative outcomes. CONCLUSIONS A surgical strategy of MHCA is at least as safe as DHCA during repair of acute type A aortic dissection. ACP during HCA is associated with reduced 30-day mortality and stroke, whereas female sex, lower extremity ischaemia, and longer CPB times are all predictive of poorer short-term outcomes.
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Affiliation(s)
- Stevan S Pupovac
- Department of Cardiothoracic Surgery, North Shore University Hospital/Northwell Health, Manhasset, NY, USA.
| | - Jonathan M Hemli
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital/Northwell Health, New York, NY, USA
| | - Ashley T Giammarino
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital/Northwell Health, New York, NY, USA
| | - Michael Varrone
- Department of Cardiothoracic Surgery, North Shore University Hospital/Northwell Health, Manhasset, NY, USA
| | - Areil Aminov
- Department of Cardiothoracic Surgery, North Shore University Hospital/Northwell Health, Manhasset, NY, USA
| | - S Jacob Scheinerman
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital/Northwell Health, New York, NY, USA
| | - Alan R Hartman
- Department of Cardiothoracic Surgery, North Shore University Hospital/Northwell Health, Manhasset, NY, USA
| | - Derek R Brinster
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital/Northwell Health, New York, NY, USA
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Štěpán J, Šulda M, Tesařík R, Zmeko D, Kuta B, Schaffelhoferová D, Foral D. Hypothermic Cardiac Arrest Managed Successfully by Changing ECMO Configurations. J Cardiothorac Vasc Anesth 2022; 36:4413-4419. [PMID: 36127217 DOI: 10.1053/j.jvca.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 08/01/2022] [Accepted: 08/08/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Josef Štěpán
- Department of Anesthesiology, Emergency and Intensive Care, Nemocnice České Budějovice, a.s., České Budějovice, Česká republika.
| | - Mirek Šulda
- Department of Cardiac Surgery, Heart Centre, Nemocnice České Budějovice, a.s., České Budějovice, Česká republika
| | - Richard Tesařík
- Department of Anesthesiology, Emergency and Intensive Care, Nemocnice České Budějovice, a.s., České Budějovice, Česká republika
| | - Dušan Zmeko
- Department of Anesthesiology, Emergency and Intensive Care, Nemocnice České Budějovice, a.s., České Budějovice, Česká republika
| | - Bohuslav Kuta
- Department of Cardiac Surgery, Heart Centre, Nemocnice České Budějovice, a.s., České Budějovice, Česká republika
| | - Dita Schaffelhoferová
- Department of Cardiology, Heart Centre, Nemocnice České Budějovice, a.s., České Budějovice, Česká republika
| | - David Foral
- Department of Cardiology, Heart Centre, Nemocnice České Budějovice, a.s., České Budějovice, Česká republika
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Arnaoutakis GJ, Ogami T, Bobba CM, Serna-Gallegos D, Brown JA, Jeng EI, Martin TD, Beaver TM, Yousef S, Navid F, Sultan I. Cerebral protection using deep hypothermic circulatory arrest versus retrograde cerebral perfusion for aortic hemiarch reconstruction. J Card Surg 2022; 37:3279-3286. [PMID: 35894828 DOI: 10.1111/jocs.16809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 06/25/2022] [Accepted: 07/02/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND With evolutions in technique, recent data encourage the use of cerebral perfusion during aortic arch repair. However, a randomized data have demonstrated higher rates of neurologic injury according to MRI lesions using antegrade cerebral perfusion during hemiarch reconstruction. METHODS This was a retrospective review of two institutional aortic center databases to identify adult patients who underwent aortic hemiarch reconstruction for elective aortic aneurysm or acute type A aortic dissection. Patients were stratified according to cerebral protection method: (1) deep hypothermic circulatory arrest (DHCA) group versus (2) DHCA/retrograde cerebral perfusion (RCP) group. RESULTS A total of 320 patients and 245 patients underwent hemiarch reconstruction for aortic aneurysm electively and aortic dissection, respectively. In aneurysmal pathology, the DHCA group included 133 patients and the DHCA/RCP group included 187 patients. Operative mortality was 0.8% in the DHCA group and 2.7% in the DHCA/RCP group (p = 0.41). Kaplan-Meier survival estimates revealed comparable 2-year survival (p = 0.14). In dissection, 43 patients and 202 patients were included in the DHCA group and the DHCA/RCP group, respectively. Operative mortality was equivalent between the two groups (11.6% in the DHCA group and 9.4% in the DHCA/RCP group, p = 0.58). Long-term survival was similar at 2 years between the groups (p = 0.06). Multivariable analysis showed cerebral perfusion strategy was not associated with the composite outcome of operative mortality and stroke. CONCLUSIONS In treating both elective and acute ascending aortic pathologies with hemiarch reconstruction, both DHCA alone or in combination with RCP yield comparable results.
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Affiliation(s)
- George J Arnaoutakis
- Division of Thoracic and Caridovascular Surgery, University of Florida Health, Gainesville, Florida, USA
| | - Takuya Ogami
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christopher M Bobba
- Division of Thoracic and Caridovascular Surgery, University of Florida Health, Gainesville, Florida, USA
| | - Derek Serna-Gallegos
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Cardiothoracic Surgery, Division of Cardiac Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - James A Brown
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Eric I Jeng
- Division of Thoracic and Caridovascular Surgery, University of Florida Health, Gainesville, Florida, USA
| | - Tomas D Martin
- Division of Thoracic and Caridovascular Surgery, University of Florida Health, Gainesville, Florida, USA
| | - Thomas M Beaver
- Division of Thoracic and Caridovascular Surgery, University of Florida Health, Gainesville, Florida, USA
| | - Sarah Yousef
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Forozan Navid
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Cardiothoracic Surgery, Division of Cardiac Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Cardiothoracic Surgery, Division of Cardiac Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Malvindi PG, Alfonsi J, Berretta P, Cefarelli M, Gatta E, Di Eusanio M. Normothermic frozen elephant trunk: our experience and literature review. Cardiovasc Diagn Ther 2022; 12:262-271. [PMID: 35800357 PMCID: PMC9253169 DOI: 10.21037/cdt-22-73] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 05/17/2022] [Indexed: 09/10/2023]
Abstract
BACKGROUND AND OBJECTIVE The frozen elephant trunk (FET) technique has undoubtable advantages in treating complex and extensive disease of the aortic arch and the thoracic descending aorta. Despite several improvements in cardiopulmonary bypass conduction and surgical strategy, operative times and the institution of systemic circulatory arrest remain the main determinants of early mortality, cerebral/spinal cord injury and visceral organs dysfunction. We have conducted this review to highlight the recent technical advances in arch and FET surgery aiming at the reduction/avoidance of systemic circulatory arrest, and their impact on early outcomes. METHODS A literature search (from origin to January 2022), limited to publications in English, was performed on online platforms and database (PubMed, Google, ResearchGate). After a further review of associated or similar papers, we found 4 experiences, described by 11 peer-reviewed published papers, which focused on minimising or avoiding systemic circulatory arrest during total arch replacement plus stenting of the descending thoracic aorta. KEY CONTENT AND FINDINGS Recent experiences reported the use of an antegrade endoaortic balloon, advanced and inflated into the stent graft, to provide an early systemic reperfusion soon after the deployment of the stented portion of the FET prosthesis and minimize the circulatory arrest time (down to a mean of 5 minutes), thus avoiding the need of moderate or deep hypothermia (mean systemic temperature 28-30 °C) while allowing a complete arch and FET repair. Our approach, based on off-pump retrograde vascular stent graft deployment in distal arch/descending thoracic aorta, and the use of a retrograde endoballoon, allows the repair of extensive aortic pathologies during uninterrupted normothermic cerebral and lower body perfusion. CONCLUSIONS The use of endoballoon occlusion has emerged in recent years as a safe and effective strategy to allow distal perfusion during FET repair. This technique minimizes or avoids the detrimental effects of hypothermia and systemic circulatory arrest and significantly reduces the operative times.
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Affiliation(s)
- Pietro Giorgio Malvindi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Jacopo Alfonsi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Paolo Berretta
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Mariano Cefarelli
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Emanuele Gatta
- Vascular Surgery Department, Lancisi Cardiovascular Center, Ancona, Italy
| | - Marco Di Eusanio
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
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Tan SZ, Singh S, Austin NJ, Alfonso Palanca J, Jubouri M, Girardi LN, Chen EP, Bashir M. Duration of deep hypothermic circulatory arrest for aortic arch surgery: is it a myth, fiction, or scientific leap? THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:243-253. [PMID: 35238523 DOI: 10.23736/s0021-9509.22.12275-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The use of deep hypothermic circulatory arrest (DHCA) to provide aortic surgeons with a bloodless operative field while simultaneously protecting the brain and peripheries from ischemic damage revolutionized cardiac and aortic surgery, and is currently used in specialist centers across the globe. However, it is associated with manifold adverse outcomes, including neurocognitive dysfunction and mortality. This review seeks to analyze the relationship between DHCA duration and clinical outcome, and evaluate the controversies and limitations surrounding its use. EVIDENCE ACQUISITION We performed a review of available literature with statistical analysis to evaluate the relationship between DHCA duration (<40 min and >40 min) and key clinical outcomes, including mortality, permanent and temporary neurological deficit, renal damage, admission length, and reintervention rate. The controversies surrounding DHCA use and future directions for care are also explored. EVIDENCE SYNTHESIS Statistical analysis revealed no significant association (P>0.05) between DHCA duration and clinical outcomes (early and late mortality rates, neurological deficit, admission length, and reintervention rate), both with and without adjunctive perfusion techniques. CONCLUSIONS Available literature suggests that the relationships between DHCA duration (with and without adjunctive perfusion) and clinical outcomes are unclear, and at present not statistically significant. Alternative surgical and endovascular techniques have been identified as promising novel approaches not requiring DHCA, as have the use of biomarkers to enable early diagnosis and intervention for aortic pathologies.
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Affiliation(s)
- Sven Z Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Sidhant Singh
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Natasha J Austin
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Joaquin Alfonso Palanca
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mohamad Bashir
- Vascular and Endovascular Surgery, Health and Education Improvement Wales, Nantgarw, UK -
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Development of aortic arch surgery in Bologna and reflections on current strategy of cerebral protection. Indian J Thorac Cardiovasc Surg 2022; 38:44-49. [PMID: 35463700 PMCID: PMC8980976 DOI: 10.1007/s12055-022-01347-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 03/04/2022] [Accepted: 03/07/2022] [Indexed: 10/18/2022] Open
Abstract
Complications after open arch repair much decreased over time thanks to better methods of organ and cerebral protection. The crossroads was the introduction of antegrade cerebral perfusion as a method of cerebral protection. Other intraoperative techniques also contributed to facilitate arch reconstruction, such as performing circulatory arrest at higher core temperature, using hybrid grafts or endografts, and monitoring cerebral functions during the procedure. As part of this exciting process, we go back in Bologna in the early 1970s to relive some of these fundamental steps on aortic arch surgery. Today a large number of issues on cerebral protection remain for which we have incomplete responses. Probably, a super specialized approach and endovascular techniques will continue to improve the quality of care of patients with different arch pathologies.
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Barrow S, Ives G. Accidental hypothermia: direct evidence for consciousness as a marker of cardiac arrest risk in the acute assessment of cold patients. Scand J Trauma Resusc Emerg Med 2022; 30:13. [PMID: 35246215 PMCID: PMC8895778 DOI: 10.1186/s13049-022-01000-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 02/07/2022] [Indexed: 11/25/2022] Open
Abstract
Background Rapid stratification of the risk of cardiac arrest is essential in the assessment of patients with isolated accidental hypothermia. Traditional methods based on measurement of core temperature are unreliable in the field. Behavioural observations have been used as predictors of core temperature and thus indirect predictors of cardiac arrest. This study aims to quantify the direct relationship between observed conscious level and cardiac arrest. Methods Retrospective case report analysis identified 114 cases of isolated accidental hypothermia meeting inclusion criteria. Level of consciousness in the acute assessment and management phase was classified using the AVPU system with an additional category of “Alert with confusion”; statistical analysis then related level of consciousness to incidence of cardiac arrest. Results All patients who subsequently suffered cardiac arrest showed some impairment of consciousness (p < < .0001), and the risk of arrest increased directly with the level of impairment; none of the 33 fully alert patients arrested. In the lowest impairment category, Alert confused, a quarter of the 12 patients went on to arrest, while in the highest Unresponsive category, two thirds of the 43 patients arrested. Where core temperature was available (62 cases), prediction of arrest by consciousness level was at least as good as prediction from core temperature. Conclusions This study provides retrospective analytical evidence that consciousness level is a valid predictor of cardiac arrest risk in isolated accidental hypothermia; the importance of including confusion as a criterion is a new finding. This study suggests the use of consciousness alone may be at least as good as core temperature in cardiac arrest risk prediction. These results are likely to be of particular relevance to the management of accidental hypothermia in the pre-hospital and mass casualty environment, allowing for rapid and accurate triage of hypothermic patients.
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Affiliation(s)
- Samuel Barrow
- Royal Army Medical Corps, British Army, DMS Whittington, Lichfield, WS14 9PY, UK.
| | - Galen Ives
- Information School, University of Sheffield, Regent Court, 211 Portobello Street, Sheffield, S1 4DP, UK
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Fukuda M, Nozawa M, Okada Y, Morita S, Ehara N, Miyamae N, Jo T, Sumida Y, Okada N, Watanabe M, Tsuruoka A, Fujimoto Y, Okumura Y, Kitamura T, Matsuyama T. Clinical relevance of impaired consciousness in accidental hypothermia: a Japanese multicenter retrospective study. Acute Med Surg 2022; 9:e730. [PMID: 35169485 PMCID: PMC8836211 DOI: 10.1002/ams2.730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 12/21/2021] [Accepted: 01/12/2022] [Indexed: 11/09/2022] Open
Abstract
Aim This study aimed to investigate the association between level of impaired consciousness and severe hypothermia (<28°C) and to evaluate the association between level of impaired consciousness and inhospital mortality among accidental hypothermia patients. Methods This was a multicenter retrospective study using the J‐Point registry database, which includes data regarding patients whose core body temperature was 35.0°C or less and who were treated as accidental hypothermia in emergency departments between April 1, 2011 and March 31, 2016. We estimated adjusted odds ratios of the level of impaired consciousness for severe hypothermia less than 28°C and inhospital mortality using a logistic regression model. Results The study included 505 of 572 patients in the J‐Point registry. Relative to mildly impaired consciousness (Glasgow Coma Scale [GCS] 13–15), the adjusted odds ratios for severe hypothermia less than 28°C were: moderate (GCS 9–12), 3.26 (95% confidence interval [CI], 1.69–6.25); and severe (GCS < 9), 4.68 (95% CI, 2.40–9.14). Relative to mildly impaired consciousness (GCS 13–15), the adjusted odds ratios for inhospital mortality were: moderate (GCS9–12), 1.65 (95% CI, 0.95–2.88); and severe (GCS < 9), 2.10 (95% CI, 1.17–3.78). Conclusion The level of impaired consciousness in patients with accidental hypothermia was associated with severe hypothermia and inhospital mortality.
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Affiliation(s)
- Masahiro Fukuda
- Department of Emergency and Critical Care Medicine Saiseikai Shiga Hospital Ritto Japan
- Senri Critical Care Medical Center Saiseikai Senri Hospital Suita Japan
| | - Masahiro Nozawa
- Department of Emergency and Critical Care Medicine Saiseikai Shiga Hospital Ritto Japan
| | - Yohei Okada
- Department of Emergency and Critical Care Medicine Japanese Red Cross Society Kyoto Daini Hospital Kyoto Japan
- Department of Primary Care and Emergency Medicine Graduate School of Medicine Kyoto University Kyoto Japan
| | - Sachiko Morita
- Senri Critical Care Medical Center Saiseikai Senri Hospital Suita Japan
| | - Naoki Ehara
- Department of Emergency Medicine Japanese Red Cross Society Kyoto Daiichi Red Cross Hospital Kyoto Japan
| | - Nobuhiro Miyamae
- Department of Emergency Medicine Rakuwa‐kai Otowa Hospital Kyoto Japan
| | - Takaaki Jo
- Department of Emergency Medicine Uji‐Tokushukai Medical Center Uji Japan
| | - Yasuyuki Sumida
- Department of Emergency Medicine North Medical Center Kyoto Prefectural University of Medicine Kyoto Japan
| | - Nobunaga Okada
- Department of Emergency Medicine Kyoto Prefectural University of Medicine Kyoto Japan
- Department of Emergency and Critical Care Medicine National Hospital Organization Kyoto Medical Center Kyoto Japan
| | - Makoto Watanabe
- Department of Emergency Medicine Kyoto Prefectural University of Medicine Kyoto Japan
| | - Ayumu Tsuruoka
- Department of Emergency and Critical Care Medicine Kyoto Min‐Iren Chuo Hospital Kyoto Japan
| | - Yoshihiro Fujimoto
- Department of Emergency Medicine, Yodogawa Christian Hospital Osaka Japan
| | - Yoshiki Okumura
- Department of Emergency Medicine Fukuchiyama City Hospital Fukuchiyama Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences Department of Social and Environmental Medicine Graduate School of Medicine Osaka University Osaka Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine Kyoto Prefectural University of Medicine Kyoto Japan
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Swol J, Darocha T, Paal P, Brugger H, Podsiadło P, Kosiński S, Puślecki M, Ligowski M, Pasquier M. Extracorporeal Life Support in Accidental Hypothermia with Cardiac Arrest-A Narrative Review. ASAIO J 2022; 68:153-162. [PMID: 34261875 PMCID: PMC8797003 DOI: 10.1097/mat.0000000000001518] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Severely hypothermic patients, especially suffering cardiac arrest, require highly specialized treatment. The most common problems affecting the recognition and treatment seem to be awareness, logistics, and proper planning. In severe hypothermia, pathophysiologic changes occur in the cardiovascular system leading to dysrhythmias, decreased cardiac output, decreased central nervous system electrical activity, cold diuresis, and noncardiogenic pulmonary edema. Cardiac arrest, multiple organ dysfunction, and refractory vasoplegia are indicative of profound hypothermia. The aim of these narrative reviews is to describe the peculiar pathophysiology of patients suffering cardiac arrest from accidental hypothermia. We describe the good chances of neurologic recovery in certain circumstances, even in patients presenting with unwitnessed cardiac arrest, asystole, and the absence of bystander cardiopulmonary resuscitation. Guidance on patient selection, prognostication, and treatment, including extracorporeal life support, is given.
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Affiliation(s)
- Justyna Swol
- From the Deparment of Respiratory Medicine, Allergology and Sleep Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Tomasz Darocha
- Department of Anesthesiology and Intensive Care, Severe Accidental Hypothermia Center, Medical University of Silesia, Katowice, Poland
| | - Peter Paal
- Department of Anesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Hermann Brugger
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - Paweł Podsiadło
- Department of Emergency Medicine, Jan Kochanowski University, Kielce, Poland
| | - Sylweriusz Kosiński
- Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Mateusz Puślecki
- Department of Medical Rescue, Poznan University of Medical Sciences, Poznan, Poland
- Departmentf Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Marcin Ligowski
- Departmentf Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Mathieu Pasquier
- Emergency Department, Lausanne University Hospital, Lausanne, Switzerland
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Gagarinskiy E, Averin A, Uteshev V, Sherbakov P, Telpuhov V, Shvirst N, Karpova Y, Gurin A, Varlachev A, Kovtun A, Fesenko E. Time Limiting Boundaries of Reversible Clinical Death in Rats Subjected to Ultra-Deep Hypothermia. Ann Card Anaesth 2022; 25:41-47. [PMID: 35075019 PMCID: PMC8865344 DOI: 10.4103/aca.aca_189_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Colls Garrido C, Riquelme Gallego B, Sánchez García JC, Cortés Martín J, Montiel Troya M, Rodríguez Blanque R. The Effect of Therapeutic Hypothermia after Cardiac Arrest on the Neurological Outcome and Survival-A Systematic Review of RCTs Published between 2016 and 2020. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182211817. [PMID: 34831572 PMCID: PMC8618610 DOI: 10.3390/ijerph182211817] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/04/2021] [Accepted: 11/07/2021] [Indexed: 01/10/2023]
Abstract
Therapeutic hypothermia is a treatment used for patients who have suffered cardiorespiratory arrest and remain conscious after the recovery of spontaneous circulation. However, its effectiveness is controversial. The objective of this systematic review is to summarize the scientific evidence available about the effect of therapeutic hypothermia on neurological status and survival in this type of patients. METHODOLOGY A primary search in CINAHL, CUIDEN, Pubmed, Web of Science, and Scopus databases was carried out. Randomized clinical trials (RCT) published from 2016 to 2020 were selected. RESULTS 17 studies were selected for inclusion and most relevant data were extracted. Methodological quality was assessed by the RoB tool. CONCLUSIONS Although therapeutic hypothermia is a safe technique with few adverse and manageable effects, it has not shown to improve survival rate and neurological status of adult nor pediatric patients. It is possible that its positive effect on neuroprotection could be achieved only by preventing hyperthermia although further investigation is needed.
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Affiliation(s)
| | - Blanca Riquelme Gallego
- School of Nursing, Faculty of Health Sciences, University of Granada, 18071 Granada, Spain; (J.C.S.G.); (J.C.M.)
- Instituto de Investigación Biosanitaria, ibs.GRANADA, 18012 Granada, Spain
- Correspondence:
| | - Juan Carlos Sánchez García
- School of Nursing, Faculty of Health Sciences, University of Granada, 18071 Granada, Spain; (J.C.S.G.); (J.C.M.)
- Research Group CTS1068, Andalusia Research Plan, Junta de Andalucía, 18014 Granada, Spain; (M.M.T.); (R.R.B.)
| | - Jonathan Cortés Martín
- School of Nursing, Faculty of Health Sciences, University of Granada, 18071 Granada, Spain; (J.C.S.G.); (J.C.M.)
- Research Group CTS1068, Andalusia Research Plan, Junta de Andalucía, 18014 Granada, Spain; (M.M.T.); (R.R.B.)
| | - María Montiel Troya
- Research Group CTS1068, Andalusia Research Plan, Junta de Andalucía, 18014 Granada, Spain; (M.M.T.); (R.R.B.)
- School of Nursing Ceuta Campus, Faculty of Health Sciences, University of Granada, 51001 Ceuta, Spain
| | - Raquel Rodríguez Blanque
- Research Group CTS1068, Andalusia Research Plan, Junta de Andalucía, 18014 Granada, Spain; (M.M.T.); (R.R.B.)
- Distrito Sanitario Granada-Metropolitano, 18013 Granada, Spain
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Gagarinsky EL, Averin AS. Restoration of Vital Functions in Rats after Clinical Death Caused by Cold Water Submersion. Biophysics (Nagoya-shi) 2021. [DOI: 10.1134/s0006350921060038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Tveita T, Sieck GC. Physiological Impact of Hypothermia: The Good, the Bad and the Ugly. Physiology (Bethesda) 2021; 37:69-87. [PMID: 34632808 DOI: 10.1152/physiol.00025.2021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Hypothermia is defined as a core body temperature of < 35°C, and as body temperature is reduced the impact on physiological processes can be beneficial or detrimental. The beneficial effect of hypothermia enables circulation of cooled experimental animals to be interrupted for 1-2 h without creating harmful effects, while tolerance of circulation arrest in normothermia is between 4 and 5 min. This striking difference has attracted so many investigators, experimental as well as clinical, to this field, and this discovery was fundamental for introducing therapeutic hypothermia in modern clinical medicine in the 1950's. Together with the introduction of cardiopulmonary bypass, therapeutic hypothermia has been the cornerstone in the development of modern cardiac surgery. Therapeutic hypothermia also has an undisputed role as a protective agent in organ transplantation and as a therapeutic adjuvant for cerebral protection in neonatal encephalopathy. However, the introduction of therapeutic hypothermia for organ protection during neurosurgical procedures or as a scavenger after brain and spinal trauma has been less successful. In general, the best neuroprotection seems to be obtained by avoiding hyperthermia in injured patients. Accidental hypothermia occurs when endogenous temperature control mechanisms are incapable of maintaining core body temperature within physiologic limits and core temperature becomes dependent on ambient temperature. During hypothermia spontaneous circulation is considerably reduced and with deep and/or prolonged cooling, circulatory failure may occur, which may limit safe survival of the cooled patient. Challenges that limit safe rewarming of accidental hypothermia patients include cardiac arrhythmias, uncontrolled bleeding, and "rewarming shock".
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Affiliation(s)
- Torkjel Tveita
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.,Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
| | - Gary C Sieck
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, United States
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38
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Biancari F, Juvonen T, Speziale G. Commentary: Cooling the brain for elective aortic hemiarch repair. J Thorac Cardiovasc Surg 2021; 165:1774-1775. [PMID: 34696901 DOI: 10.1016/j.jtcvs.2021.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 10/07/2021] [Accepted: 10/07/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Fausto Biancari
- Clinica Montevergine, GVM Care & Research, Mercogliano, Italy; Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.
| | - Tatu Juvonen
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland; Research Unit of Surgery, Anesthesia and Critical Care, University of Oulu, Oulu, Finland
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Wallner B, Giesbrecht G, Pasquier M, Gordon L, Lechner R, Brugger H, Paal P, Darocha T, Zafren K. Resuscitation of an Unconscious Victim of Accidental Hypothermia in 1805. Wilderness Environ Med 2021; 32:548-553. [PMID: 34620550 DOI: 10.1016/j.wem.2021.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 08/23/2021] [Accepted: 08/25/2021] [Indexed: 10/20/2022]
Abstract
In 1805, W.D., a 16-y-old boy, became hypothermic after he was left alone on a grounded boat in Leith Harbour, near Edinburgh, Scotland. He was brought to his own house and resuscitated with warm blankets, smelling salts, and massage by Dr. George Kellie. W.D. made an uneventful recovery. We discuss the pathophysiology and treatment of accidental hypothermia, contrasting treatment in 1805 with treatment today. W.D. was hypothermic when found by passersby. Although he appeared dead, he was rewarmed with help from Dr. Kellie and his assistants over 200 y ago using simple methods. One concept that has not changed is the critical importance of attempting resuscitation, even if it seems to be futile. Don't give up!
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Affiliation(s)
- Bernd Wallner
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria; Department of General and Surgical Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria; Institute of Mountain Emergency Medicine, EURAC Research, Bolzano, Italy
| | - Gordon Giesbrecht
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, Canada; Department of Emergency Medicine, University of Manitoba, Winnipeg, Canada; Department of Anesthesia, University of Manitoba, Winnipeg, Canada
| | - Mathieu Pasquier
- Emergency Department, Lausanne University Hospital, and University of Lausanne, Lausanne, Switzerland; International Commission for Mountain Emergency Medicine (ICAR MedCom), Zürich, Switzerland
| | - Les Gordon
- Department of Anaesthesia, University Hospitals of Morecambe Bay Trust, Royal Lancaster Infirmary, Lancaster, UK; Langdale Ambleside Mountain Rescue Team, Ambleside, UK
| | - Raimund Lechner
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine, and Pain, Medicine, Armed Forces Hospital Ulm, Ulm, Germany
| | - Hermann Brugger
- Institute of Mountain Emergency Medicine, EURAC Research, Bolzano, Italy; International Commission for Mountain Emergency Medicine (ICAR MedCom), Zürich, Switzerland; Medical University of Innsbruck, Innsbruck, Austria
| | - Peter Paal
- International Commission for Mountain Emergency Medicine (ICAR MedCom), Zürich, Switzerland; Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Tomasz Darocha
- Department of Anesthesiology and Intensive Care, Medical University of Silesia, Katowice, Poland
| | - Ken Zafren
- International Commission for Mountain Emergency Medicine (ICAR MedCom), Zürich, Switzerland; Department of Emergency Medicine, Alaska Native Medical Center, Anchorage, Alaska; Department of Emergency Medicine, Stanford University Medical Center, Stanford, California.
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40
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Brown JA, Navid F, Serna-Gallegos D, Aranda-Michel E, Wang Y, Bianco V, Sultan I. Long-term outcomes of hemiarch replacement with hypothermic circulatory arrest and retrograde cerebral perfusion. J Thorac Cardiovasc Surg 2021:S0022-5223(21)01137-5. [PMID: 34420792 DOI: 10.1016/j.jtcvs.2021.07.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 07/11/2021] [Accepted: 07/21/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This study sought to report outcomes of hemiarch replacement with hypothermic circulatory arrest and retrograde cerebral perfusion, and secondarily, to report outcomes of this operative approach by type of underlying aortic disease. METHODS This was an observational study of aortic surgeries from 2010 to 2018. All patients who underwent hemiarch replacement with retrograde cerebral perfusion were included, whereas patients undergoing partial or total arch replacement or concomitant elephant trunk procedures were excluded. Patients were dichotomized into 2 groups by underlying aortic disease; that is, acute aortic dissection (AAD) or aneurysmal degeneration of the aorta. These groups were analyzed for differences in short-term postoperative outcomes, including stroke and operative mortality (Society of Thoracic Surgeons definition). Multivariable Cox analysis was performed to identify variables associated with long-term survival after hemiarch replacement. RESULTS A total of 500 patients undergoing hemiarch replacement with hypothermic circulatory arrest plus retrograde cerebral perfusion were identified, of whom 53.0% had aneurysmal disease and 47.0% had AAD. For the entire cohort, operative mortality was 6.4%, whereas stroke occurred in 4.6% of patients. Comparing AAD with aneurysm, operative mortality and stroke rates were similar across each group. Five-year survival was 84.4% ± 0.02% for the entire hemiarch cohort, whereas 5-year survival was 88.0% ± 0.02% for the aneurysm subgroup and was 80.5% ± 0.03% for the AAD subgroup. On multivariable analysis, AAD was not associated with an increased hazard of death, compared with aneurysm (P = .790). CONCLUSIONS Morbidity and mortality after hemiarch replacement with hypothermic circulatory arrest plus retrograde cerebral perfusion are acceptably low, and this operative approach may be as advantageous for AAD as it is for aneurysm.
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Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Forozan Navid
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Center for Thoracic Aortic Disease, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Center for Thoracic Aortic Disease, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Yisi Wang
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Center for Thoracic Aortic Disease, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Valentino Bianco
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Center for Thoracic Aortic Disease, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
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41
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The Role of Deep Hypothermia in Cardiac Surgery. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18137061. [PMID: 34280995 PMCID: PMC8297075 DOI: 10.3390/ijerph18137061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/27/2021] [Accepted: 06/28/2021] [Indexed: 12/24/2022]
Abstract
Hypothermia is defined as a decrease in body core temperature to below 35 °C. In cardiac surgery, four stages of hypothermia are distinguished: mild, moderate, deep, and profound. The organ protection offered by deep hypothermia (DH) enables safe circulatory arrest as a prerequisite to carrying out cardiac surgical intervention. In adult cardiac surgery, DH is mainly used in aortic arch surgery, surgical treatment of pulmonary embolism, and acute type-A aortic dissection interventions. In surgery treating congenital defects, DH is used to assist aortic arch reconstructions, hypoplastic left heart syndrome interventions, and for multi-stage treatment of infants with a single heart ventricle during the neonatal period. However, it should be noted that a safe duration of circulatory arrest in DH for the central nervous system is 30 to 40 min at most and should not be exceeded to prevent severe neurological adverse events. Personalized therapy for the patient and adequate blood temperature monitoring, glycemia, hematocrit, pH, and cerebral oxygenation is a prerequisite and indispensable part of DH.
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42
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Mustonen C, Honkanen HP, Lehtonen S, Tuominen H, Mäkelä T, Kaakinen T, Kiviluoma K, Anttila V, Juvonen T. Moderate hypothermia with remote ischaemic preconditioning improves cerebral protection compared to deep hypothermia: a study using a surviving porcine model. Eur J Cardiothorac Surg 2021; 58:269-276. [PMID: 32236538 DOI: 10.1093/ejcts/ezaa065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 01/30/2020] [Accepted: 02/05/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The optimal temperature management of hypothermic circulatory arrest is still controversial. Moderate hypothermia preserves cerebral autoregulation and shortens cardiopulmonary bypass (CPB) duration. However, moderate hypothermia alone has inferior organ protection to deep hypothermia, so adjuncts that increase the ischaemic tolerance are needed. Thus, we hypothesized that a combination of remote ischaemic preconditioning (RIPC) and moderate hypothermia would be superior to deep hypothermia alone. METHODS Sixteen pigs were randomized to either RIPC or control groups (8 + 8). The RIPC group underwent 4 cycles of transient hind limb ischaemia. The RIPC group underwent cooling with CPB to 24°C, and the control group underwent cooling with CPB to 18°C, followed by a 30-min arrest period and subsequent rewarming to 36°C. Measurements of cerebral metabolism were made from sagittal sinus blood samples and common carotid artery blood flow. The permissible periods of hypothermic circulatory arrest were calculated based on these measurements. Neurological recovery was evaluated daily during a 7-day follow-up, and the brain was harvested for histopathological analysis. RESULTS Six pigs in the RIPC group reached normal neurological function, but none in the control group reached normal neurological function (P = 0.007). The composite neurological score of all postoperative days was higher in the RIPC group than in the control group [55 (52-58) vs 45 (39-51), P = 0.026]. At 24°C, the estimated permissible periods of hypothermic circulatory arrest were 21 (17-25) min in the RIPC group and 11 (9-13) min in the control group (P = 0.007). CONCLUSIONS RIPC combined with moderate hypothermia provides superior cerebral protection.
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Affiliation(s)
- Caius Mustonen
- Research Unit of Surgery, Anaesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland
| | - Hannu-Pekka Honkanen
- Research Unit of Surgery, Anaesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland
| | - Siri Lehtonen
- Department of Obstetrics and Gynecology, Oulu University Hospital, Oulu, Finland
| | - Hannu Tuominen
- Department of Pathology, Oulu University Hospital, Oulu, Finland
| | - Tuomas Mäkelä
- Research Unit of Surgery, Anaesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland
| | - Timo Kaakinen
- Research Unit of Surgery, Anaesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland
| | - Kai Kiviluoma
- Research Unit of Surgery, Anaesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland
| | - Vesa Anttila
- Research Unit of Surgery, Anaesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland.,Heart Center, University of Turku, Turku University Hospital, Turku, Finland
| | - Tatu Juvonen
- Research Unit of Surgery, Anaesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland.,Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Central Hospital, Helsinki University Hospital, Helsinki, Finland
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43
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. Postreanimationsbehandlung. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00892-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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44
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Luehr M, Wahlers T. The long road to excellence in aortic surgery: Practice. Adopt. Repeat. Eur J Cardiothorac Surg 2021; 60:976-977. [PMID: 34037745 DOI: 10.1093/ejcts/ezab257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Maximilian Luehr
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, Cologne, Germany
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45
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care. Intensive Care Med 2021; 47:369-421. [PMID: 33765189 PMCID: PMC7993077 DOI: 10.1007/s00134-021-06368-4] [Citation(s) in RCA: 417] [Impact Index Per Article: 139.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/08/2021] [Indexed: 12/13/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation and organ donation.
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Affiliation(s)
- Jerry P. Nolan
- University of Warwick, Warwick Medical School, Coventry, CV4 7AL UK
- Royal United Hospital, Bath, BA1 3NG UK
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
- Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W. Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC), Université Catholique de Louvain, Brussels, Belgium
- Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Division of Health Sciences, Warwick Medical School, University of Warwick, Room A108, Coventry, CV4 7AL UK
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Véronique R. M. Moulaert
- Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Markus B. Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB UK
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46
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Mittermair C, Foidl E, Wallner B, Brugger H, Paal P. Extreme Cooling Rates in Avalanche Victims: Case Report and Narrative Review. High Alt Med Biol 2021; 22:235-240. [PMID: 33761270 DOI: 10.1089/ham.2020.0222] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Mittermair, Christof, Eva Foidl, Bernd Wallner, Hermann Brugger, and Peter Paal. Extreme cooling rates in avalanche victims: case report and narrative review. High Alt Med Biol. 22: 235-240, 2021. Background: We report a 25-year-old female backcountry skier who was buried by an avalanche during ascent. A cooling rate of 8.5°C/h from burial to hospital is the fastest reported in a person with persistent circulation. Methods: A case report according to the CARE guidelines is presented. A literature search with the keywords "avalanche" AND "hypothermia" was performed and yielded 96 results, and the last update was on October 25, 2020. A narrative review complements this work. Results: A literature search revealed four avalanche patients with extreme cooling rates (>5°/h). References of included articles were searched for further relevant studies. Nineteen additional pertinent articles were included. Overall, 32 studies were included in this work. Discussion: An avalanche patient cools in different phases, and every phase may have different cooling rates: (1) during burial, (2) with postburial exposure on-site, and (3) during transport. It is important to measure the core temperature correctly, ideally with an esophageal probe. Contributing factors to fast cooling are sweating, impaired consciousness, no shivering, wearing thin monolayer clothing and head and hands uncovered, an air pocket, and development of hypercapnia, being slender. Conclusions: Rescuers should be prepared to encounter severely hypothermic subjects (<30°C) even after burials of <60 minutes. Subjects rescued from an avalanche may cool extremely fast the more contributing factors for rapid cooling exist. After avalanche burial (≥60 minutes) and unwitnessed cardiac arrest, chances of neurologically intact survival are small and depend on rapid cooling and onset of severe hypothermia (<30°C) before hypoxia-induced cardiac arrest.
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Affiliation(s)
- Christof Mittermair
- Department of Surgery, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Eva Foidl
- Department of Anaesthesiology and Intensive Care Medicine, Kufstein Hospital, Kufstein, Austria
| | - Bernd Wallner
- Department of Anaesthesiology and General Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria.,Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - Hermann Brugger
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy.,International Commission of Mountain Emergency Medicine (ICAR MEDCOM), Kloten, Switzerland
| | - Peter Paal
- International Commission of Mountain Emergency Medicine (ICAR MEDCOM), Kloten, Switzerland.,Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
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47
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Mariero Olasveengen T, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care. Resuscitation 2021; 161:220-269. [PMID: 33773827 DOI: 10.1016/j.resuscitation.2021.02.012] [Citation(s) in RCA: 338] [Impact Index Per Article: 112.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation, and organ donation.
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Affiliation(s)
- Jerry P Nolan
- University of Warwick, Warwick Medical School, Coventry CV4 7AL, UK; Royal United Hospital, Bath, BA1 3NG, UK.
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy; Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W Böttiger
- University Hospital of Cologne, Kerpener Straße 62, D-50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC) Université Catholique de Louvain, Brussels, Belgium; Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Room A108, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Gisela Lilja
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden
| | - Véronique R M Moulaert
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB, UK
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48
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Alkhatip AAAMM, Kamel MG, Farag EM, Elayashy M, Farag A, Yassin HM, Bahr MH, Abdelhaq M, Sallam A, Kamal AM, Emady MFE, Wagih M, Naguib AA, Helmy M, Algameel HZ, Abdelkader M, Mohamed H, Younis M, Purcell A, Elramely M, Hamza MK. Deep Hypothermic Circulatory Arrest in the Pediatric Population Undergoing Cardiac Surgery With Electroencephalography Monitoring: A Systematic Review and Meta-Analysis. J Cardiothorac Vasc Anesth 2021; 35:2875-2888. [PMID: 33637420 DOI: 10.1053/j.jvca.2021.01.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/15/2021] [Accepted: 01/19/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Cardiac surgery for repair of congenital heart defects poses unique hazards to the developing brain. Deep hypothermic circulatory arrest (DHCA) is a simple and effective method for facilitating a bloodless surgical field during congenital heart defect repair. There are, however, some concerns that prolonged DHCA increases the risk of nervous system injury. The electroencephalogram (EEG) is used in adult and, to a lesser extent, pediatric cardiac procedures as a neuromonitoring method. The present study was performed to assess outcomes following DHCA with EEG monitoring in the pediatric population. DESIGN In this systematic review and meta-analysis, the PubMed, Cochrane Central Register of Controlled Trials, Scopus, Institute of Science Index, and Embase databases were searched from inception for relevant articles. A fixed- or random-effects model, as appropriate, was used. SETTING Surgical setting. PARTICIPANTS Pediatric population (≤18 y old). INTERVENTIONS DHCA (18°C) with EEG monitoring. MEASUREMENTS AND MAIN RESULTS Nineteen articles with 1,267 pediatric patients ≤18 years were included. The event rate of clinical and EEG seizures among patients who underwent DHCA was 12.9% and 14.9%, respectively. Mortality was found to have a 6.3% prevalence. A longer duration of DHCA was associated with a higher risk of EEG seizure and neurologic abnormalities. In addition, seizures were associated with increased neurologic abnormalities and neurodevelopmental delay. CONCLUSIONS EEG and neurologic abnormalities were common after DHCA. A longer duration of DHCA was found to lead to more EEG seizure and neurologic abnormalities. Moreover, EEG seizures were more common than clinical seizures. Seizures were found to be associated with increased neurologic abnormalities and neurodevelopmental delay.
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Affiliation(s)
- Ahmed Abdelaal Ahmed Mahmoud M Alkhatip
- Department of Anaesthesia, Birmingham Children's Hospital, Birmingham, UK; Department of Anaesthesia, Beni-Suef University Hospital and Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt.
| | | | - Ehab Mohamed Farag
- Department of Anaesthesia, Beni-Suef University Hospital and Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | - Mohamed Elayashy
- Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Farag
- Department of Anesthesia, King Abdullah Medical City - Holy Capital, Makkah, Saudi Arabia
| | - Hany Mahmoud Yassin
- Department of Anesthesia, Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Mahmoud Hussein Bahr
- Department of Anaesthesia, Beni-Suef University Hospital and Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | - Mohamed Abdelhaq
- Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Amr Sallam
- Department of Anaesthesia, Beaumont Hospital, Dublin, Ireland; Department of Anaesthesia, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | - Ahmed Mostafa Kamal
- Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - Mohamed Wagih
- Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Amr Ahmed Naguib
- Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Helmy
- Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - Mohamed Abdelkader
- Department of Anaesthesia, Beni-Suef University Hospital and Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | - Hassan Mohamed
- Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt; Department of Anaesthesia, Royal Papworth Hospital, Cambridge, UK
| | - Mohamed Younis
- Department of Anaesthesia, Cambridge University Hospital, Cambridge, UK
| | - Andrew Purcell
- Department of Anaesthesia, Beaumont Hospital, Dublin, Ireland
| | - Mohamed Elramely
- Department of Anaesthesia, National Cancer Institute, Cairo University, Cairo, Egypt
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Pupovac SS, Hemli JM, Bavaria JE, Patel HJ, Trimarchi S, Pacini D, Bekeredjian R, Chen EP, Myrmel T, Ouzounian M, Fanola C, Korach A, Montgomery DG, Eagle KA, Brinster DR. Moderate Versus Deep Hypothermia in Type A Acute Aortic Dissection Repair: Insights from the International Registry of Acute Aortic Dissection. Ann Thorac Surg 2021; 112:1893-1899. [PMID: 33515541 DOI: 10.1016/j.athoracsur.2021.01.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 01/06/2021] [Accepted: 01/07/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND The optimal strategy for cerebral protection during repair of type A acute aortic dissection has yet to be determined. We sought to determine the impact of differing degrees of hypothermia in patients undergoing acute dissection repair. METHODS All patients in the International Registry of Acute Aortic Dissection Interventional Cohort database who underwent type A acute aortic dissection repair between 2010 and 2018 were identified. Data for operative temperature were available for 1962 patients subsequently divided into 2 groups according to lowest temperature: moderate hypothermic circulatory arrest (MHCA) (20-28°C) versus deep hypothermic circulatory arrest (DHCA) (<20°C). We then propensity matched 362 pairs of patients and analyzed operative data and short-term outcomes. RESULTS The median lowest temperature was 25.0°C in the matched MHCA group as compared with 18.0°C in the DHCA group. For the entire cohort of 1962 patients, in-hospital mortality was 14.2% (278 deaths) but was not significantly different between DHCA and MHCA. The perioperative stroke rate was comparable between groups, before and after propensity matching. Circulatory arrest times were significantly longer in the MHCA cohort, regardless of matching. Use of antegrade or retrograde cerebral perfusion was similar in matched groups. There were no differences in 30-day survival or in other major postoperative morbidity between the 2 matched cohorts. CONCLUSIONS A surgical strategy of MHCA + antegrade cerebral perfusion is at least as safe as DHCA during repair of acute type A aortic dissection.
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Affiliation(s)
- Stevan S Pupovac
- Department of Cardiovascular & Thoracic Surgery, North Shore University Hospital/Northwell Health, Manhasset, New York.
| | - Jonathan M Hemli
- Department of Cardiovascular & Thoracic Surgery, Lenox Hill Hospital/Northwell Health, New York, New York
| | - Joseph E Bavaria
- Division of Cardiothoracic Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Himanshu J Patel
- Cardiovascular Center, University of Michigan Health System, Ann Arbor, Michigan
| | - Santi Trimarchi
- Department of Scienze Cliniche e di Comunita, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Davide Pacini
- Department of Cardiac Surgery, University Hospital S. Orsola, Bologna, Italy
| | - Raffi Bekeredjian
- Department of Cardiology, Robert-Bosch Krankenhaus, Stuttgart, Germany
| | - Edward P Chen
- Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
| | - Truls Myrmel
- Department of Thoracic & Cardiovascular Surgery, Tromso University Hospital, Tromso, Norway
| | - Maral Ouzounian
- Division of Cardiac Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Christina Fanola
- Cardiovascular Division, University of Minnesota Physicians Heart Practice, Minneapolis, Minnesota
| | - Amit Korach
- Department of Cardiothoracic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Daniel G Montgomery
- Cardiovascular Center, University of Michigan Health System, Ann Arbor, Michigan
| | - Kim A Eagle
- Cardiovascular Center, University of Michigan Health System, Ann Arbor, Michigan
| | - Derek R Brinster
- Department of Cardiovascular & Thoracic Surgery, Lenox Hill Hospital/Northwell Health, New York, New York
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50
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Li Y, He C, Chen X, Yao J, Zhang T, Zhang H. Endovascular In Situ Fenestration Technique of Aortic Arch Pathology: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2021; 76:472-480. [PMID: 33508460 DOI: 10.1016/j.avsg.2020.12.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 11/29/2020] [Accepted: 12/13/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the safety, applicability and outcomes of the endovascular in situ fenestration (ISF) technique for patients with aortic arch pathologies by performing a systematic review. METHODS We conducted a systematic search using the PubMed, Embase, and Cochrane databases to identify English language articles between January 2004 and March 2019 on the management of aortic arch pathologies using an in situ fenestration technique. Two independent observers selected studies for inclusion in the study, assessed the methodological quality of the included studies, and extracted the data. The studies included all investigated the clinical outcomes and postprocedural complications of using ISF techniques. RESULTS Seven studies reported on a total of 117 aortic arch pathologies patients. Including 52 dissection patients, 47 aneurysm patients, 18 intramural hematomas and penetrating ulcers patients. Needle fenestration and laser fenestration were performed in 62 and 45 patients respectively, and the rest 10 patients received radiofrequency fenestration. The follow-up period ranged from 1 to 55 months. The pooled technical success rates were 94% (95% confidence interval [CI]: 79-98%). The stroke rate was 6% (95% CI: 3-13%). The 30-day MAE was 11% (95% CI: 6-18%). CONCLUSION The results of the study showed that using the in-situ fenestration technique for treating patients with aortic arch pathologies produced encouraging mid-outcomes. Long-term outcomes remain undefined.
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Affiliation(s)
- Yue Li
- Department of Cardio-Vascular Surgery, Air Force Medical Center of People's Liberation Army, Beijing, 100142, China
| | - Changshun He
- Department of Vascular Surgery, Peking University People's Hospital, Beijing, People's Republic of China
| | - Xia Chen
- Department of Cardio-Vascular Surgery, Air Force Medical Center of People's Liberation Army, Beijing, 100142, China
| | - Jing Yao
- Department of Cardio-Vascular Surgery, Air Force Medical Center of People's Liberation Army, Beijing, 100142, China
| | - Tao Zhang
- Department of Vascular Surgery, Peking University People's Hospital, Beijing, People's Republic of China.
| | - Hongchao Zhang
- Department of Cardio-Vascular Surgery, Air Force Medical Center of People's Liberation Army, Beijing, 100142, China.
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