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Tanizawa S, Kojima M, Shoko T, Inoue A, Hifumi T, Sakamoto T, Kuroda Y. Extracorporeal cardiopulmonary resuscitation in hypothermic cardiac arrest: A secondary analysis of multicenter extracorporeal cardiopulmonary resuscitation registry data in Japan. Resusc Plus 2024; 19:100705. [PMID: 39049960 PMCID: PMC11268326 DOI: 10.1016/j.resplu.2024.100705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 06/13/2024] [Accepted: 06/20/2024] [Indexed: 07/27/2024] Open
Abstract
Aim Extracorporeal cardiopulmonary resuscitation (ECPR) is used to resuscitate patients with cardiac arrest; however, its effect in treating hypothermic cardiac arrest has not been well studied. Therefore, in this study, we aimed to examine the characteristics and outcomes of patients with hypothermic cardiac arrest who underwent ECPR, using a multicenter out-of-hospital cardiac arrest (OHCA) registry in Japan. Methods Baseline characteristics of patients with hypothermic OHCA and body temperature below 32 °C were assessed. Logistic regression analysis was performed to identify factors associated with in-hospital mortality and neurological outcomes in these patients. Outcomes of hypothermic and cardiogenic OHCA cases were compared using propensity-score matching to investigate differences among subgroups. Results We included 2,157 patients, with 102 and 1,646 in the hypothermic and cardiogenic groups, respectively. Higher age and longer low-flow time were independent risk factors for mortality, and higher age was an independent risk factor for unfavorable neurological outcomes in the hypothermic OHCA group.Eighty matched pairs were selected during propensity-score matching, and the mortality rate was lower in the hypothermic group than in the cardiogenic group (46.2% vs. 77.5%; p < 0.01). Unfavorable neurological outcome rate was lower in the hypothermic group than in the cardiogenic group (62.5% vs. 87.5%; p < 0.01). Conclusions Increased age and prolonged low-flow time were identified as negative prognostic factors in patients with hypothermic OHCA who underwent ECPR. These patients showed lower mortality and unfavorable neurological outcome rates than patients with cardiogenic OHCA, suggesting that ECPR is a promising strategy for treating hypothermic OHCA.
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Affiliation(s)
- Shu Tanizawa
- Emergency and Critical Care Centre, Tokyo Women’s Medical University Adachi Medical Centre, 4-33-1, Kohoku, Adachi, Tokyo 123-8558, Japan
- Department of Acute Critical Care and Disaster Medicine, Tokyo Medical and Dental University Hospital, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Mitsuaki Kojima
- Emergency and Critical Care Centre, Tokyo Women’s Medical University Adachi Medical Centre, 4-33-1, Kohoku, Adachi, Tokyo 123-8558, Japan
- Department of Acute Critical Care and Disaster Medicine, Tokyo Medical and Dental University Hospital, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Tomohisa Shoko
- Emergency and Critical Care Centre, Tokyo Women’s Medical University Adachi Medical Centre, 4-33-1, Kohoku, Adachi, Tokyo 123-8558, Japan
| | - Akihiko Inoue
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Centre, 1-3-1 Wakinohamakaigandori, Chuo, Kobe, Hyogo 651-0073, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke’s International Hospital, 9‐1 Akashi‐cho, Chuo‐ku, Tokyo 104‐8560, Japan
| | - Tetsuya Sakamoto
- Department of Emergency Medicine, Teikyo University School of Medicine, 2-11-2 Kaga, Itabashi, Tokyo 173-8606, Japan
| | - Yasuhiro Kuroda
- Department of Emergency Medicine, Kagawa University School of Medicine, 1750-1 Ikenobe, Miki, Kita, Kagawa 761-0793, Japan
| | - SAVE-J Ⅱ study group
- Emergency and Critical Care Centre, Tokyo Women’s Medical University Adachi Medical Centre, 4-33-1, Kohoku, Adachi, Tokyo 123-8558, Japan
- Department of Acute Critical Care and Disaster Medicine, Tokyo Medical and Dental University Hospital, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Centre, 1-3-1 Wakinohamakaigandori, Chuo, Kobe, Hyogo 651-0073, Japan
- Department of Emergency and Critical Care Medicine, St. Luke’s International Hospital, 9‐1 Akashi‐cho, Chuo‐ku, Tokyo 104‐8560, Japan
- Department of Emergency Medicine, Teikyo University School of Medicine, 2-11-2 Kaga, Itabashi, Tokyo 173-8606, Japan
- Department of Emergency Medicine, Kagawa University School of Medicine, 1750-1 Ikenobe, Miki, Kita, Kagawa 761-0793, Japan
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Pumiglia L, Williams JM, Prey BJ, Francis AD, Lammers DT, Zhang BZ, Palmerton HM, Pak GE, Gurney JM, Bingham JR, McClellan JM. Hypothermia and the Global War on Terror: 18 Years of Minimal Progress. Mil Med 2024; 189:190-195. [PMID: 39160793 DOI: 10.1093/milmed/usae072] [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: 11/30/2023] [Revised: 01/23/2024] [Accepted: 02/17/2024] [Indexed: 08/21/2024] Open
Abstract
INTRODUCTION The association between hypothermia, coagulopathy, and acidosis in trauma is well described. Hypothermia mitigation starts in the prehospital setting; however, it is often a secondary focus after other life-saving interventions. The deployed environment further compounds the problem due to prolonged evacuation times in rotary wing aircraft, resource limitations, and competing priorities. This analysis evaluates hypothermia in combat casualties and the relationship to resuscitation strategy with blood products. METHODS Using the data from the Department of Defense Joint Trauma Registry from 2003 to 2021, a retrospective analysis was conducted on adult trauma patients. Inclusion criteria was arrival at the first military treatment facility (MTF) hypothermic (<95ºF). Study variables included: mortality, year, demographics, battle vs non-battle injury, mechanism, theater of operation, vitals, and labs. Subgroup analysis was performed on severely injured (15 < ISS < 75) hypothermic trauma patients resuscitated with whole blood (WB) vs only component therapy. RESULTS Of the 69,364 patients included, 908 (1.3%) arrived hypothermic; the vast majority of whom (N = 847, 93.3%) arrived mildly hypothermic (90-94.9°F). Overall mortality rate was 14.8%. Rates of hypothermia varied by year from 0.7% in 2003 to 3.9% in 2014 (P <0.005). On subgroup analysis, mortality rates were similar between patients resuscitated with WB vs only component therapy; though base deficit values were higher in the WB cohort (-10 vs -6, P < 0.001). CONCLUSION Despite nearly 20 years of combat operations, hypothermia continues to be a challenge in military trauma and is associated with a high mortality rate. Mortality was similar between hypothermic trauma patients resuscitated with WB vs component therapy, despite greater physiologic derangements on arrival in patients who received WB. As the military has the potential to conduct missions in environments where the risk of hypothermia is high, further research into hypothermia mitigation techniques and resuscitation strategies in the deployed setting is warranted.
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Affiliation(s)
- Luke Pumiglia
- Department of Surgery, Madigan Army Medical Center, Joint Base Lewis-McChord, WA 98431, USA
| | - James M Williams
- Department of Surgery, Madigan Army Medical Center, Joint Base Lewis-McChord, WA 98431, USA
| | - Beau J Prey
- Department of Surgery, Madigan Army Medical Center, Joint Base Lewis-McChord, WA 98431, USA
| | - Andrew D Francis
- Department of Surgery, Madigan Army Medical Center, Joint Base Lewis-McChord, WA 98431, USA
| | - Daniel T Lammers
- Department of Surgery, University of Alabama Birmingham, Birmingham, AL 35233, USA
| | - Bobby Z Zhang
- Department of Surgery, Madigan Army Medical Center, Joint Base Lewis-McChord, WA 98431, USA
| | - Hannah M Palmerton
- Department of Surgery, Madigan Army Medical Center, Joint Base Lewis-McChord, WA 98431, USA
| | - Grace E Pak
- Department of Surgery, Madigan Army Medical Center, Joint Base Lewis-McChord, WA 98431, USA
| | - Jennifer M Gurney
- Joint Trauma System, DoD Center of Excellence for Trauma, JBSA Fort Sam Houston, TX 78234, USA
| | - Jason R Bingham
- Department of Surgery, Madigan Army Medical Center, Joint Base Lewis-McChord, WA 98431, USA
| | - John M McClellan
- Department of Surgery, University of North Carolina Chapel Hill, Chapel Hill, NC 27514, USA
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Falat C. Environmental Hypothermia. Emerg Med Clin North Am 2024; 42:493-511. [PMID: 38925770 DOI: 10.1016/j.emc.2024.02.011] [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: 06/28/2024]
Abstract
Although a rare diagnosis in the Emergency Department, hypothermia affects patients in all environments, from urban to mountainous settings. Classic signs of death cannot be interpreted in the hypothermic patient, thus resulting in the mantra, "No one is dead until they're warm and dead." This comprehensive review of environmental hypothermia covers the clinical significance and pathophysiology of hypothermia, pearls and pitfalls in the prehospital management of hypothermia (including temperature measurement techniques and advanced cardiac life support deviations), necessary Emergency Department diagnostics, available rewarming modalities including extracorporeal life support, and criteria for termination of resuscitation.
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Affiliation(s)
- Cheyenne Falat
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
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4
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Scaife JH, Hewes HA, Iantorno SE, Clinker CE, Fenton SJ, Skarda DE, Kastenberg ZJ, Swendiman RA, Russell KW. Optimizing patient selection for ECMO after pediatric hypothermic cardiac arrest. Injury 2024:111731. [PMID: 39048398 DOI: 10.1016/j.injury.2024.111731] [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: 02/03/2024] [Revised: 06/12/2024] [Accepted: 07/14/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND In 2004, our level 1 regional pediatric trauma center created a protocol to activate ECMO for children with suspected hypothermic cardiac arrest based on inclusion criteria: serum potassium ≤9, submersion <90 min, and core body temperature <30 °C. In 2017, Pasquier et al. developed a model to help predict the survival of adults after hypothermic cardiac arrest (HOPE score) that has not been validated in children. We sought to apply this score to our pediatric patient population to determine if it can optimize our patient selection. METHODS This was a retrospective review of all patients cannulated onto VA ECMO for hypothermic cardiac arrest between 2004 and 2022. We used abstracted data points to calculate the HOPE score for our patient population, both with and without presumed asphyxia. RESULTS Over 19 years, 18 patients were cannulated for suspected hypothermic arrest, with three survivors (17 %). The HOPE score survival prediction ranged from 1 to 86 % with presumed asphyxia and 6-98 % without presumed asphyxia. Survivor HOPE scores ranged from 9 to 86 % with presumed asphyxia and 42-98 % without presumed asphyxia. Non-survivors' scores ranged 1-29 % with asphyxia and 6-57 % without asphyxia. A cutoff of >5 % predicted survival with asphyxia for ECMO could have decreased our cannulations by half without missing survivors. CONCLUSION ECMO can be a lifesaving measure for specific children after hypothermic arrest. However, identifying the patients that will benefit from this resource-intensive intervention remains difficult. HOPE score utilization may decrease the rate of futile cannulation in children, but multi-centered research is needed in the pediatric population.
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Affiliation(s)
- Jack H Scaife
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Hilary A Hewes
- Department of Pediatric Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Stephanie E Iantorno
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Christopher E Clinker
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Stephen J Fenton
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - David E Skarda
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Zachary J Kastenberg
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Robert A Swendiman
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Katie W Russell
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
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Brown GC. Bioenergetic myths of energy transduction in eukaryotic cells. Front Mol Biosci 2024; 11:1402910. [PMID: 38952719 PMCID: PMC11215017 DOI: 10.3389/fmolb.2024.1402910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 04/15/2024] [Indexed: 07/03/2024] Open
Abstract
The study of energy transduction in eukaryotic cells has been divided between Bioenergetics and Physiology, reflecting and contributing to a variety of Bioenergetic myths considered here: 1) ATP production = energy production, 2) energy transduction is confined to mitochondria (plus glycolysis and chloroplasts), 3) mitochondria only produce heat when required, 4) glycolysis is inefficient compared to mitochondria, and 5) mitochondria are the main source of reactive oxygen species (ROS) in cells. These myths constitute a 'mitocentric' view of the cell that is wrong or unbalanced. In reality, mitochondria are the main site of energy dissipation and heat production in cells, and this is an essential function of mitochondria in mammals. Energy transduction and ROS production occur throughout the cell, particularly the cytosol and plasma membrane, and all cell membranes act as two-dimensional energy conduits. Glycolysis is efficient, and produces less heat per ATP than mitochondria, which might explain its increased use in muscle and cancer cells.
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Affiliation(s)
- Guy C. Brown
- Department of Biochemistry, University of Cambridge, Cambridge, United Kingdom
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Greene M, Dodds N, Gordon L. The Outcome of Walking Cold Patients with Potential Mild Hypothermia to Safety-A Mountain Rescue Case Series. Wilderness Environ Med 2024:10806032241259943. [PMID: 38874534 DOI: 10.1177/10806032241259943] [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: 06/15/2024]
Abstract
INTRODUCTION Some experts recommend that ambulant hypothermic patients should be rewarmed, fed, and not permitted to exercise for 30 min because of concerns that afterdrop can cause cardiac instability. We investigated the outcome of ambulant hypothermic patients in a case series from mountain rescue teams in Great Britain. METHODS A questionnaire was used to collect information on a series of adult patients with a clinical diagnosis of mild hypothermia. All patients were alert on the AVPU scale and evacuated by walking from the mountain. The outcome measures were survival or a change in management because of medical deterioration during evacuation. RESULTS A series of 108 eligible cases were reported over a 5-year period. When rescuers arrived on the scene, 98 (91%) patients were stationary, and 10 (9%) were still mobile. Thirty-eight (39%) of the stationary cases were walked immediately off the mountain without any on-scene delay. In the remaining 60 (61%) stationary cases, the decision was taken to delay evacuation to provide food, drinks, and additional clothing. In 3 cases, the use of heat packs indicated an intention to actively rewarm. In cases where the on-scene time was reported, 27 (79%) were known to be mobile again within 20 min. All patients survived, and no adverse medical events occurred in all 108 cases. CONCLUSIONS In this study, no adverse events occurred because of immediate mobilization, suggesting that in these cases, there appears to be minimal risk of early activity.
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Affiliation(s)
- Mike Greene
- Mountain Rescue England and Wales, Kendal, UK
| | | | - Les Gordon
- Langdale Ambleside Mountain Rescue Team, Ambleside, England
- University Hospitals Morecambe Bay Trust, Kendal, England
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Shoji K, Ohbe H, Matsuyama T, Inoue A, Hifumi T, Sakamoto T, Kuroda Y, Kushimoto S. Low-flow time and outcomes in hypothermic cardiac arrest patients treated with extracorporeal cardiopulmonary resuscitation: a secondary analysis of a multi-center retrospective cohort study. J Intensive Care 2024; 12:22. [PMID: 38863061 PMCID: PMC11165865 DOI: 10.1186/s40560-024-00735-1] [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: 02/28/2024] [Accepted: 05/27/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND In out-of-hospital cardiac arrest (OHCA) patients with extracorporeal cardiopulmonary resuscitation (ECPR), the association between low-flow time and outcomes in accidental hypothermia (AH) patients compared to those of patients without AH has not been fully investigated. METHODS This was a secondary analysis of the retrospective multicenter registry in Japan. We enrolled patients aged ≥ 18 years who had been admitted to the emergency department for OHCA and had undergone ECPR between January, 2013 and December, 2018. AH was defined as an arrival body temperature below 32 °C. The primary outcome was survival to discharge. Cubic spline analyses were performed to assess the non-linear associations between low-flow time and outcomes stratified by the presence of AH. We also analyzed the interaction between low-flow time and the presence of AH. RESULTS Of 1252 eligible patients, 105 (8.4%) and 1147 (91.6%) were in the AH and non-AH groups, respectively. Median low-flow time was 60 (47-79) min in the AH group and 51 (42-62) min in the non-AH group. The survival discharge rates in the AH and non-AH groups were 44.8% and 25.4%, respectively. The cubic spline analyses showed that survival discharge rate remained constant regardless of low-flow time in the AH group. Conversely, a decreasing trend was identified in the survival discharge rate with longer low-flow time in the non-AH group. The interaction analysis revealed a significant interaction between low-flow time and AH in survival discharge rate (p for interaction = 0.048). CONCLUSIONS OHCA patients with arrival body temperature < 32 °C who had received ECPR had relatively good survival outcomes regardless of low-flow time, in contrast to those of patients without AH.
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Affiliation(s)
- Kosuke Shoji
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, 1-1, Seiryo-Machi, Aoba-ku, Sendai, Miyagi, 9808574, Japan
- Department of Emergency Medicine, Japanese Red Cross Ishinomaki Hospital, Ishinomaki, Japan
| | - Hiroyuki Ohbe
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, 1-1, Seiryo-Machi, Aoba-ku, Sendai, Miyagi, 9808574, Japan.
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Akihiko Inoue
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Tetsuya Sakamoto
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Yasuhiro Kuroda
- Department of Emergency Medicine, Kagawa University School of Medicine, Miki, Kagawa, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, 1-1, Seiryo-Machi, Aoba-ku, Sendai, Miyagi, 9808574, Japan
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Sugiyama K, Nomura O, Irie J, Ishizawa Y, Takauji S, Hayakawa M, Tamada Y, Hanada H. Effects of rewarming therapies on outcomes in accidental hypothermia: A secondary analysis of a multicenter prospective study. Am J Emerg Med 2024; 79:91-96. [PMID: 38412669 DOI: 10.1016/j.ajem.2024.02.014] [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: 09/14/2023] [Revised: 01/22/2024] [Accepted: 02/12/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND Rewarming therapies for accidental hypothermia (AH) include extracorporeal membrane oxygenation (ECMO) and non-ECMO related (conventional) therapies. However, there are limited data available to inform the selection of conventional rewarming therapy. The aim of the present study was to explore what patients' factors and which rewarming therapy predicted favorable prognosis. METHODS This study is a secondary analysis of the Intensive Care with Extra Corporeal membrane oxygenation Rewarming in Accidentally Severe Hypothermia (ICE-CRASH) study, a multicenter prospective, observational study conducted in Japan. Enrolled in the ICE-CRASH study were patients aged ≥18 years with a core temperature of ≤32 °C who were transported to the emergency departments of 36 tertiary care hospitals in Japan between 1 December 2019 and 31 March 2022, among whom those who were rewarmed with conventional rewarming therapy were included in the present study. Logistic regression analysis was performed with 28-day survival as the objective variable; and seven factors including age, activities of daily living (ADL) independence, sequential organ failure assessment (SOFA) score, and each rewarming technique as explanatory variables. We performed linear regression analysis to identify whether each rewarming technique was associated with rewarming rate. RESULTS Of the 499 patients enrolled in the ICE-CRASH study, 371 were eligible for this secondary analysis. The median age was 81 years, 50.9% were male, and the median initial body temperature was 28.8 °C. Age (odds ratio [OR]: 0.97, 95% confidence interval [CI]: 0.94-1.00) and SOFA score (OR: 0.73, 95% CI: 0.67-0.81) were associated with lower survival, whereas ADL independence (OR: 2.31, 95% CI: 1.15-4.63) was associated with higher survival. No conventional rewarming therapy was associated with 28-day survival. Hot bath was associated with a high rewarming rate (regression coefficient: 1.14, 95% CI: 0.75-1.53). CONCLUSION No conventional rewarming therapy was associated with improved 28-day survival, which suggests that background factors such as age, ADL, and severity of condition contribute more to prognosis than does the selection of rewarming technique.
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Affiliation(s)
- Kana Sugiyama
- Department of Emergency and Disaster Medicine, Hirosaki University, 5, Zaifu-cho, Hirosaki 036-8562, Japan.
| | - Osamu Nomura
- Department of Health Sciences Education, Hirosaki University, 5, Zaifu-cho, Hirosaki 036-8562, Japan
| | - Jin Irie
- Department of Emergency Medicine, Hirosaki General Medical Center, 1, Tomino-cho, Hirosaki 036-8545, Japan
| | - Yoshiya Ishizawa
- Department of Emergency and Critical Care Center, Aomori Prefectural Central, Hospital, 2-1-1, Higashitsukurimichi, Aomori 030-8553, Japan
| | - Shuhei Takauji
- Emergency and Critical Care Center, Hokkaido University Hospital, N15W7, Kita-ku, Sapporo 060-8648, Japan
| | - Mineji Hayakawa
- Emergency and Critical Care Center, Hokkaido University Hospital, N15W7, Kita-ku, Sapporo 060-8648, Japan
| | - Yoshinori Tamada
- Department of Medical Data Intelligence, Hirosaki University, 5, Zaifu-cho, Hirosaki 036-8562, Japan
| | - Hiroyuki Hanada
- Department of Emergency and Disaster Medicine, Hirosaki University, 5, Zaifu-cho, Hirosaki 036-8562, Japan
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Kadden M, Zhang A, Shoykhet M. Association of temperature management strategy with fever in critically ill children after out-of-hospital cardiac arrest. Front Pediatr 2024; 12:1355385. [PMID: 38659696 PMCID: PMC11039828 DOI: 10.3389/fped.2024.1355385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 03/21/2024] [Indexed: 04/26/2024] Open
Abstract
Objective To determine whether ICU temperature management strategy is associated with fever in children with return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA). Methods We conducted a single-center retrospective cohort study at a quaternary Children's hospital between 1/1/2016-31/12/2020. Mechanically ventilated children (<18 y/o) admitted to Pediatric or Cardiac ICU (PICU/CICU) with ROSC after OHCA who survived at least 72 h were included. Primary exposure was initial PICU/CICU temperature management strategy of: (1) passive management; or (2) warming with an air-warming blanket; or (3) targeted temperature management with a heating/cooling (homeothermic) blanket. Primary outcome was fever (≥38°C) within 72 h of admission. Results Over the study period, 111 children with ROSC after OHCA were admitted to PICU/CICU, received mechanical ventilation and survived at least 72 h. Median age was 31 (IQR 6-135) months, 64% (71/111) were male, and 49% (54/111) were previously healthy. Fever within 72 h of admission occurred in 51% (57/111) of patients. The choice of initial temperature management strategy was associated with occurrence of fever (χ2 = 9.36, df = 2, p = 0.009). Fever occurred in 60% (43/72) of patients managed passively, 45% (13/29) of patients managed with the air-warming blanket and 10% (1/10) of patients managed with the homeothermic blanket. Compared to passive management, use of homeothermic, but not of air-warming, blanket reduced fever risk [homeothermic: Risk Ratio (RR) = 0.17, 95%CI 0.03-0.69; air-warming: RR = 0.75, 95%CI 0.46-1.12]. To prevent fever in one child using a homeothermic blanket, number needed to treat (NNT) = 2. Conclusion In critically ill children with ROSC after OHCA, ICU temperature management strategy is associated with fever. Use of a heating/cooling blanket with homeothermic feedback reduces fever incidence during post-arrest care.
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Affiliation(s)
- Micah Kadden
- Pediatric Critical Care Medicine, Children’s National Hospital, Washington, DC,United States
- Pediatric Critical Care Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, United States
| | - Anqing Zhang
- Division of Biostatistics and Study Methodology, Children’s National Hospital, Silver Spring, MD, United States
- Department of Pediatrics, School of Medicine and Health Sciences, The George Washington University, Washington, DC,United States
| | - Michael Shoykhet
- Pediatric Critical Care Medicine, Children’s National Hospital, Washington, DC,United States
- Department of Pediatrics, School of Medicine and Health Sciences, The George Washington University, Washington, DC,United States
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Takiguchi T, Tominaga N, Hamaguchi T, Seki T, Nakata J, Yamamoto T, Tagami T, Inoue A, Hifumi T, Sakamoto T, Kuroda Y, Yokobori S. Etiology-Based Prognosis of Extracorporeal CPR Recipients After Out-of-Hospital Cardiac Arrest: A Retrospective Multicenter Cohort Study. Chest 2024; 165:858-869. [PMID: 37879561 DOI: 10.1016/j.chest.2023.10.022] [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: 06/21/2023] [Revised: 10/04/2023] [Accepted: 10/17/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND A better understanding of the relative contributions of various factors to patient outcomes is essential for optimal patient selection for extracorporeal CPR (ECPR) therapy for patients with out-of-hospital cardiac arrest (OHCA). However, evidence on the prognostic comparison based on the etiologies of cardiac arrest is limited. RESEARCH QUESTION What is the etiology-based prognosis of patients undergoing ECPR for OHCA? STUDY DESIGN AND METHODS This retrospective multicenter registry study involved 36 institutions in Japan and included all adult patients with OHCA who underwent ECPR between January 2013 and December 2018. The primary etiology for OHCA was determined retrospectively from all hospital-based data at each institution. We performed a multivariable logistic regression model to determine the association between etiology of cardiac arrest and two outcomes: favorable neurologic outcome and survival at hospital discharge. RESULTS We identified 1,781 eligible patients, of whom 1,405 (78.9%) had cardiac arrest because of cardiac causes. Multivariable logistic regression analysis for favorable neurologic outcome showed that accidental hypothermia (adjusted OR, 5.12; 95% CI, 2.98-8.80; P < .001) was associated with a significantly higher rate of favorable neurologic outcome than cardiac causes. Multivariable logistic regression analysis for survival showed that accidental hypothermia (adjusted OR, 5.19; 95% CI, 3.15-8.56; P < .001) had significantly higher rates of survival than cardiac causes. Acute aortic dissection/aneurysm (adjusted OR, 0.07; 95% CI, 0.02-0.28; P < .001) and primary cerebral disorders (adjusted OR, 0.12; 95% CI, 0.03-0.50; P = .004) had significantly lower rates of survival than cardiac causes. INTERPRETATION In this retrospective multicenter cohort study, although most patients with OHCA underwent ECPR for cardiac causes, accidental hypothermia was associated with favorable neurologic outcome and survival; in contrast, acute aortic dissection/aneurysm and primary cerebral disorders were associated with nonsurvival compared with cardiac causes.
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Affiliation(s)
- Toru Takiguchi
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan; Department of Healthcare Information Management, The University of Tokyo Hospital, Tokyo, Japan.
| | - Naoki Tominaga
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Takuro Hamaguchi
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Tomohisa Seki
- Department of Healthcare Information Management, The University of Tokyo Hospital, Tokyo, Japan
| | - Jun Nakata
- Division of Cardiovascular Intensive Care, Department of Cardiovascular Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Takeshi Yamamoto
- Division of Cardiovascular Intensive Care, Department of Cardiovascular Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan; Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Akihiko Inoue
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Tetsuya Sakamoto
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Yasuhiro Kuroda
- Department of Emergency Medicine, Kagawa University School of Medicine, Kagawa, Japan
| | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
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11
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Podsiadło P, Brožek T, Balik M, Nowak E, Mendrala K, Hymczak H, Dąbrowski W, Miazgowski B, Rutkiewicz A, Burysz M, Witt-Majchrzak A, Jędrzejczak T, Podsiadło R, Darocha T. Predictors of cardiac arrest in severe accidental hypothermia. Am J Emerg Med 2024; 78:145-150. [PMID: 38281374 DOI: 10.1016/j.ajem.2024.01.031] [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: 11/12/2023] [Revised: 01/15/2024] [Accepted: 01/19/2024] [Indexed: 01/30/2024] Open
Abstract
STUDY OBJECTIVE To indicate predictors of witnessed hypothermic cardiac arrest. METHODS We conducted a retrospective analysis of 182 patients with severe accidental hypothermia (i.e., with core body temperature of ≤28 °C) who presented with preserved spontaneous circulation at first contact with medical services. We divided the study population into two groups: patients who suffered hypothermic cardiac arrest (HCA) at any time between encounter with medical service and restoration of normothermia, and those who did not sustain HCA. The analyzed outcome was the occurrence of cardiac arrest prior to achieving normothermia. Hemodynamic and biochemical parameters were analyzed with regard to their association with the outcome. RESULTS Fifty-two (29%) patients suffered HCA. In a univariable analysis, four variables were significantly associated with the outcome, namely heart rate (p < 0.001), systolic blood pressure (p = 0.03), ventricular arrhythmia (p = 0.001), and arterial oxygen partial pressure (p = 0.002). In the multivariable logistic regression the best model predicting HCA included heart rate, PaO2, and Base Excess (AUROC = 0.78). In prehospital settings, when blood gas analysis is not available, other multivariable model including heart rate and occurrence of ventricular arrhythmia (AUROC = 0.74) can be used. In this study population, threshold values of heart rate of 43/min, temperature-corrected PaO2 of 72 mmHg, and uncorrected PaO2 of 109 mmHg, presented satisfactory sensitivity and specificity for HCA prediction. CONCLUSIONS In patients with severe accidental hypothermia, the occurrence of HCA is associated with a lower heart rate, hypoxemia, ventricular arrhythmia, lower BE, and lower blood pressure. These parameters can be helpful in the early selection of high-risk patients and their allocation to extracorporeal rewarming facilities.
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Affiliation(s)
- Paweł Podsiadło
- Department of Emergency Medicine, Jan Kochanowski University, Kielce, Poland.
| | - Tomáš Brožek
- Department of Anaesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Martin Balik
- Department of Anaesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Ewelina Nowak
- Institute of Health Sciences, Jan Kochanowski University, Kielce, Poland
| | - Konrad Mendrala
- Department of Anaesthesiology and Intensive Care, Medical University of Silesia, Katowice, Poland
| | - Hubert Hymczak
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Kraków University, Kraków, Poland
| | - Wojciech Dąbrowski
- Department of Anaesthesiology and Intensive Care, Medical University of Lublin, Poland
| | - Bartosz Miazgowski
- Emergency Department, University Hospital, Pomeranian Medical University, Szczecin, Poland
| | | | - Marian Burysz
- Departament of Cardiac Surgery, Dr. Władysław Biegański Regional Specialist Hospital, Grudziądz, Poland
| | - Anna Witt-Majchrzak
- Department of Cardiac Surgery Provincial Specialist Hospital, Olsztyn, Poland
| | - Tomasz Jędrzejczak
- Department of Cardiosurgery, Pomeranian Medical University in Szczecin, Poland
| | - Rafał Podsiadło
- Department of Anaesthesiology and Intensive Care, University Hospital, Wrocław, Poland
| | - Tomasz Darocha
- Department of Anaesthesiology and Intensive Care, Medical University of Silesia, Katowice, Poland
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12
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Taira T, Inoue A, Kuroda Y, Oosuki G, Suga M, Nishimura T, Ijuin S, Ishihara S. The association between blood glucose levels on arrival at the hospital and patient outcomes after out-of-hospital cardiac arrest: A multicenter cohort study. Am J Emerg Med 2024; 77:46-52. [PMID: 38101226 DOI: 10.1016/j.ajem.2023.12.004] [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: 07/25/2023] [Revised: 11/09/2023] [Accepted: 12/02/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND This study aimed to investigate the association between blood glucose levels on arrival at the hospital and 1-month survival and favorable neurological outcomes in patients with OHCA using a large Japanese dataset. METHODS This study was a secondary analysis of data from the JAAM-OHCA Registry. Adult (≥18 years) patients with witnessed OHCA transported to emergency departments and registered in the database from June 2014 to December 2019 were included in the study. The primary and secondary endpoints were 1-month survival and 1-month favorable neurological outcomes (Glasgow-Pittsburgh Cerebral Performance Category score 1 or 2), respectively. Patients were categorized into the following four groups based on blood glucose levels on arrival at the hospital: <80 mg/dL, 80-179 mg/dL, 180-299 mg/dL, and ≥300 mg/dL. RESULTS This study included 11,387 patients. Survival rates were 1.3%, 3.1%, 7.0%, and 5.7% in the <80 mg/dL, 80-179 mg/dL, 180-299 mg/dL, and ≥ 300 mg/dL blood glucose groups, respectively. The rates of favorable neurological outcomes in each group were 0.4%, 1.5%, 3.3%, and 2.5%, respectively. Multivariable analysis showed that 180-299 mg/dL glucose was significantly associated with 1-month survival and favorable neurological outcomes compared with 80-179 mg/dL glucose (odds ratio [OR], 1.77; 95% confidence interval [CI], 1.34-2.31; p < 0.001 and OR, 1.52; 95 % Cl, 1.02-2.25; p = 0.035, respectively). In this study, blood glucose levels with the best outcomes likely ranged from 200 to 250 mg/dL based on the cubic spline regression model. CONCLUSIONS Blood glucose level of 180-299 mg/dL on arrival at the hospital was significantly associated with 1-month survival and favorable neurological outcomes compared to blood glucose level of 80-179 mg/dL in patients with OHCA.
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Affiliation(s)
- Takuya Taira
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Hyogo, Japan; Faculty of Medicine, Graduate School of Medicine, Kagawa University, Kagawa, Japan
| | - Akihiko Inoue
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Hyogo, Japan.
| | - Yasuhiro Kuroda
- Faculty of Medicine, Graduate School of Medicine, Kagawa University, Kagawa, Japan
| | - Gentoku Oosuki
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Hyogo, Japan
| | - Masafumi Suga
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Hyogo, Japan
| | - Takeshi Nishimura
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Hyogo, Japan
| | - Shinichi Ijuin
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Hyogo, Japan
| | - Satoshi Ishihara
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Hyogo, Japan
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13
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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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14
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Van Tilburg C, Paal P, Strapazzon G, Grissom CK, Haegeli P, Hölzl N, McIntosh S, Radwin M, Smith WWR, Thomas S, Tremper B, Weber D, Wheeler AR, Zafren K, Brugger H. Wilderness Medical Society Clinical Practice Guidelines for Prevention and Management of Avalanche and Nonavalanche Snow Burial Accidents: 2024 Update. Wilderness Environ Med 2024; 35:20S-44S. [PMID: 37945433 DOI: 10.1016/j.wem.2023.05.014] [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: 11/09/2022] [Revised: 04/03/2023] [Accepted: 05/10/2023] [Indexed: 11/12/2023]
Abstract
To provide guidance to the general public, clinicians, and avalanche professionals about best practices, the Wilderness Medical Society convened an expert panel to revise the evidence-based guidelines for the prevention, rescue, and resuscitation of avalanche and nonavalanche snow burial victims. The original panel authored the Wilderness Medical Society Practice Guidelines for Prevention and Management of Avalanche and Nonavalanche Snow Burial Accidents in 2017. A second panel was convened to update these guidelines and make recommendations based on quality of supporting evidence.
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Affiliation(s)
- Christopher Van Tilburg
- Occupational Medicine, Mountain Clinic, and Emergency Medicine, Providence Hood River Memorial Hospital, Hood River, OR
- Mountain Rescue Association, San Diego, CA
- International Commission for Alpine Rescue
| | - Peter Paal
- International Commission for Alpine Rescue
- Department of Anesthesiology and Critical Care Medicine, St. John of God Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Giacomo Strapazzon
- International Commission for Alpine Rescue
- Department of Anesthesiology and Critical Care Medicine, University Hospital Innsbruck, Innsbruck, Austria
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - Colin K Grissom
- Department of Pulmonary and Critical Care, Intermountain Medical Center, Murray, UT
| | | | - Natalie Hölzl
- International Commission for Alpine Rescue
- German Association of Mountain and Expedition Medicine, Munich, Germany
| | - Scott McIntosh
- International Commission for Alpine Rescue
- Division of Emergency Medicine, University of Utah Health, Salt Lake City, UT
| | | | - William Will R Smith
- Mountain Rescue Association, San Diego, CA
- International Commission for Alpine Rescue
- Division of Emergency Medicine, University of Utah Health, Salt Lake City, UT
- Department of Emergency Medicine, St. Johns Health, Jackson, WY
- University of Washington School of Medicine, Seattle, WA
| | - Stephanie Thomas
- Mountain Rescue Association, San Diego, CA
- International Commission for Alpine Rescue
| | | | - David Weber
- Intermountain Life Flight, Salt Lake City, UT
| | - Albert R Wheeler
- Mountain Rescue Association, San Diego, CA
- International Commission for Alpine Rescue
- Division of Emergency Medicine, University of Utah Health, Salt Lake City, UT
- Department of Emergency Medicine, St. Johns Health, Jackson, WY
| | - Ken Zafren
- International Commission for Alpine Rescue
- Himalayan Rescue Association, Kathmandu, Nepal
- Stanford University Medical Center, Palo Alto, CA
| | - Hermann Brugger
- International Commission for Alpine Rescue
- Department of Anesthesiology and Critical Care Medicine, University Hospital Innsbruck, Innsbruck, Austria
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
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15
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Jyoti AS, Kamrul-Hasan A, Rahman M, Hasan MJ. Acute hypothermia in a patient with COVID-19: a case report and summary of the evidence. Ann Med Surg (Lond) 2024; 86:1691-1694. [PMID: 38463048 PMCID: PMC10923324 DOI: 10.1097/ms9.0000000000001709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 12/29/2023] [Indexed: 03/12/2024] Open
Abstract
Introduction and importance SARS-COV-2 has many presenting signs including a number of typical and atypical symptoms. However, having the enormous capacity of mutation, the virus is changing its genetic pattern continuously, giving rise to newer and rarer manifestations. Here, the authors report a case of adult COVID-19 along with features of hypothermia which is relatively rare and has future implications in clinical perspective. Case presentation The patient presented with hypothermia and indicative symptoms of COVID-19 during admission. Comorbidities were assessed, potential differentials were ruled out thorough appropriate clinical examination and investigations. Insulation with a blanket and room heater was used to stabilize the normal body temperature (98.6°F) in the hospital setting, during this period vitals (Blood pressure, Pulse rate and oxygen saturation) were assessed regularly. On the sixth day of hospital admission, he was discharged from the hospital with advice. Clinical discussion COVID-19 virus can enter into brain through olfactory tract and may cause dysfunction in the medial preoptic area of the hypothalamus containing warm sensitive neurons directly or via cytokine-induced release of prostaglandin E2 from endothelial cells, which acts through a paracrine mechanism that may provoke hypothermia in our case. Conclusions This case highlights a rare presentation of COVID-19 infection that has not been thoroughly explored. The authors believe the case report holds particular importance especially in dealing with COVID-19 cases in both clinical and home settings.
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Affiliation(s)
| | - A.B.M Kamrul-Hasan
- Department of Endocrinology, Mymensingh Medical College, Mymensingh, Bangladesh
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16
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Shiozumi T, Miyamoto Y, Morita S, Ehara N, Miyamae N, Okada Y, Jo T, Sumida Y, Okada N, Watanabe M, Nozawa M, Tsuruoka A, Fujimoto Y, Okumura Y, Kitamura T, Matsuyama T. Association between the severity of hypothermia and in-hospital mortality in patients with infectious diseases: The J-Point registry. Acute Med Surg 2024; 11:e964. [PMID: 38756721 PMCID: PMC11096693 DOI: 10.1002/ams2.964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 04/16/2024] [Accepted: 04/27/2024] [Indexed: 05/18/2024] Open
Abstract
Aim Hypothermia is associated with poor prognosis in patients with sepsis. However, no studies have explored the correlation between the severity of hypothermia and prognosis. Methods Using data from the Japanese accidental hypothermia network registry (J-Point registry), we examined adult patients aged ≥18 years with infectious diseases whose initial body temperature was ≤35°C from April 1, 2011 to March 31, 2016, in 12 centers. Patients were divided into three groups according to their body temperature: Tertile 1 (T1) (32.0-35.0°C), Tertile 2 (T2) (28.0-31.9°C), and Tertile 3 (T3) (<28.0°C). In-hospital mortality was employed as a metric to assess outcomes. We conducted a multivariate logistic regression analysis to investigate the relationship between the three categories and the occurrence of in-hospital mortality. Results A total of 572 patients were registered, and 170 eligible patients were identified. Of these patients, 55 were in T1 (32.0-35.0°C), 76 in T2 (28.0-31.9°C), and 39 in T3 (<28.0°C) groups. The overall in-hospital mortality rate in accidental hypothermia (AH) patients with infectious diseases was 34.1%. The in-hospital mortality rates in the T1, T2, and T3 groups were 34.5%, 36.8%, and 28.2%, respectively. The multivariable analysis demonstrated no significant differences regarding in-hospital mortality among the three groups (T2 vs. T1, adjusted odds ratio [OR]: 1.29; 95% confidence interval [CI]: 0.58-2.89 and T3 vs. T1, adjusted OR: 0.83; 95% CI: 0.30-2.31). Conclusion In this multicenter retrospective observational study, hypothermia severity was not associated with in-hospital mortality in AH patients with infectious diseases.
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Affiliation(s)
- Tadaharu Shiozumi
- Department of Emergency MedicineKyoto Prefectural University of MedicineKyotoJapan
| | - Yuki Miyamoto
- Department of Emergency MedicineKyoto Prefectural University of MedicineKyotoJapan
| | - Sachiko Morita
- Department of Emergency and Critical Care MedicineSenri Critical Care Medical Center, Saiseikai Senri HospitalSuitaJapan
| | - Naoki Ehara
- Department of Emergency MedicineJapanese Red Cross Kyoto Daiichi HospitalKyotoJapan
| | - Nobuhiro Miyamae
- Department of Emergency MedicineRakuwa‐kai Otowa HospitalKyotoJapan
| | - Yohei Okada
- Department of Emergency and Critical Care MedicineJapanese Red Cross Society Kyoto Daini Red Cross HospitalKyotoJapan
- Health Services and Systems Research, Duke‐NUS Medical SchoolNational University of SingaporeSingapore CitySingapore
| | - Takaaki Jo
- Department of Emergency MedicineUji‐Tokushukai Medical CenterUjiJapan
| | - Yasuyuki Sumida
- Department of Emergency MedicineRakuwa‐kai Otowa HospitalKyotoJapan
- Department of Emergency MedicineNorth Medical Center, Kyoto Prefectural University of MedicineYosa‐GunJapan
| | - Nobunaga Okada
- Department of Emergency MedicineKyoto Prefectural University of MedicineKyotoJapan
- Department of Emergency MedicineJapanese Red Cross Kyoto Daiichi HospitalKyotoJapan
- Department of Emergency and Critical Care MedicineNational Hospital Organization, Kyoto Medical CenterKyotoJapan
| | - Makoto Watanabe
- Department of Emergency MedicineKyoto Prefectural University of MedicineKyotoJapan
| | - Masahiro Nozawa
- Department of Emergency and Critical Care MedicineSaiseikai Shiga HospitalRittoJapan
- Department of Emergency MedicineShiga General HospitalMoriyamaJapan
| | - Ayumu Tsuruoka
- Department of Emergency and Critical Care MedicineKidney and Cardiovascular Center, Kyoto min‐Iren Chuo HospitalKyotoJapan
- Department of Emergency and Critical Care MedicineEmergency and Critical Care Medical Center, Osaka City General HospitalOsakaJapan
| | | | - Yoshiki Okumura
- Department of Emergency MedicineFukuchiyama City HospitalFukuchiyamaJapan
| | - Tetsuhisa Kitamura
- Department of Social and Environmental Medicine, Division of Environmental Medicine and Population SciencesGraduate School of Medicine, Osaka UniversitySuitaJapan
| | - Tasuku Matsuyama
- Department of Emergency MedicineKyoto Prefectural University of MedicineKyotoJapan
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17
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Azarkane M, Rijnhout TWH, van Merwijk IAL, Tromp TN, Tan ECTH. Impact of accidental hypothermia in trauma patients: A retrospective cohort study. Injury 2024; 55:110973. [PMID: 37563046 DOI: 10.1016/j.injury.2023.110973] [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: 02/20/2023] [Revised: 07/05/2023] [Accepted: 08/01/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Trauma patients with hypothermia have substantial increases in mortality and morbidity. In severely injured patients, hypothermia is common with a rate up to 50% in various geographic areas. This study aims to elucidate the incidence, predictors, and impact of hypothermia on outcomes in severely injured patients. METHODS This was a retrospective cohort study which included trauma patients with an Injury Severity Score (ISS) ≥ 16 admitted to a level 1 trauma center in the Netherlands between January 1, 2015 and December 31, 2021. Primary outcome was incidence of hypothermia on arrival at the emergency department. Factors associated with hypothermia were identified. Secondary outcomes were transfusion requirement, mortality, and intensive care unit (ICU) admission. Logistic regression analysis was used to identify associations. RESULTS A total of 2032 severely injured patients were included of which 257 (12.6%) were hypothermic on hospital arrival. Predictors for hypothermia on hospital arrival included higher ISS, prehospital intubation, cervical spine immobilization, winter months, systolic blood pressure (SBP) < 90 mmHg and Glasgow Coma Scale (GCS) ≤ 8. Hypothermia was independently associated with transfusion requirement (OR, 2.68; 95% CI, 1.94 - 3.73; p < 0.001), mortality (OR, 2.12; 95% CI, 1.40 - 3.19; p < 0.001) and more often ICU admission (OR, 1.81; 95% CI, 1.10 - 2.97, p = 0.019). CONCLUSIONS In this study, hypothermia was present in 12.6% of severely injured patients. Hypothermia was associated with increased transfusion requirement, mortality, and ICU admission. Identified predictors for hypothermia included the severity of injury, intubation, and immobilization, as well as winter season, SBP < 90 mmHg, and GCS ≤ 8.
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Affiliation(s)
- Mozdalefa Azarkane
- Department of Trauma Surgery, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Tim W H Rijnhout
- Department of Trauma Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Isa A L van Merwijk
- Department of Trauma Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Tjarda N Tromp
- Department of Trauma Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Edward C T H Tan
- Department of Trauma Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
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18
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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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19
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Jones DM, Weller RS, McClintock RJ, Roberts N, Zheng W, Dunn TL. Prevalence of hypothermia and critical hand temperatures during military cold water immersion training. Int J Circumpolar Health 2023; 82:2236777. [PMID: 37469312 PMCID: PMC10361000 DOI: 10.1080/22423982.2023.2236777] [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: 07/05/2023] [Accepted: 07/11/2023] [Indexed: 07/21/2023] Open
Abstract
Cold-weather military operations can quickly undermine warfighter readiness and performance. Specifically, accidental cold-water immersion (CWI) contributes to rapid body heat loss and impaired motor function. This study evaluated the prevalence of hypothermia and critical hand temperatures during CWI. One-hundred seventeen (N = 117) military personnel (mean ± SD age: 27 ± 6 yr, height: 176 ± 8 cm, weight: 81.5 ± 11.6 kg) completed CWI and rewarming during cold-weather training, which included a 10-min outdoor CWI (1.3 ± 1.4°C) combined with cold air (-4.2 ± 8.5°C) exposure. Following CWI, students removed wet clothing, donned dry clothing, and entered sleeping systems. Core (Tc) and hand (Thand) temperatures were recorded continuously during the training exercise. Tc for 96 students (mean ± SD lowest Tc = 35.6 ± 0.9°C) revealed that 24 students (25%) experienced Tc below 35.0°C. All of 110 students (100%) experienced Thand below 15.0°C, with 71 students (65%) experiencing Thand at or below 8.0°C. Loss of hand function and hypothermia should be anticipated in warfighters who experience CWI in field settings. Given the high prevalence of low Thand, focus should be directed on quickly rewarming hands to recover function.
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Affiliation(s)
- Douglas M Jones
- Warfighter Performance, Naval Health Research Center, San Diego, CA, USA
| | - Rebecca S Weller
- Warfighter Performance, Naval Health Research Center, San Diego, CA, USA
| | | | - Nicholas Roberts
- Mountain Medicine, Marine Corps Mountain Warfare Training Center, Bridgeport, CA, USA
| | - Weimin Zheng
- Warfighter Performance, Naval Health Research Center, San Diego, CA, USA
| | - Timothy L Dunn
- Warfighter Performance, Naval Health Research Center, San Diego, CA, USA
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20
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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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Selli AL, Ghasemi M, Watters T, Burton F, Smith G, Dietrichs ES. Proarrhythmic changes in human cardiomyocytes during hypothermia by milrinone and isoprenaline, but not levosimendan: an experimental in vitro study. Scand J Trauma Resusc Emerg Med 2023; 31:61. [PMID: 37880801 PMCID: PMC10601188 DOI: 10.1186/s13049-023-01134-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 10/15/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Accidental hypothermia, recognized by core temperature below 35 °C, is a lethal condition with a mortality rate up to 25%. Hypothermia-induced cardiac dysfunction causing increased total peripheral resistance and reduced cardiac output contributes to the high mortality rate in this patient group. Recent studies, in vivo and in vitro, have suggested levosimendan, milrinone and isoprenaline as inotropic treatment strategies in this patient group. However, these drugs may pose increased risk of ventricular arrhythmias during hypothermia. Our aim was therefore to describe the effects of levosimendan, milrinone and isoprenaline on the action potential in human cardiomyocytes during hypothermia. METHODS Using an experimental in vitro-design, levosimendan, milrinone and isoprenaline were incubated with iCell2 hiPSC-derived cardiomyocytes and cellular action potential waveforms and contraction were recorded from monolayers of cultured cells. Experiments were conducted at temperatures from 37 °C down to 26 °C. One-way repeated measures ANOVA was performed to evaluate differences from baseline recordings and one-way ANOVA was performed to evaluate differences between drugs, untreated control and between drug concentrations at the specific temperatures. RESULTS Milrinone and isoprenaline both significantly increases action potential triangulation during hypothermia, and thereby the risk of ventricular arrhythmias. Levosimendan, however, does not increase triangulation and the contractile properties also remain preserved during hypothermia down to 26 °C. CONCLUSIONS Levosimendan remains a promising candidate drug for inotropic treatment of hypothermic patients as it possesses ability to treat hypothermia-induced cardiac dysfunction and no increased risk of ventricular arrhythmias is detected. Milrinone and isoprenaline, on the other hand, appears more dangerous in the hypothermic setting.
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Affiliation(s)
- Anders Lund Selli
- Experimental and Clinical Pharmacology, Department of Medical Biology, Faculty of Health Sciences, UiT - The Arctic University of Norway, Postboks 6050, 9037, Langnes, Tromsø, Norway
| | | | | | - Francis Burton
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland
- Clyde Biosciences, Newhouse, Scotland
| | - Godfrey Smith
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland
- Clyde Biosciences, Newhouse, Scotland
| | - Erik Sveberg Dietrichs
- Experimental and Clinical Pharmacology, Department of Medical Biology, Faculty of Health Sciences, UiT - The Arctic University of Norway, Postboks 6050, 9037, Langnes, Tromsø, Norway.
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway.
- Institute of Oral Biology, University of Oslo, Oslo, Norway.
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Hall N, Métrailler-Mermoud J, Cools E, Fehlmann C, Carron PN, Rousson V, Grabherr S, Schrag B, Kirsch M, Frochaux V, Pasquier M. Hypothermic cardiac arrest patients admitted to hospital who were not rewarmed with extracorporeal life support: A retrospective study. Resusc Plus 2023; 15:100443. [PMID: 37638095 PMCID: PMC10448201 DOI: 10.1016/j.resplu.2023.100443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/13/2023] [Accepted: 07/25/2023] [Indexed: 08/29/2023] Open
Abstract
Aims Our goal was to study hypothermic cardiac arrest (CA) patients who were not rewarmed by Extracorporeal Life Support (ECLS) but were admitted to a hospital equipped for it. The focus was on whether the decisions of non-rewarming, meaning termination of resuscitation, were compliant with international guidelines based on serum potassium at hospital admission. Methods We retrospectively included all hypothermic CA who were not rewarmed, from three Swiss centers between 1st January 2000 and 2nd May 2021. Data were extracted from medical charts and assembled into two groups for analysis according to serum potassium. We identified the criteria used to terminate resuscitation. We also retrospectively calculated the HOPE score, a multivariable tool predicting the survival probability in hypothermic CA undergoing ECLS rewarming. Results Thirty-eight victims were included in the study. The decision of non-rewarming was compliant with international guidelines for 12 (33%) patients. Among the 36 patients for whom the serum potassium was measured at hospital admission, 24 (67%) had a value that - alone - would have indicated ECLS. For 13 of these 24 (54%) patients, the HOPE score was <10%, meaning that ECLS was not indicated. The HOPE estimation of the survival probabilities, when used with a 10% threshold, supported 23 (68%) of the non-rewarming decisions made by the clinicians. Conclusions This study showed a low adherence to international guidelines for hypothermic CA patients. In contrast, most of these non-rewarming decisions made by clinicians would have been compliant with current guidelines based on the HOPE score.
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Affiliation(s)
- Nicolas Hall
- Department of Emergency Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | - Evelien Cools
- Acute Medicine Department, Anesthesiology Service, Geneva, Switzerland
| | | | - Pierre-Nicolas Carron
- Department of Emergency Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Valentin Rousson
- Center for Primary Care and Public Health (Unisanté), Lausanne, Switzerland
| | - Silke Grabherr
- University Center of Legal Medicine, Lausanne – Geneva, Switzerland
- Lausanne University Hospital and University of Lausanne, Geneva University Hospital and University of Geneva, Switzerland
| | - Bettina Schrag
- Legal Medicine Service, Hospitals Central Institute (ICH), Sion, Switzerland
| | - Matthias Kirsch
- Department of Cardiac Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Mathieu Pasquier
- Department of Emergency Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Kapoor MP, Moriwaki M, Abe A, Morishima S, Ozeki M, Sato N. Hesperetin-7- O-glucoside/β-cyclodextrin Inclusion Complex Induces Acute Vasodilator Effect to Inhibit the Cold Sensation Response during Localized Cold-Stimulate Stress in Healthy Human Subjects: A Randomized, Double-Blind, Crossover, and Placebo-Controlled Study. Nutrients 2023; 15:3702. [PMID: 37686734 PMCID: PMC10489958 DOI: 10.3390/nu15173702] [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: 08/09/2023] [Revised: 08/17/2023] [Accepted: 08/20/2023] [Indexed: 09/10/2023] Open
Abstract
Hesperetin, a citrus flavonoid, exerts vasodilation and is expected to improve endothelial function and alleviate cold sensation by activating nervous system thermal transduction pathways. In this randomized, double-blind, crossover, and placebo-controlled study, the purpose was to assess the effect of an orally administered highly bioavailable soluble inclusion complex of hesperetine-7-O-glucoside with β-cyclodextrin (HEPT7G/βCD; SunActive® HES/HCD) on cold sensation response during localized cold-stimulated stress in healthy humans. A significant (p ≤ 0.05) dose-dependent increase in skin cutaneous blood flow following relatively small doses of HEPT7G/βCD inclusion complex ingestion was confirmed, which led to a relatively effective recovery of peripheral skin temperature. The time delay of an increase in blood flow during rewarming varied significantly between low- and high-dose HEPT7G/βCD inclusion complex consumption (e.g., 150 mg and 300 mg contain 19.5 mg and 39 mg of HEPT7G, respectively). In conclusion, the substantial alteration in peripheral skin blood flow observed during local cooling stress compared to placebo suggested that deconjugated hesperetin metabolites may have a distinct capacity for thermoregulatory control of human skin blood flow to maintain a constant body temperature during cold stress exposure via cutaneous vasodilation and vasoconstriction systems.
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Affiliation(s)
- Mahendra P. Kapoor
- Nutrition Division, Taiyo Kagaku Co., Ltd., 1-3 Takaramachi, Yokkaichi 510-0844, Mie, Japan
| | - Masamitsu Moriwaki
- Nutrition Division, Taiyo Kagaku Co., Ltd., 1-3 Takaramachi, Yokkaichi 510-0844, Mie, Japan
| | - Aya Abe
- Nutrition Division, Taiyo Kagaku Co., Ltd., 1-3 Takaramachi, Yokkaichi 510-0844, Mie, Japan
| | - So Morishima
- Nutrition Division, Taiyo Kagaku Co., Ltd., 1-3 Takaramachi, Yokkaichi 510-0844, Mie, Japan
| | - Makoto Ozeki
- Nutrition Division, Taiyo Kagaku Co., Ltd., 1-3 Takaramachi, Yokkaichi 510-0844, Mie, Japan
| | - Norio Sato
- Taiyo Kagaku Co., Ltd., 800 Yamada-Cho, Yokkaichi 510-1111, Mie, Japan
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Kouchit Y, Canac B, Levraut J, Martis N. Prevalence of hypothermia and its associated clinical and biological features (such as thrombocytopenia) in emergency department patients: a case series. Intern Emerg Med 2023; 18:1595-1598. [PMID: 37395981 DOI: 10.1007/s11739-023-03345-1] [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: 03/03/2023] [Accepted: 06/12/2023] [Indexed: 07/04/2023]
Affiliation(s)
- Yanis Kouchit
- Internal Medicine Department, University Hospital of Nice, Archet 1 Hospital, 151 Route de Saint-Antoine de Ginestière, 06200, Nice, France
- Côte d'Azur University, Nice, France
| | - Benoit Canac
- Côte d'Azur University, Nice, France
- Emergency Medicine Department, University Hospital of Nice, Nice, France
| | - Jacques Levraut
- Côte d'Azur University, Nice, France
- Emergency Medicine Department, University Hospital of Nice, Nice, France
| | - Nihal Martis
- Internal Medicine Department, University Hospital of Nice, Archet 1 Hospital, 151 Route de Saint-Antoine de Ginestière, 06200, Nice, France.
- Côte d'Azur University, Nice, France.
- INSERM U1065, Mediterranean Centre for Molecular Medicine, Team: Control of Gene Expression, Nice, France.
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Nedelea PL, Manolescu E, Ciumanghel AI, Constantin M, Hauta A, Sirbu O, Ionescu L, Blaj M, Corlade-Andrei M, Sorodoc V, Cimpoesu D. The Beginning of an ECLS Center: First Successful ECPR in an Emergency Department in Romania-Case-Based Review. J Clin Med 2023; 12:4922. [PMID: 37568324 PMCID: PMC10419366 DOI: 10.3390/jcm12154922] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/01/2023] [Accepted: 07/20/2023] [Indexed: 08/13/2023] Open
Abstract
According to the latest international resuscitation guidelines, extracorporeal cardiopulmonary resuscitation (ECPR) involves the utilization of extracorporeal membrane oxygenation (ECMO) in specific patients experiencing cardiac arrest, and it can be considered in situations where standard cardiopulmonary resuscitation efforts fail if they have a potentially reversible underlying cause, among which we can also find hypothermia. In cases of cardiac arrest, both witnessed and unwitnessed, hypothermic patients have higher chances of survival and favorable neurological outcomes compared to normothermic patients. ECPR is a multifaceted procedure that requires a proficient team, specialized equipment, and comprehensive multidisciplinary support within a healthcare system. However, it also carries the risk of severe, life-threatening complications. With the increasing use of ECPR in recent years and the growing number of centers implementing this technique outside the intensive care units, significant uncertainties persist in both prehospital and emergency department (ED) settings. Proper organization is crucial for an ECPR program in emergency settings, especially given the challenges and complexities of these treatments, which were previously not commonly used in ED. Therefore, within a narrative review, we have incorporated the initial case of ECPR in an ED in Romania, featuring a successful resuscitation in the context of severe hypothermia (20 °C) and a favorable neurological outcome (CPC score of 1).
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Affiliation(s)
- Paul Lucian Nedelea
- Department of Emergency Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Emergency Department, “St. Spiridon” Emergency Clinical County Hospital, 700111 Iasi, Romania
| | - Emilian Manolescu
- Department of Emergency Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Emergency Department, “St. Spiridon” Emergency Clinical County Hospital, 700111 Iasi, Romania
| | - Adi-Ionut Ciumanghel
- Department of Emergency Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Anesthesia Intensive Care Unit, “St. Spiridon” Emergency Clinical County Hospital, 700111 Iasi, Romania
| | - Mihai Constantin
- 2nd Internal Medicine Clinic, “St. Spiridon” Emergency Clinical County Hospital, 700111 Iasi, Romania
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Alexandra Hauta
- Department of Emergency Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Oana Sirbu
- 2nd Internal Medicine Clinic, “St. Spiridon” Emergency Clinical County Hospital, 700111 Iasi, Romania
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Lidia Ionescu
- 3rd Surgery Clinic, “St. Spiridon” Emergency Clinical County Hospital, 700111 Iasi, Romania
| | - Mihaela Blaj
- Anesthesia Intensive Care Unit, “St. Spiridon” Emergency Clinical County Hospital, 700111 Iasi, Romania
| | | | - Victorita Sorodoc
- 2nd Internal Medicine Clinic, “St. Spiridon” Emergency Clinical County Hospital, 700111 Iasi, Romania
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Diana Cimpoesu
- Department of Emergency Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Emergency Department, “St. Spiridon” Emergency Clinical County Hospital, 700111 Iasi, Romania
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McLellan H, Rijnhout TWH, Peterson LM, Stuhlmiller DFE, Edwards J, Jarrouj A, Samanta D, Tager A, Tan ECTH. Prehospital Active and Passive Warming in Trauma Patients. Air Med J 2023; 42:252-258. [PMID: 37356885 DOI: 10.1016/j.amj.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/13/2023] [Accepted: 03/15/2023] [Indexed: 06/27/2023]
Abstract
OBJECTIVE Hypothermia is common among trauma patients and can lead to a serious rise in morbidity and mortality. This study was performed to investigate the effect of active and passive warming measures implemented in the prehospital phase on the body temperature of trauma patients. METHODS In a multicenter, multinational prospective observational design, the effect of active and passive warming measures on the incidence of hypothermia was investigated. Adult trauma patients who were transported by helicopter emergency medical services (HEMS) or ground emergency medical services with an HEMS physician directly from the scene of injury were included. Four HEMS/ground emergency medical services programs from Canada, the United States, and the Netherlands participated. RESULTS A total of 80 patients (n = 20 per site) were included. Eleven percent had hypothermia on presentation, and the initial evaluation occurred predominantly within 60 minutes after injury. In-line fluid warmers and blankets were the most frequently used active and passive warming measures, respectively. Independent risk factors for a negative change in body temperature were transportation by ground ambulance (odds ratio = 3.20; 95% confidence interval, 1.06-11.49; P = .03) and being wet on initial presentation (odds ratio = 3.64; 95% confidence interval, 0.99-13.36; P = .05). CONCLUSION For adult patients transported from the scene of injury to a trauma center, active and passive warming measures, most notably the removal of wet clothing, were associated with a favorable outcome, whereas wet patients and ground ambulance transport were associated with an unfavorable outcome with respect to temperature.
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Affiliation(s)
- Heather McLellan
- Advanced Studies in Critical Care Nursing, Mount Royal University, Mount Royal Gate, Calgary, Alberta, Canada.
| | - Tim W H Rijnhout
- Department of Trauma Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - L Michael Peterson
- Charleston Area Medical Center, Institute for Academic Medicine, Charleston, WV; HealthNet Aeromedical Services, Charleston, WV
| | | | - Jerry Edwards
- Charleston Area Medical Center, Institute for Academic Medicine, Charleston, WV
| | - Aous Jarrouj
- Charleston Area Medical Center, Institute for Academic Medicine, Charleston, WV
| | - Damayanti Samanta
- Charleston Area Medical Center, Institute for Academic Medicine, Charleston, WV
| | - Alfred Tager
- Charleston Area Medical Center, Institute for Academic Medicine, Charleston, WV
| | - Edward C T H Tan
- Department of Trauma Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
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Ushimoto T, Murasaka K, Wato Y, Inaba H. Associations between prehospital defibrillation and outcomes of out-of-hospital cardiac arrests presumed to be caused by hypothermia: A nationwide observational study with epidemiological analysis. Medicine (Baltimore) 2023; 102:e33618. [PMID: 37115090 PMCID: PMC10146074 DOI: 10.1097/md.0000000000033618] [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: 01/18/2023] [Revised: 04/03/2023] [Accepted: 04/04/2023] [Indexed: 04/29/2023] Open
Abstract
This study aimed to clarify the epidemiology of out of-hospital cardiac arrest (OHCA) cases caused by hypothermia. The associations between the presence/absence of shockable initial electrocardiography rhythm, prehospital defibrillation and the outcomes of OHCA were also investigated. This study involved the retrospective analysis of prospectively collected, nationwide, population-based data for OHCA cases caused by hypothermia. One thousand five hundred seventy-five emergency medical service (EMS)-confirmed OHCA cases with hypothermia, recorded between 2013 and 2019, were extracted from the Japanese nationwide database. The primary outcome was neurologically favorable 1-month survival, defined as cerebral performance category 1 or 2. The secondary outcome was 1-month survival. OHCA cases with hypothermia occurred more frequently in the winter. In approximately half (837) of the hypothermic OHCA cases, EMS was activated in the morning (6:00 am to 11:59 am). Shockable initial electrocardiogram rhythms were recorded in 30.8% (483/1570) of cases. prehospital defibrillation was attempted in 96.1% (464/483) of cases with shockable rhythms and 25.8% (280/1087) of cases with non-shockable initial rhythms. EMS-witnessed cases, prolonged transportation time intervals and prehospital epinephrine administration were associated with rhythm conversion in cases with non-shockable initial rhythms. Binominal logit test followed by multivariable logistic regression revealed that shockable initial rhythms were associated with better outcomes. prehospital defibrillation was not significantly associated with better outcomes, regardless of the type of initial rhythm (shockable or non-shockable). Transportation to high-level emergency hospitals was associated with better outcomes (adjusted odds ratio: 2.94, 95% confidence interval: 1.66-5.21). In hypothermic OHCA, shockable initial rhythm but not prehospital defibrillation is likely to be associated with better neurologically favorable outcomes. In addition, transport to a high-level acute care hospital may be appropriately considered despite prolonged transport. Further investigation, including core temperature data in analyses, is necessary to determine the benefit of prehospital defibrillation in hypothermic OHCA.
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Affiliation(s)
- Tomoyuki Ushimoto
- Department of Emergency Medicine, Kanazawa Medical University, Uchinada, Japan
| | - Kenshi Murasaka
- Department of Emergency Medicine, Kanazawa Medical University, Uchinada, Japan
| | - Yukihiro Wato
- Department of Emergency Medicine, Kanazawa Medical University, Uchinada, Japan
| | - Hideo Inaba
- Department of Emergency Medicine, Kanazawa Medical University, Uchinada, Japan
- Kanazawa University, Kanazawa, Japan
- Department of Emergency Medical Sciences, Niigata University of Health and Welfare, Niigata, Japan
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Stickley A, Baburin A, Jasilionis D, Krumins J, Martikainen P, Kondo N, Shin JI, Oh H, Waldman K, Leinsalu M. Educational inequalities in hypothermia mortality in the Baltic countries and Finland in 2000-15. Eur J Public Health 2023:7140394. [PMID: 37094965 PMCID: PMC10393481 DOI: 10.1093/eurpub/ckad062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND Despite an increased focus on cold-related mortality in recent years, there has been comparatively little research specifically on hypothermia mortality and its associated factors. METHODS Educational inequalities in hypothermia mortality among individuals aged 30-74 in the Baltic countries (Estonia, Latvia, Lithuania) and Finland in 2000-15 were examined using data from longitudinal mortality follow-up studies of population censuses (the Baltics) and from a longitudinal register-based population data file (Finland). RESULTS Age-standardized mortality rates (ASMRs) were much higher in the Baltic countries than in Finland across the study period. From 2000-07 to 2008-15, overall ASMRs declined in all countries except among Finnish women. Although a strong educational gradient was observed in hypothermia mortality in all countries in 2000-07, inequalities were larger in the Baltic countries. Between 2000-07 and 2008-15, ASMRs declined in all educational groups except for high-educated women in Finland and low-educated women in Lithuania; the changes however were not always statistically significant. The absolute mortality decline was often larger among the low educated resulting in narrowing absolute inequalities (excepting Lithuania), whereas a larger relative decline among the high educated (excepting Finnish women) resulted in a considerable widening of relative inequalities in hypothermia mortality by 2008-15. CONCLUSION Although some reduction was observed in absolute educational inequalities in hypothermia mortality in 2000-15, substantial and widening relative inequalities highlight the need for further action in combatting factors behind deaths from excessive cold in socioeconomically disadvantaged groups, including risky alcohol consumption and homelessness.
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Affiliation(s)
- Andrew Stickley
- Stockholm Centre for Health and Social Change, Södertörn University, Huddinge, Sweden
- Department of Social Epidemiology, Graduate School of Medicine and School of Public Health, Kyoto University, Kyoto, Japan
| | - Aleksei Baburin
- Department of Epidemiology and Biostatistics, National Institute for Health Development, Tallinn, Estonia
| | - Domantas Jasilionis
- Max Planck Institute for Demographic Research, Rostock, Germany
- Demographic Research Centre, Vytautas Magnus University, Kaunas, Lithuania
| | - Juris Krumins
- Demography Unit, Faculty of Business, Management and Economics, University of Latvia, Riga, Latvia
| | - Pekka Martikainen
- Max Planck Institute for Demographic Research, Rostock, Germany
- Population Research Unit, University of Helsinki, Helsinki, Finland
| | - Naoki Kondo
- Department of Social Epidemiology, Graduate School of Medicine and School of Public Health, Kyoto University, Kyoto, Japan
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Hans Oh
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA, USA
| | - Kyle Waldman
- Department of Sociology, Harvard University, Cambridge, MA, USA
| | - Mall Leinsalu
- Stockholm Centre for Health and Social Change, Södertörn University, Huddinge, Sweden
- Department of Epidemiology and Biostatistics, National Institute for Health Development, Tallinn, Estonia
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Yamamoto R, Yoshizawa J, Takauji S, Hayakawa M, Sasaki J. Hyperoxia for accidental hypothermia and increased mortality: a post-hoc analysis of a multicenter prospective observational study. Crit Care 2023; 27:131. [PMID: 37005646 PMCID: PMC10067299 DOI: 10.1186/s13054-023-04407-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/16/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND Supraphysiologic oxygen administration causes unfavorable clinical outcomes in various diseases, including traumatic brain injury, post-cardiac arrest syndrome, and acute lung injury. Accidental hypothermia is a critical illness that reduces oxygen demands, and excessive oxygen is likely to emerge. This study aimed to determine whether hyperoxia would be associated with increased mortality in patients with accidental hypothermia. METHODS A post-hoc analysis of a nationwide multicenter prospective observational study (ICE-CRASH study) on patients with accidental hypothermia admitted in 2019-2022 was conducted. Adult patients without cardiac arrest whose core body temperature was < 32 °C and whose arterial partial pressure of oxygen (PaO2) was measured at the emergency department were included. Hyperoxia was defined as a PaO2 level of 300 mmHg or higher, and 28-day mortality was compared between patients with and without hyperoxia before rewarming. Inverse probability weighting (IPW) analyses with propensity scores were performed to adjust patient demographics, comorbidities, etiology and severity of hypothermia, hemodynamic status and laboratories on arrival, and institution characteristics. Subgroup analyses were conducted according to age, chronic cardiopulmonary diseases, hemodynamic instability, and severity of hypothermia. RESULTS Of the 338 patients who were eligible for the study, 65 had hyperoxia before rewarming. Patients with hyperoxia had a higher 28-day mortality rate than those without (25 (39.1%) vs. 51 (19.5%); odds ratio (OR) 2.65 (95% confidence interval 1.47-4.78); p < 0.001). IPW analyses with propensity scores revealed similar results (adjusted OR 1.65 (1.14-2.38); p = 0.008). Subgroup analyses showed that hyperoxia was harmful in the elderly and those with cardiopulmonary diseases and severe hypothermia below 28 °C, whereas hyperoxia exposure had no effect on mortality in patients with hemodynamic instability on hospital arrival. CONCLUSIONS Hyperoxia with PaO2 levels of 300 mmHg or higher before initiating rewarming was associated with increased 28-day mortality in patients with accidental hypothermia. The amount of oxygen to administer to patients with accidental hypothermia should be carefully determined. TRIAL REGISTRATION The ICE-CRASH study was registered at the University Hospital Medical Information Network Clinical Trial Registry on April 1, 2019 (UMIN-CTR ID, UMIN000036132).
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Affiliation(s)
- Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan.
| | - Jo Yoshizawa
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Shuhei Takauji
- Department of Emergency Medicine, Asahikawa Medical University Hospital, Asahikawa, Japan
| | - Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
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Li D, Ma W, Xiong M, Xie P, Feng Y, Liu D, Qiao Y, Shi C. Water Rewarming After Seawater Hypothermia Mitigates IL-1β in Both Intestinal Tissue and Blood. Ther Hypothermia Temp Manag 2023; 13:1-10. [PMID: 35731005 DOI: 10.1089/ther.2021.0033] [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: 11/13/2022] Open
Abstract
In this study, the rat models of severe hypothermia induced by seawater immersion were established in artificial seawater immersion at 15°C for 5 hours. With the rewarming measurement of 37°C water bath, the rewarming effects were evaluated by monitoring basic vital signs and dynamically detecting intestinal inflammation cytokines. Fifty Sprague-Dawley rats were randomly divided into five groups including the control group (group C), hypothermia group (group H), 2-hour rewarming group (group R2), 6-hour rewarming group (group R6), and 12-hour rewarming group (group R12), with 10 in each group. The basic vital signs of rats (i.e., core temperature, respiration, heart rate, and muscle tremor) were constantly recorded. The inflammatory factors were detected in the intestinal tissue via a protein chip GSR-CAA-67 of Innopsys, and the verification by reverse transcription-quantitative polymerase chain reaction. The levels of cytokines (interleukin IL-1β, IL-6, and IL-10) were detected from blood samples collected at the end of the observation period via enzyme-linked immunosorbent assay. The expression landscape of IL-1β in the intestinal tissue was validated by immunohistochemistry. Five hours of immersion in artificial seawater at 15°C successfully induced severe hypothermia of rats. After 2 hours of constant water bath rewarming at 37°C, the basic vital signs recovered to the normal level and maintained stably as well as the acute inflammatory reaction alleviated effectively, which indicated that 37°C of water immersion rewarming had the potential to be a suitable method for early treatment of water immersion hypothermia. After the process of hypothermia, several inflammatory cytokines of rats in rewarming groups changed distinctly with IL-1β, showing the most significant variations compared with group C, which confirmed IL-1β as a potential monitoring biomarker referring to the therapeutic effect of rewarming for severe hypothermia caused by seawater immersion.
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Affiliation(s)
- Dandan Li
- The Sixth Medical Center, Chinese PLA General Hospital, Beijing, China.,Department of Blood Transfusion, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Wei Ma
- The Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Ming Xiong
- The Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Peng Xie
- The Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Youxin Feng
- The Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Dongdong Liu
- The Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yuanyuan Qiao
- The Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Chenghe Shi
- The Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
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31
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Sixtus RP, Berry MJ, Gray CL, Dyson RM. A novel whole-body thermal stress test for monitoring cardiovascular responses in Guinea pigs. J Therm Biol 2023; 113:103500. [PMID: 37055107 DOI: 10.1016/j.jtherbio.2023.103500] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 01/27/2023] [Accepted: 02/04/2023] [Indexed: 03/12/2023]
Abstract
Cardiovascular disease is a leading cause of morbidity and mortality worldwide. Stress tests are frequently employed to expose early signs of cardiovascular dysfunction or disease and can be employed, for example, in the context of preterm birth. We aimed to establish a safe and effective thermal stress test to examine cardiovascular function. Guinea pigs were anaesthetized using a 0.8% isoflurane, 70% N2O mix. ECG, non-invasive blood pressure, laser Doppler flowmetry, respiratory rate, and an array of skin and rectal thermistors were applied. A physiologically relevant heating and a cooling thermal stress test was developed. Upper and lower thermal limits for core body temperature were set at 41.5 OC and 34 OC, for the safe recovery of animals. This protocol therefore presents a viable thermal stress test for use in guinea pig models of health and disease that facilitates exploration of whole-system cardiovascular function.
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Affiliation(s)
- Ryan P Sixtus
- Department of Paediatrics and Child Health, University of Otago, Wellington, New Zealand.
| | - Mary J Berry
- Department of Paediatrics and Child Health, University of Otago, Wellington, New Zealand
| | - Clint L Gray
- Department of Paediatrics and Child Health, University of Otago, Wellington, New Zealand
| | - Rebecca M Dyson
- Department of Paediatrics and Child Health, University of Otago, Wellington, New Zealand
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32
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Unraveling the molecular mechanism of collagen flexibility during physiological warmup using molecular dynamics simulation and machine learning. Comput Struct Biotechnol J 2023; 21:1630-1638. [PMID: 36860343 PMCID: PMC9969283 DOI: 10.1016/j.csbj.2023.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 02/08/2023] [Accepted: 02/08/2023] [Indexed: 02/12/2023] Open
Abstract
Physiological warmup plays an important role in reducing the injury risk in different sports. In response to the associated temperature increase, the muscle and tendon soften and become easily stretched. In this study, we focused on type I collagen, the main component of the Achilles tendon, to unveil the molecular mechanism of collagen flexibility upon slight heating and to develop a model to predict the strain of collagen sequences. We used molecular dynamics approaches to simulate the molecular structures and mechanical behavior of the gap and overlap regions in type I collagen at 307 K, 310 K, and 313 K. The results showed that the molecular model in the overlap region is more sensitive to temperature increases. Upon increasing the temperature by 3 degrees Celsius, the end-to-end distance and Young's modulus of the overlap region decreased by 5% and 29.4%, respectively. The overlap region became more flexible than the gap region at higher temperatures. GAP-GPA and GNK-GSK triplets are critical for providing molecular flexibility upon heating. A machine learning model developed from the molecular dynamics simulation results showed good performance in predicting the strain of collagen sequences at a physiological warmup temperature. The strain-predictive model could be applied to future collagen designs to obtain desirable temperature-dependent mechanical properties.
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33
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Chen F, Fu M, Li Y, Shen S, Yang J, Weng W. A numerical tool for assessing human thermal safety and thermal comfort in cold-weather activities. INTERNATIONAL JOURNAL OF BIOMETEOROLOGY 2023; 67:377-388. [PMID: 36515728 DOI: 10.1007/s00484-022-02416-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 12/02/2022] [Accepted: 12/04/2022] [Indexed: 06/17/2023]
Abstract
This paper describes a newly developed software tool to evaluate human thermal safety and thermal comfort in cold-weather activities aimed at guiding users to arrange activity plans and select appropriate clothing ensembles. The software inputs include conditions of activity, environment, human body, and clothing ensemble. It outputs physiological temperatures, cold injury risks, thermal sensations, and thermal comforts in intuitive ways like cloud maps and curves. The software tool is characterized by (1) integration of a thermoregulatory model that predicts human thermophysiological responses under exercise conditions in cold environments, (2) the functions of clothing ensemble database and individual parameter database, (3) the human centric outputs that directly reflect human physiological and mental status, and (4) the user-friendly operation interface and output interface, as well as a wide applicability. The software is validated with human test studies covering ambient temperatures from - 30.6 to 5 °C, clothing ensembles from 1.34 to 3.20 clo, and activity intensities from 2 to 9 Mets. The average prediction RMSEs of core temperature, mean skin temperature, thermal sensation, and thermal comfort are 0.16 °C, 0.45 °C, 0.58, and 1.41, respectively. The software is an advanced expansion to current standards and guidance of cold exposure assessment and a meaningful tool for the fields of occupational health care, cold protection, and environmental ergonomics.
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Affiliation(s)
- Feiyu Chen
- Institute of Public Safety Research, Department of Engineering Physics, Tsinghua University, Beijing, 100084, China
| | - Ming Fu
- Hefei Institute for Public Safety Research, Tsinghua University, Hefei, 230601, Anhui Province, China.
- Anhui Province Key Laboratory of Human Safety, Hefei, 230601, Anhui Province, China.
| | - Yayun Li
- Hefei Institute for Public Safety Research, Tsinghua University, Hefei, 230601, Anhui Province, China
- Anhui Province Key Laboratory of Human Safety, Hefei, 230601, Anhui Province, China
| | - Shifei Shen
- Institute of Public Safety Research, Department of Engineering Physics, Tsinghua University, Beijing, 100084, China.
| | - Jie Yang
- College of Safety Science and Engineering, Xi'an University of Science and Technology, Xi'an, 710054, China
| | - Wenguo Weng
- Institute of Public Safety Research, Department of Engineering Physics, Tsinghua University, Beijing, 100084, China
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Kraai E, Wray TC, Ball E, Tawil I, Mitchell J, Guliani S, Dettmer T, Marinaro J. E-CPR in Cardiac Arrest due to Accidental Hypothermia Using Intensivist Cannulators: A Case Series of Nine Consecutive Patients. J Intensive Care Med 2023; 38:215-219. [PMID: 35876344 DOI: 10.1177/08850666221116594] [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: 01/01/2023]
Abstract
Background: Severe accidental hypothermia (AH) accounts for over 1300 deaths/year in the United States. Early extracorporeal life support (ECLS) is recommended for hypothermic cardiac arrest. We describe the use of a rapid-deployment extracorporeal cardiopulmonary resuscitation (E-CPR) team using intensivist physicians (IPs) as cannulators and report the outcomes of consecutive patients cannulated for ECLS to manage cardiac arrest due to AH. Methods: We reviewed all patients managed with veno-arterial (V-A) ECLS for hypothermic cardiac arrest between January 1, 2017 and November 1, 2021. For each patient- age, sex, cause of hypothermia, initial core temperature, initial rhythm, time from arrest to cannulation, cannula configuration, pH, lactate, potassium, cannulation complications, duration of ECLS, hospital length of stay, mortality, and cerebral performance category (CPC) at discharge were reviewed. Results: Nine consecutive patients were identified that underwent V-A ECLS for cardiac arrest due to AH. Seven (78%) were witnessed arrests. Initial rhythm was ventricular fibrillation (VF) in eight patients and pulseless electrical activity (PEA) in one. The mean initial core temperature was 23.8 degrees Celsius. The mean time from arrest to cannulation was 58 min (range 17 to 251 min). There were no complications related to cannulation. The mean duration of ECLS was 39.1 h. All nine patients were discharged alive with a Cerebral Performance score of one or two. Conclusion: In this case series of consecutive patients reporting intensivist-deployed E-CPR for cardiac arrest due to AH, all patients survived to discharge with a favorable neurologic outcome. A rapidly available E-CPR team utilizing intensivist cannulators may improve outcomes in patients with cardiac arrest due to AH.
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Affiliation(s)
- Erik Kraai
- Department of Internal Medicine, Center for Adult Critical Care, 21764University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Trenton C Wray
- Department of Emergency Medicine, Center for Adult Critical Care, 12289University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Emily Ball
- Department of Emergency Medicine, Center for Adult Critical Care, 12289University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Isaac Tawil
- Department of Emergency Medicine, Center for Adult Critical Care, 12289University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Jessica Mitchell
- Department of Emergency Medicine, Center for Adult Critical Care, 12289University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Sundeep Guliani
- Department of Surgery, Center for Adult Critical Care, 12289University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Todd Dettmer
- Department of Emergency Medicine, Center for Adult Critical Care, 12289University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Jonathan Marinaro
- Department of Emergency Medicine, Center for Adult Critical Care, 12289University of New Mexico Health Sciences Center, Albuquerque, NM, USA
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Shirasaki K, Hifumi T, Goto M, Shin K, Horie K, Isokawa S, Inoue A, Sakamoto T, Kuroda Y, Imai R, Otani N. Clinical characteristics and outcomes after extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest patients with an initial asystole rhythm. Resuscitation 2023; 183:109694. [PMID: 36646370 DOI: 10.1016/j.resuscitation.2023.109694] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/29/2022] [Accepted: 01/06/2023] [Indexed: 01/15/2023]
Abstract
AIM This study aimed to describe the characteristics of cases of out-of-hospital cardiac arrest (OHCA) with an initial asystole rhythm in which extracorporeal cardiopulmonary resuscitation (ECPR) was introduced and discuss the clinical indications for ECPR in such patients. METHODS This was a secondary analysis of the SAVE-J II study, a retrospective, multicentre, registry study involving 36 participating institutions in Japan. Patients with an initial asystole rhythm were selected. Favourable neurological outcomes (cerebral performance categories 1-2) constituted the primary outcome. RESULTS In total, 202 patients met the inclusion criteria, with favourable neurological outcomes at hospital discharge in 12 patients (5.9%). Causes of cardiac arrest with favourable neurological outcomes were hypothermia (7 cases), acute coronary syndrome (2 cases), arrhythmia (2 cases), and pulmonary embolism (1 case). Among patients with non-hypothermia (temperature ≥32 °C) on hospital arrival with the cardiac rhythm of asystole or pulseless electrical activity (PEA) on arrival, all 107 patients (66 asystole, 41 PEA) who lacked one or more of the requirements (witness; bystander CPR; signs of life or pupil < 5 mm) had unfavourable neurological outcomes. All 5 cases with favourable neurological outcomes, except for 1 case with a short duration of no-flow time that was highly suspected based on the patient's history, met all the requirements on hospital arrival. CONCLUSIONS A total of 202 ECPR cases with an initial asystole rhythm, including 12 patients with favourable neurological outcomes, were described. Even if the initial cardiac rhythm is asystole, ECPR could be considered if certain conditions are met.
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Affiliation(s)
- Kasumi Shirasaki
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan.
| | - Masahiro Goto
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Kijong Shin
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Katsuhiro Horie
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Shutaro Isokawa
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Akihiko Inoue
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Japan
| | - Tetsuya Sakamoto
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Yasuhiro Kuroda
- Department of Emergency Medicine, Kagawa University School of Medicine, Kagawa, Japan
| | - Ryosuke Imai
- Department of Pulmonary Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Norio Otani
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
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36
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Prekker ME, Rischall M, Carlson M, Driver BE, Touroutoutoudis M, Boland J, Hu M, Heather B, Simpson NS. Extracorporeal membrane oxygenation versus conventional rewarming for severe hypothermia in an urban emergency department. Acad Emerg Med 2023; 30:6-15. [PMID: 36000288 DOI: 10.1111/acem.14585] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/28/2022] [Accepted: 08/19/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Severe hypothermia (core body temperature < 28°C) is life-threatening and predisposes to cardiac arrest. The comparative effectiveness of different active internal rewarming methods in an urban U.S. population is unknown. We aim to compare outcomes between hypothermic emergency department (ED) patients rewarmed conventionally using an intravascular rewarming catheter or warm fluid lavage versus those rewarmed using extracorporeal membrane oxygenation (ECMO). METHODS We performed a retrospective cohort analysis of adults with severe hypothermia due to outdoor exposure presenting to an urban ED in Minnesota, 2007-2021. The primary outcome was hospital survival. We also calculated the rewarming rate in the 4 h after ED arrival and compared these data between patients rewarmed with ECMO (the extracorporeal rewarming group) versus without ECMO (the conventional rewarming group). We repeated these analyses in the subgroup of patients with cardiac arrest. RESULTS We analyzed 44 hypothermic ED patients: 25 patients in the extracorporeal rewarming group (median temperature 24.1°C, 84% with cardiac arrest) and 19 patients in the conventional rewarming group (median temperature 26.3°C, 37% with cardiac arrest; 89% received an intravascular rewarming catheter). The median rewarming rate was greater in the extracorporeal versus conventional group (2.3°C/h vs. 1.5°C/h, absolute difference 0.8°C/h, 95% confidence interval [CI] 0.3-1.2°C/h) yet hospital survival was similar (68% vs. 74%). Among patients with cardiac arrest, hospital survival was greater in the extracorporeal versus conventional group (71% vs. 29%, absolute difference 42%, 95% CI 4%-82%). CONCLUSIONS Among ED patients with severe hypothermia and cardiac arrest, survival was significantly higher with ECMO versus conventional rewarming. Among all hypothermic patients, ECMO use was associated with faster rewarming than conventional methods.
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Affiliation(s)
- Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA.,Division of Pulmonary and Critical Care, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Megan Rischall
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Michelle Carlson
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | | | - Jessica Boland
- Department of Critical Care Medicine, Allina Health, Minneapolis, Minnesota, USA
| | - Michael Hu
- Department of Surgery, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Beth Heather
- Critical Care Nursing and the Extracorporeal Life Support Program, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Nicholas S Simpson
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA.,Hennepin Emergency Medical Services, Minneapolis, Minnesota, USA
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37
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Brief Report: Diabetic Keto-Acidosis (DKA) Induced Hypothermia may be Neuroprotective in Cardiac Arrest. J Crit Care Med (Targu Mures) 2023; 9:39-42. [PMID: 36890974 PMCID: PMC9987267 DOI: 10.2478/jccm-2023-0004] [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: 08/23/2022] [Accepted: 01/11/2023] [Indexed: 02/11/2023] Open
Abstract
Despite the decreased survival associated with diabetes with out-of-hospital cardiac arrest and the overall low survival to hospital discharge, we would like to present two cases of OHCA in diabetics who despite prolonged resuscitation efforts had complete neurological recovery likely due to concomitant hypothermia. There is a steady decreasing rate of ROSC with longer durations of CPR so that outcomes are best when <20 minutes compared to prolonged resuscitation efforts (>30-40 minutes). It has been previously recognized that hypothermia prior to cardiac arrest can be neurologically protective even with up to 9 hours of cardiopulmonary resuscitation. Hypothermia has been associated with DKA and although often indicates sepsis with mortality rates of 30-60%, it may indeed be protective if occurring prior to cardiac arrest. The critical factor for neuroprotection may be a slow drop to a temperature <250C prior to OHCA as is achieved in deep hypothermic circulatory arrest for operative procedures of the aortic arch and great vessels. It may be worthwhile continuing aggressive resuscitation efforts even for prolonged periods before attaining ROSC for OHCA in patients found hypothermic from metabolic illnesses as compared to only from environmental exposures (avalanche victims, cold water submersions, etc.) as has been traditionally reported in the medical literature.
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38
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Takauji S, Hayakawa M, Yamada D, Tian T, Minowa K, Inoue A, Fujimoto Y, Isokawa S, Miura N, Endo T, Irie J, Otomo G, Sato H, Bando K, Suzuki T, Toyohara T, Tomita A, Iwahara M, Murata S, Shimazaki J, Matsuyoshi T, Yoshizawa J, Nitta K, Sato Y. Outcome of extracorporeal membrane oxygenation use in severe accidental hypothermia with cardiac arrest and circulatory instability: A multicentre, prospective, observational study in Japan (ICE-CRASH study). Resuscitation 2023; 182:109663. [PMID: 36509361 DOI: 10.1016/j.resuscitation.2022.12.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/30/2022] [Accepted: 12/03/2022] [Indexed: 12/14/2022]
Abstract
AIM To elucidate the effectiveness of extracorporeal membrane oxygenation (ECMO) in accidental hypothermia (AH) patients with and without cardiac arrest (CA), including details of complications. METHODS This study was a multicentre, prospective, observational study of AH in Japan. All adult (aged ≥18 years) AH patients with body temperature ≤32 °C who presented to the emergency department between December 2019 and March 2022 were included. Among the patients, those with CA or circulatory instability, defined as severe AH, were selected and divided into the ECMO and non-ECMO groups. We compared 28-day survival and favourable neurological outcomes at discharge between the ECMO and non-ECMO groups by adjusting for the patients' background characteristics using multivariable logistic regression analysis. RESULTS Among the 499 patients in this study, 242 patients with severe AH were included in the analysis: 41 in the ECMO group and 201 in the non-ECMO group. Multivariable analysis showed that the ECMO group was significantly associated with better 28-day survival and favourable neurological outcomes at discharge in patients with CA compared to the non-ECMO group (odds ratio [OR] 0.17, 95% confidence interval [CI]: 0.05-0.58, and OR 0.22, 95%CI: 0.06-0.81). However, in patients without CA, ECMO not only did not improve 28-day survival and neurological outcomes, but also decreased the number of event-free days (ICU-, ventilator-, and catecholamine administration-free days) and increased the frequency of bleeding complications. CONCLUSIONS ECMO improved survival and neurological outcomes in AH patients with CA, but not in AH patients without CA.
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Affiliation(s)
- Shuhei Takauji
- Department of Emergency Medicine, Asahikawa Medical University Hospital, Asahikawa, Japan.
| | - Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Daisuke Yamada
- Senri Critical Care Medical Center, Saiseikai Senri Hospital, Suita, Japan
| | - Tian Tian
- Emergency and Critical Care Medical Center, Kishiwada Tokushukai Hospital, Osaka, Japan
| | - Keita Minowa
- Department of Emergency and Critical Care Medicine, Hachinohe City Hospital, Hachinohe, Japan
| | - Akihiko Inoue
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Japan
| | - Yoshihiro Fujimoto
- Department of Emergency Medicine, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Shutaro Isokawa
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Naoya Miura
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Tokai, Japan
| | - Tomoyuki Endo
- Department of Emergency and Disaster Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Jin Irie
- Department of Emergency and Disaster Medicine, Hirosaki University, Hirosaki, Japan
| | - Gen Otomo
- Emergency and Critical Care Medicine, Asahikawa Red Cross Hospital, Asahikawa, Japan
| | - Hiroki Sato
- Critical Care and Emergency Center National Hospital Organization Hokkaido Medical Center, Sapporo, Japan
| | - Keisuke Bando
- Department of Emergency Medicine and Critical Care, Sapporo City General Hospital, Sapporo, Japan
| | - Tsuyoshi Suzuki
- Department of Emergency and Critical Care Medicine, Fukushima Medical University, Fukushima City, Fukushima, Japan
| | - Takashi Toyohara
- Department of Emergency Medicine, Kushiro City General Hospital, Kushiro, Japan
| | - Akiko Tomita
- Department of Emergency Medicine, Sunagawa City Medical Center, Sunagawa, Japan
| | - Motoko Iwahara
- Department of Emergency Medicine, Nayoro City General Hospital, Nayoro, Japan
| | - Satoru Murata
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Junya Shimazaki
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takeo Matsuyoshi
- Emergency and Critical Care Center, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Jo Yoshizawa
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kenichi Nitta
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yuta Sato
- Emergency and Critical Care Center, Aomori Prefectural Central Hospital, Aomori, Japan
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Nemeth J, Alameddine L, El Tawil C. Just the facts: environmental pediatric hypothermia. CAN J EMERG MED 2023; 25:17-19. [PMID: 36449142 DOI: 10.1007/s43678-022-00418-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 11/11/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Joe Nemeth
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Canada
| | - Lama Alameddine
- Division of Critical Care Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Canada
| | - Chady El Tawil
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Canada.
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40
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Khalilov RA, Dzhafarova AM, Abdullaev VR. Activity and Catalytic Characteristics of Rat Liver Mitochondrial Succinate Dehydrogenase under Moderate Hypothermia. Biophysics (Nagoya-shi) 2022. [DOI: 10.1134/s0006350922060094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023] Open
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41
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Low-Flow Duration and Outcomes of Extracorporeal Cardiopulmonary Resuscitation in Adults With In-Hospital Cardiac Arrest: A Nationwide Inpatient Database Study*. Crit Care Med 2022. [DOI: 10.1097/ccm.0000000000005679 10.1097/ccm.0000000000005679] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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42
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Low-Flow Duration and Outcomes of Extracorporeal Cardiopulmonary Resuscitation in Adults With In-Hospital Cardiac Arrest: A Nationwide Inpatient Database Study. Crit Care Med 2022; 50:1768-1777. [PMID: 36190237 DOI: 10.1097/ccm.0000000000005679] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Although existing guidelines recommend commencing cannulation for extracorporeal cardiopulmonary resuscitation (ECPR) within 10-20 minutes of failed conventional resuscitation efforts for cardiac arrest, there is little supportive evidence. The present study aimed to determine the association of low-flow duration with survival-to-discharge rate in in-hospital cardiac arrest patients who received ECPR. DESIGN A nationwide retrospective cohort study analyzed a nationwide inpatient database in Japan. Low-flow duration was defined as the time interval from initiation of chest compression to termination of chest compression. We assessed the association between low-flow duration and survival-to-discharge rate by predicting estimates with covariate adjustment stratified by categories of low-flow duration. SETTING More than 1,600 acute-care hospitals in Japan. PATIENTS All in-hospital cardiac arrest patients greater than or equal to 18 years old who received ECPR during hospitalization from July 2010 to March 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among 303,319 in-hospital cardiac arrest patients, 9,844 (3.2%) received ECPR in 697 hospitals during the study period and 9,433 were eligible in the study. The overall survival-to-discharge rate was 20.5% (1,932/9,433). The median low-flow duration was 26.0 minutes (interquartile range, 12.0-46.0 min) in the overall cohort. The highest and lowest estimated survival-to-discharge rates were 35.1% in the group with low-flow duration 0-5 minutes and 7.9% in the group with low-flow duration greater than 90 minutes. The estimated survival-to-discharge rate dropped sharply by about 20% during the first 35 minutes of low-flow duration (decreasing by about 3% every 5 min), followed by small decreases after the first 35 minutes. CONCLUSIONS The estimated survival-to-discharge rate was markedly decreased by approximately 20% during the first 35 minutes of low-flow duration. Whether we should wait for the first 10-20 minutes of cardiac arrest without preparing for ECPR is questionable.
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Bhatnagar A, Mackman S. Successful Nonextracorporeal Life Support Resuscitation and Rewarming of a Patient with Hypothermia in Cardiac Arrest. Wilderness Environ Med 2022; 33:476-478. [PMID: 36180333 DOI: 10.1016/j.wem.2022.07.009] [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: 02/01/2022] [Revised: 07/12/2022] [Accepted: 07/20/2022] [Indexed: 11/22/2022]
Abstract
We report full recovery of a patient with hypothermia in cardiac arrest following continuous and prolonged cardiopulmonary resuscitation (CPR) and conventional, nonextracorporeal life support (non-ECLS) methods. A 57-y-old man presented with unwitnessed cardiac arrest and a core temperature of 23°C (73°F). The presenting cardiac rhythm was ventricular fibrillation. The team administered epinephrine and performed defibrillation and CPR. Because ECLS was unavailable at the facility, the medical team externally and internally rewarmed the patient using heated blankets, forced warmed air, thoracic lavage, and warmed IV fluids. The patient achieved return of spontaneous circulation after 4 h 56 min of continuous CPR and rewarming. The medical team admitted the patient to the intensive care unit. He achieved full neurologic recovery the following day. When ECLS is not available and transfer is not appropriate because of patient instability or hospital location, conventional rewarming methods and continuous, prolonged CPR can lead to successful outcomes in patients with hypothermia in cardiac arrest. This case demonstrates that CPR in patients with hypothermia-associated cardiac arrest can lead to full recovery.
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Affiliation(s)
| | - Sean Mackman
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI.
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44
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Tuncaboylu DC, Wischke C. Opportunities and Challenges of Switchable Materials for Pharmaceutical Use. Pharmaceutics 2022; 14:2331. [PMID: 36365149 PMCID: PMC9696173 DOI: 10.3390/pharmaceutics14112331] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 10/19/2022] [Accepted: 10/22/2022] [Indexed: 06/27/2024] Open
Abstract
Switchable polymeric materials, which can respond to triggering signals through changes in their properties, have become a major research focus for parenteral controlled delivery systems. They may enable externally induced drug release or delivery that is adaptive to in vivo stimuli. Despite the promise of new functionalities using switchable materials, several of these concepts may need to face challenges associated with clinical use. Accordingly, this review provides an overview of various types of switchable polymers responsive to different types of stimuli and addresses opportunities and challenges that may arise from their application in biomedicine.
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45
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Tavazzi G, Dammassa V, Colombo CNJ, Arbustini E, Castelein T, Balik M, Vandenbriele C. Mechanical circulatory support in ventricular arrhythmias. Front Cardiovasc Med 2022; 9:987008. [PMID: 36304552 PMCID: PMC9593033 DOI: 10.3389/fcvm.2022.987008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 09/15/2022] [Indexed: 11/27/2022] Open
Abstract
In atrial and ventricular tachyarrhythmias, reduced time for ventricular filling and loss of atrial contribution lead to a significant reduction in cardiac output, resulting in cardiogenic shock. This may also occur during catheter ablation in 11% of overall procedures and is associated with increased mortality. Managing cardiogenic shock and (supra) ventricular arrhythmias is particularly challenging. Inotropic support may exacerbate tachyarrhythmias or accelerate heart rate; antiarrhythmic drugs often come with negative inotropic effects, and electrical reconversions may risk worsening circulatory failure or even cardiac arrest. The drop in native cardiac output during an arrhythmic storm can be partly covered by the insertion of percutaneous mechanical circulatory support (MCS) devices guaranteeing end-organ perfusion. This provides physicians a time window of stability to investigate the underlying cause of arrhythmia and allow proper therapeutic interventions (e.g., percutaneous coronary intervention and catheter ablation). Temporary MCS can be used in the case of overt hemodynamic decompensation or as a “preemptive strategy” to avoid circulatory instability during interventional cardiology procedures in high-risk patients. Despite the increasing use of MCS in cardiogenic shock and during catheter ablation procedures, the recommendation level is still low, considering the lack of large observational studies and randomized clinical trials. Therefore, the evidence on the timing and the kinds of MCS devices has also scarcely been investigated. In the current review, we discuss the available evidence in the literature and gaps in knowledge on the use of MCS devices in the setting of ventricular arrhythmias and arrhythmic storms, including a specific focus on pathophysiology and related therapies.
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Affiliation(s)
- Guido Tavazzi
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy,Department of Anaesthesia, Intensive Care and Pain Therapy, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy,*Correspondence: Guido Tavazzi
| | - Valentino Dammassa
- PhD in Experimental Medicine, University of Pavia, Pavia, Italy,Adult Intensive Care Unit, Royal Brompton Hospital, London, United Kingdom
| | | | - Eloisa Arbustini
- Centre for Inherited Cardiovascular Diseases, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Thomas Castelein
- Cardiovascular Center, Onze-Lieve-Vrouwziekenhuis Hospital, Aalst, Belgium
| | - Martin Balik
- Department of Anesthesiology and Intensive Care, First Medical Faculty and General University Hospital, Charles University in Prague, Prague, Czechia
| | - Christophe Vandenbriele
- Adult Intensive Care Unit, Royal Brompton Hospital, London, United Kingdom,Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium,Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
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46
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Schauer SG, April MD, Fisher AD, Weymouth WL, Maddry JK, Gillespie KR, Salinas J, Cap AP. Hypothermia in the Combat Trauma Population. PREHOSP EMERG CARE 2022; 27:934-940. [PMID: 36037100 DOI: 10.1080/10903127.2022.2119315] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/29/2022] [Accepted: 08/25/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND The MARCH (Massive hemorrhage, Airway, Respirations, Circulation, and Hypothermia/Head injuries) algorithm taught to military medics includes interventions to prevent hypothermia. As possible sequelae from major trauma, hypothermia is associated with coagulopathy and lower survival. This paper sought to define hypothermia within our combat trauma population using an outcomes-based method, and determine clinical variables associated with hypothermia. METHODS This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry focused on casualties who received prehospital care. A receiver operating curve was constructed and Youden's index was used to define hypothermia within the predetermined population based on mortality risk. A multivariable regression model was used to identify associations. RESULTS There were 23,243 encounters that met the inclusion criteria for this study with patients having received prehospital care and documentation of at least one emergency department temperature. An optimal threshold of 36.2° C was found to predict mortality; 3,159 casualties had temperatures below this threshold (14%). Survival to discharge was lower among casualties with hypothermia (91% versus 98%). Hypothermic casualties were less likely to undergo blanket application (38% versus 40%). However, they had higher proportions with Hypothermia Prevention and Management Kit application (11% versus 7%) and radiant warming (2% versus 1%). On multivariable regression modeling, none of the hypothermia interventions were associated with a decreased likelihood of hypothermia. Non-hypothermia interventions associated with hypothermia included prehospital intubation (OR 1.57, 95% CI 1.45-1.69) and blood product administration. CONCLUSIONS Hypothermia, including a single recorded low temperature in the patient care record, was associated with worse outcomes in this combat trauma population. Prehospital intubation was most strongly associated with developing hypothermia. Prehospital warming interventions were not associated with a reduction in hypothermia risk. Our dataset suggests that current methods for prehospital warming are inadequate.
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Affiliation(s)
- Steven G Schauer
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
- Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, USA
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Michael D April
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- 40th Forward Resuscitation and Surgical Detachment, Fort Carson, Colorado, USA
| | - Andrew D Fisher
- University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
- Texas Army National Guard, Austin, Texas, USA
| | - Wells L Weymouth
- 160th Special Operations Aviation Regiment, Hunter Army Airfield, Georgia, USA
| | - Joseph K Maddry
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
- Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, USA
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- 59th Medical Wing, JBSA Fort Sam Houston, Texas, USA
| | - Kevin R Gillespie
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
| | - Jose Salinas
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
| | - Andrew P Cap
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
- Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, USA
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Singh P, Nagori A, Lodha R, Sethi T. Early prediction of hypothermia in pediatric intensive care units using machine learning. Front Physiol 2022; 13:921884. [PMID: 36171970 PMCID: PMC9511412 DOI: 10.3389/fphys.2022.921884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 07/28/2022] [Indexed: 11/13/2022] Open
Abstract
Hypothermia is a life-threatening condition where the temperature of the body drops below 35°C and is a key source of concern in Intensive Care Units (ICUs). Early identification can help to nudge clinical management to initiate early interventions. Despite its importance, very few studies have focused on the early prediction of hypothermia. In this study, we aim to monitor and predict Hypothermia (30 min-4 h) ahead of its onset using machine learning (ML) models developed on physiological vitals and to prospectively validate the best performing model in the pediatric ICU. We developed and evaluated ML algorithms for the early prediction of hypothermia in a pediatric ICU. Sepsis advanced forecasting engine ICU Database (SafeICU) data resource is an in-house ICU source of data built in the Pediatric ICU at the All-India Institute of Medical Science (AIIMS), New Delhi. Each time-stamp at 1-min resolution was labeled for the presence of hypothermia to construct a retrospective cohort of pediatric patients in the SafeICU data resource. The training set consisted of windows of the length of 4.2 h with a lead time of 30 min-4 h from the onset of hypothermia. A set of 3,835 hand-engineered time-series features were calculated to capture physiological features from the time series. Features selection using the Boruta algorithm was performed to select the most important predictors of hypothermia. A battery of models such as gradient boosting machine, random forest, AdaBoost, and support vector machine (SVM) was evaluated utilizing five-fold test sets. The best-performing model was prospectively validated. A total of 148 patients with 193 ICU stays were eligible for the model development cohort. Of 3,939 features, 726 were statistically significant in the Boruta analysis for the prediction of Hypothermia. The gradient boosting model performed best with an Area Under the Receiver Operating Characteristic curve (AUROC) of 85% (SD = 1.6) and a precision of 59.2% (SD = 8.8) for a 30-min lead time before the onset of Hypothermia onset. As expected, the model showed a decline in model performance at higher lead times, such as AUROC of 77.2% (SD = 2.3) and precision of 41.34% (SD = 4.8) for 4 h ahead of Hypothermia onset. Our GBM(gradient boosting machine) model produced equal and superior results for the prospective validation, where an AUROC of 79.8% and a precision of 53% for a 30-min lead time before the onset of Hypothermia whereas an AUROC of 69.6% and a precision of 38.52% for a (30 min-4 h) lead time prospective validation of Hypothermia. Therefore, this work establishes a pipeline termed ThermoGnose for predicting hypothermia, a major complication in pediatric ICUs.
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Affiliation(s)
- Pradeep Singh
- Indraprastha Institute of Information Technology, Delhi, India
| | - Aditya Nagori
- Indraprastha Institute of Information Technology, Delhi, India
- CSIR-Institute of Genomics and Integrative Biology, New Delhi, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, India
| | - Rakesh Lodha
- All India Institute of Medical Sciences, Department of Pediatrics, New Delhi, India
| | - Tavpritesh Sethi
- Indraprastha Institute of Information Technology, Delhi, India
- All India Institute of Medical Sciences, Department of Pediatrics, New Delhi, India
- *Correspondence: Tavpritesh Sethi,
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48
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Habegger K, Brechbühler S, Vogt K, Lienert JS, Engelhardt BM, Müller M, Exadaktylos AK, Brodmann Maeder M. Accidental Hypothermia in a Swiss Alpine Trauma Centre-Not an Alpine Problem. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10735. [PMID: 36078450 PMCID: PMC9518193 DOI: 10.3390/ijerph191710735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 08/17/2022] [Accepted: 08/24/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Research in accidental hypothermia focuses on trauma patients, patients exposed to cold environments or patients after drowning but rarely on hypothermia in combination with intoxications or on medical or neurological issues. The aim of this retrospective single-centre cohort study was to define the aetiologies, severity and relative incidences of accidental hypothermia, methods of measuring temperature and in-hospital mortality. METHODS The study included patients ≥18 years with a documented body temperature ≤35 °C who were admitted to the emergency department (ED) of the University Hospital in Bern between 2000 and 2019. RESULTS 439 cases were included, corresponding to 0.32 per 1000 ED visits. Median age was 55 years (IQR 39-70). A total of 167 patients (38.0%) were female. Furthermore, 63.3% of the patients suffered from mild, 24.8% from moderate and 11.9% from severe hypothermia. Exposure as a single cause for accidental hypothermia accounted for 12 cases. The majority were combinations of hypothermia with trauma (32.6%), medical conditions (34.2%), neurological conditions (5.2%), intoxications (20.3%) or drowning (12.0%). Overall mortality was 22.3% and depended on the underlying causes, severity of hypothermia, age and sex.
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Affiliation(s)
- Katrin Habegger
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Simon Brechbühler
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Karin Vogt
- Hôpital du Valais, Spitalzentrum Oberwallis, 3930 Visp, Switzerland
| | - Jasmin S. Lienert
- Department of Emergency Medicine, Fribourg Hospital, 1752 Villars-sur-Glâne, Switzerland
| | - Bianca M. Engelhardt
- Swiss Army, Military Medical Service, Regional Military Medical Center of Thun, 3600 Thun, Switzerland
| | - Martin Müller
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Aristomenis K. Exadaktylos
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Monika Brodmann Maeder
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
- EURAC Research, Institute of Mountain Emergency Medicine, 39100 Bolzano, Italy
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49
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Weishaar K, Bailey E, El Ado Mikdachi H, Murphy JE. Postpartum Maternal Hypothermia in an Adolescent Patient Following Spontaneous Vaginal Delivery. Cureus 2022; 14:e28142. [PMID: 35990562 PMCID: PMC9388955 DOI: 10.7759/cureus.28142] [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] [Accepted: 08/18/2022] [Indexed: 11/29/2022] Open
Abstract
Postpartum hypothermia, though rare after spontaneous vaginal delivery, can be life-threatening, warranting efficient workup and intervention. A 14-year-old primigravida developed postpartum hypothermia following spontaneous vaginal delivery. No clear etiology was identified despite extensive workup. Intervention with warmed fluids and application of forced air warming system resolved the hypothermia in less than 24 hours without relapse. Following negative workup, the most likely etiology was administration of chilled intravenous fluids in the setting of acute blood loss of delivery and physiologic vasodilation of pregnancy. This case demonstrates the importance of considering common and unusual causes of postpartum hypothermia and leads to a recommendation for routine postpartum temperature checks and hypothermia protocols that include warmed fluid replacement and a forced air warming system.
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50
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Andrijevic D, Vrselja Z, Lysyy T, Zhang S, Skarica M, Spajic A, Dellal D, Thorn SL, Duckrow RB, Ma S, Duy PQ, Isiktas AU, Liang D, Li M, Kim SK, Daniele SG, Banu K, Perincheri S, Menon MC, Huttner A, Sheth KN, Gobeske KT, Tietjen GT, Zaveri HP, Latham SR, Sinusas AJ, Sestan N. Cellular recovery after prolonged warm ischaemia of the whole body. Nature 2022; 608:405-412. [PMID: 35922506 PMCID: PMC9518831 DOI: 10.1038/s41586-022-05016-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 06/23/2022] [Indexed: 02/05/2023]
Abstract
After cessation of blood flow or similar ischaemic exposures, deleterious molecular cascades commence in mammalian cells, eventually leading to their death1,2. Yet with targeted interventions, these processes can be mitigated or reversed, even minutes or hours post mortem, as also reported in the isolated porcine brain using BrainEx technology3. To date, translating single-organ interventions to intact, whole-body applications remains hampered by circulatory and multisystem physiological challenges. Here we describe OrganEx, an adaptation of the BrainEx extracorporeal pulsatile-perfusion system and cytoprotective perfusate for porcine whole-body settings. After 1 h of warm ischaemia, OrganEx application preserved tissue integrity, decreased cell death and restored selected molecular and cellular processes across multiple vital organs. Commensurately, single-nucleus transcriptomic analysis revealed organ- and cell-type-specific gene expression patterns that are reflective of specific molecular and cellular repair processes. Our analysis comprises a comprehensive resource of cell-type-specific changes during defined ischaemic intervals and perfusion interventions spanning multiple organs, and it reveals an underappreciated potential for cellular recovery after prolonged whole-body warm ischaemia in a large mammal.
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Affiliation(s)
- David Andrijevic
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA.,These authors contributed equally: David Andrijevic, Zvonimir Vrselja, Taras Lysyy, Shupei Zhang
| | - Zvonimir Vrselja
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA.,These authors contributed equally: David Andrijevic, Zvonimir Vrselja, Taras Lysyy, Shupei Zhang
| | - Taras Lysyy
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA.,Department of Surgery, Yale School of Medicine New Haven, New Haven, CT, USA.,These authors contributed equally: David Andrijevic, Zvonimir Vrselja, Taras Lysyy, Shupei Zhang
| | - Shupei Zhang
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA.,Department of Genetics, Yale School of Medicine, New Haven, CT, USA.,These authors contributed equally: David Andrijevic, Zvonimir Vrselja, Taras Lysyy, Shupei Zhang
| | - Mario Skarica
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA
| | - Ana Spajic
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA
| | - David Dellal
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA.,Department of Biomedical Engineering, Yale University, New Haven, CT, USA
| | - Stephanie L. Thorn
- Yale Translational Research Imaging Center, Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Robert B. Duckrow
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Shaojie Ma
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA
| | - Phan Q. Duy
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA.,Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA.,Medical Scientist Training Program (MD-PhD), Yale School of Medicine, New Haven, CT, USA
| | - Atagun U. Isiktas
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA
| | - Dan Liang
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA
| | - Mingfeng Li
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA
| | - Suel-Kee Kim
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA
| | - Stefano G. Daniele
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA.,Medical Scientist Training Program (MD-PhD), Yale School of Medicine, New Haven, CT, USA
| | - Khadija Banu
- Department of Nephrology, Yale School of Medicine, New Haven, CT, USA
| | - Sudhir Perincheri
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
| | - Madhav C. Menon
- Department of Nephrology, Yale School of Medicine, New Haven, CT, USA
| | - Anita Huttner
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
| | - Kevin N. Sheth
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA.,Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Kevin T. Gobeske
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Gregory T. Tietjen
- Department of Surgery, Yale School of Medicine New Haven, New Haven, CT, USA.,Department of Biomedical Engineering, Yale University, New Haven, CT, USA
| | - Hitten P. Zaveri
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Stephen R. Latham
- Interdisciplinary Center for Bioethics, Yale University, New Haven, CT, USA
| | - Albert J. Sinusas
- Department of Genetics, Yale School of Medicine, New Haven, CT, USA.,Department of Biomedical Engineering, Yale University, New Haven, CT, USA.,Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT, USA.,Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Nenad Sestan
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA. .,Department of Genetics, Yale School of Medicine, New Haven, CT, USA. .,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA. .,Department of Comparative Medicine, Yale School of Medicine, New Haven, CT, USA. .,Program in Cellular Neuroscience, Neurodegeneration and Repair, Yale School of Medicine, New Haven, CT, USA. .,Yale Child Study Center, New Haven, CT, USA.
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