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Furrer F, Wendel-Garcia PD, Pfister P, Hofmaenner DA, Franco C, Sachs A, Fleischer J, Both C, Kim BS, Schuepbach RA, Steiger P, Camen G, Buehler PK. Perioperative targeted temperature management of severely burned patients by means of an oesophageal temperature probe. Burns 2023; 49:401-407. [PMID: 35513952 DOI: 10.1016/j.burns.2022.03.015] [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: 01/31/2022] [Revised: 03/20/2022] [Accepted: 03/22/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND Hypothermia in severely burned patients is associated with a significant increase in morbidity and mortality. The use of an oesophageal heat exchanger tube (EHT) can improve perioperative body temperatures in severely burned patients. The aim of this study was to investigate the intraoperative warming effect of oesophageal heat transfer in severe burn patients. METHODS Single-centre retrospective study performed at the Burns Centre of the University Hospital Zurich. Between January 2020 and May 2021 perioperative temperature management with EHT was explored in burned patients with a total body surface area (TBSA) larger than 30%. Data from patients, who received perioperative temperature management by EHT, were compared to data from the same patients during interventions performed under standard temperature management matching for length and type of intervention. RESULTS A total of 30 interventions (15 with and 15 without EHT) in 10 patients were analysed. Patient were 38 [26-48] years of age, presented with severe burns covering a median of 50 [42-64] % TBSA and were characterized by an ABSI of 10 [8-12] points. When receiving EHT management patients experienced warming at 0.07 °C per minute (4.2 °C/h) compared to a temperature loss of - 0.03 °C per minute (1.8 °C/h) when only receiving standard temperature management (p < 0.0001). No adverse or serious adverse events were reported. CONCLUSION The use of an oesophageal heat transfer device was effective and safe in providing perioperative warming to severely burned patients when compared to a standard temperature management protocol. By employing an EHT as primary temperature management device perioperative hypothermia in severely burned patients can possibly be averted, potentially leading to reduced hypothermia-associated complications.
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Affiliation(s)
- Florian Furrer
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | | | - Pablo Pfister
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | | | - Carlos Franco
- Institute of Robotics and Intelligent Systems, ETH Zurich, Zurich, Switzerland
| | - Alexandra Sachs
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Juliane Fleischer
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Christian Both
- Department of Anesthesia, University Children's Hospital, Zurich, Switzerland
| | - Bong Sun Kim
- Department of Plastic and Hand Surgery, Burn Center, University Hospital Zurich, Zurich, Switzerland
| | - Reto A Schuepbach
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Peter Steiger
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Giovanni Camen
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Philipp Karl Buehler
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland.
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Leung LWM, Akhtar Z, Elbatran AI, Bajpai A, Li A, Norman M, Kaba R, Sohal M, Zuberi Z, Gallagher MM. Effect of esophageal cooling on ablation lesion formation in the left atrium: Insights from Ablation Index data in the IMPACT trial and clinical outcomes. J Cardiovasc Electrophysiol 2022; 33:2546-2557. [PMID: 36284450 PMCID: PMC10091801 DOI: 10.1111/jce.15717] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 07/29/2022] [Accepted: 08/19/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The IMPACT study established the role of controlled esophageal cooling in preventing esophageal thermal injury during radiofrequency (RF) ablation for atrial fibrillation (AF). The effect of esophageal cooling on ablation lesion delivery and procedural and patient outcomes had not been previously studied. The objective was to determine the effect of esophageal cooling on the formation of RF lesions, the ability to achieve procedural endpoints, and clinical outcomes. METHODS Participants in the IMPACT trial underwent AF ablation guided by Ablation Index (30 W at 350-400 AI posteriorly, 40 W at ≥450 AI anteriorly). A blinded 1:1 randomization assigned patients to the use of the ensoETM® device to keep esophageal temperature at 4°C during ablation or standard practice using a single-sensor temperature probe. Ablation parameters and clinical outcomes were analyzed. RESULTS Procedural data from 188 patients were analyzed. Procedure and fluoroscopy times were similar, and all pulmonary veins were isolated. First-pass pulmonary vein isolation and reconnection at the end of the waiting period were similar in both randomized groups (51/64 vs. 51/68; p = 0.54 and 5/64 vs. 7/68; p = 0.76, respectively). Posterior wall isolation was also similar: 24/33 versus 27/38; p = 0.88. Ablation effect on tissue, measured in impedance drop, was no different between the two randomized groups: 8.6Ω (IQR: 6-11.8) versus 8.76Ω (IQR: 6-12.2; p = 0.25). Arrhythmia recurrence was similar after 12 months (21.1% vs. 24.1%; 95% CI: 0.38-1.84; HR: 0.83; p = 0.66). CONCLUSIONS Esophageal cooling has been shown to be effective in reducing ablation-related thermal injury during RF ablation. This protection does not compromise standard procedural endpoints or clinical success at 12 months.
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Affiliation(s)
- Lisa W M Leung
- Department of Cardiology, St. George's Hospital NHS Foundation Trust, St. George's Hospital, London, UK
| | - Zaki Akhtar
- Department of Cardiology, St. George's Hospital NHS Foundation Trust, St. George's Hospital, London, UK
| | - Ahmed I Elbatran
- Department of Cardiology, St. George's Hospital NHS Foundation Trust, St. George's Hospital, London, UK.,Department of Cardiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Abhay Bajpai
- Department of Cardiology, St. George's Hospital NHS Foundation Trust, St. George's Hospital, London, UK
| | - Anthony Li
- Department of Cardiology, St. George's Hospital NHS Foundation Trust, St. George's Hospital, London, UK
| | - Mark Norman
- Department of Cardiology, St. George's Hospital NHS Foundation Trust, St. George's Hospital, London, UK
| | - Riyaz Kaba
- Department of Cardiology, St. George's Hospital NHS Foundation Trust, St. George's Hospital, London, UK
| | - Manav Sohal
- Department of Cardiology, St. George's Hospital NHS Foundation Trust, St. George's Hospital, London, UK
| | - Zia Zuberi
- Department of Cardiology, St. George's Hospital NHS Foundation Trust, St. George's Hospital, London, UK
| | - Mark M Gallagher
- Department of Cardiology, St. George's Hospital NHS Foundation Trust, St. George's Hospital, London, UK
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- Department of Cardiology, St. George's Hospital NHS Foundation Trust, St. George's Hospital, London, UK
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Leung LWM, Bajpai A, Zuberi Z, Li A, Norman M, Kaba RA, Akhtar Z, Evranos B, Gonna H, Harding I, Sohal M, Al-Subaie N, Louis-Auguste J, Hayat J, Gallagher MM. Randomized comparison of oesophageal protection with a temperature control device: results of the IMPACT study. Europace 2021; 23:205-215. [PMID: 33205201 PMCID: PMC7868886 DOI: 10.1093/europace/euaa276] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/13/2020] [Accepted: 08/18/2020] [Indexed: 02/04/2023] Open
Abstract
Aims Thermal injury to the oesophagus is an important cause of life-threatening complication after ablation for atrial fibrillation (AF). Thermal protection of the oesophageal lumen by infusing cold liquid reduces thermal injury to a limited extent. We tested the ability of a more powerful method of oesophageal temperature control to reduce the incidence of thermal injury. Methods and results A single-centre, prospective, double-blinded randomized trial was used to investigate the ability of the ensoETM device to protect the oesophagus from thermal injury. This device was compared in a 1:1 randomization with a control group of standard practice utilizing a single-point temperature probe. In the protected group, the device maintained the luminal temperature at 4°C during radiofrequency (RF) ablation for AF under general anaesthesia. Endoscopic examination was performed at 7 days post-ablation and oesophageal injury was scored. The patient and the endoscopist were blinded to the randomization. We recruited 188 patients, of whom 120 underwent endoscopy. Thermal injury to the mucosa was significantly more common in the control group than in those receiving oesophageal protection (12/60 vs. 2/60; P = 0.008), with a trend toward reduction in gastroparesis (6/60 vs. 2/60, P = 0.27). There was no difference between groups in the duration of RF or in the force applied (P value range= 0.2–0.9). Procedure duration and fluoroscopy duration were similar (P = 0.97, P = 0.91, respectively). Conclusion Thermal protection of the oesophagus significantly reduces ablation-related thermal injury compared with standard care. This method of oesophageal protection is safe and does not compromise the efficacy or efficiency of the ablation procedure.
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Affiliation(s)
- Lisa W M Leung
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Abhay Bajpai
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Zia Zuberi
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Anthony Li
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Mark Norman
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Riyaz A Kaba
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Zaki Akhtar
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Banu Evranos
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Hanney Gonna
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Idris Harding
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Manav Sohal
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
| | - Nawaf Al-Subaie
- Anesthetic Department, Anesthesia and Intensive Care Medicine, Kuwait Oil Company Ahmadi Hospital, Kuwait
| | - John Louis-Auguste
- Department of Gastroenterology, St. George's University Hospitals NHS Foundation Trust, St. George's, London, UK
| | - Jamal Hayat
- Department of Gastroenterology, St. George's University Hospitals NHS Foundation Trust, St. George's, London, UK
| | - Mark M Gallagher
- Cardiology Department, Cardiology Clinical Academic Group, St. George's NHS Foundation Trust, London SW17 0QT, UK
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Bonfanti N, Gundert E, Drewry AM, Goff K, Bedimo R, Kulstad E. Core warming of coronavirus disease 2019 (COVID-19) patients undergoing mechanical ventilation-A protocol for a randomized controlled pilot study. PLoS One 2020; 15:e0243190. [PMID: 33259540 PMCID: PMC7707531 DOI: 10.1371/journal.pone.0243190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 11/17/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19), caused by the virus SARS-CoV-2, is spreading rapidly across the globe, with little proven effective therapy. Fever is seen in most cases of COVID-19, at least at the initial stages of illness. Although fever is typically treated (with antipyretics or directly with ice or other mechanical means), increasing data suggest that fever is a protective adaptive response that facilitates recovery from infectious illness. OBJECTIVE To describe a randomized controlled pilot study of core warming patients with COVID-19 undergoing mechanical ventilation. METHODS This prospective single-site randomized controlled pilot study will enroll 20 patients undergoing mechanical ventilation for respiratory failure due to COVID-19. Patients will be randomized 1:1 to standard-of-care or to receive core warming via an esophageal heat exchanger commonly utilized in critical care and surgical patients. The primary outcome is patient viral load measured by lower respiratory tract sample. Secondary outcomes include severity of acute respiratory distress syndrome (as measured by PaO2/FiO2 ratio) 24, 48, and 72 hours after initiation of treatment, hospital and intensive care unit length of stay, duration of mechanical ventilation, and 30-day mortality. RESULTS Resulting data will provide effect size estimates to guide a definitive multi-center randomized clinical trial. ClinicalTrials.gov registration number: NCT04426344. CONCLUSIONS With growing data to support clinical benefits of elevated temperature in infectious illness, this study will provide data to guide further understanding of the role of active temperature management in COVID-19 treatment and provide effect size estimates to power larger studies.
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Affiliation(s)
- Nathaniel Bonfanti
- Department of Emergency Medicine, University of Texas, Southwestern Medical Center, Dallas, TX, United States of America
- Department of Anesthesia/Critical Care, University of Texas, Southwestern Medical Center, Dallas, TX, United States of America
| | - Emily Gundert
- Department of Emergency Medicine, University of Texas, Southwestern Medical Center, Dallas, TX, United States of America
- Department of Anesthesia/Critical Care, University of Texas, Southwestern Medical Center, Dallas, TX, United States of America
| | - Anne M. Drewry
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Kristina Goff
- Department of Anesthesiology and Pain Management, University of Texas, Southwestern Medical Center, Dallas, TX, United States of America
| | - Roger Bedimo
- Infectious Diseases Section, VA North Texas Health Care System, Dallas, TX, United States of America
- Department of Internal Medicine, University of Texas, Southwestern Medical Center, Dallas, TX, United States of America
| | - Erik Kulstad
- Department of Emergency Medicine, University of Texas, Southwestern Medical Center, Dallas, TX, United States of America
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W M Leung L, M Gallagher M. Why just detect? We can protect: A letter to the authors of "Prevention of left atrium esophagus fistula". PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 44:406-407. [PMID: 33043476 PMCID: PMC7898476 DOI: 10.1111/pace.14087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/18/2020] [Accepted: 09/06/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Lisa W M Leung
- Cardiology Clinical Academic Group, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Mark M Gallagher
- Cardiology Clinical Academic Group, St George's University Hospitals NHS Foundation Trust, London, UK
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Leung LW, Gallagher MM. Esophageal cooling for protection: an innovative tool that improves the safety of atrial fibrillation ablation. Expert Rev Med Devices 2020; 17:981-982. [PMID: 32933326 DOI: 10.1080/17434440.2020.1824674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
This letter to the editor concerns the article: 'Innovative tools for atrial fibrillation ablation' by Rottner et al., published in the journal on 13th of May 2020. We read the article with great interest and congratulate the authors on an impressively detailed summary of the current tools and technological advances in atrial fibrillation ablation. Improving the safety of this procedure is very important due to widespread clinical practice and the increasing demand for this procedure. We would like to share further discussion with the authors and the journal's readership on current advances in improving the safety of this procedure - esophageal cooling. The results of a large randomized trial was recently presented, the IMPACT study (NCT03819946), which showed that a simple, standardized method of esophageal cooling with the ensoETM® device can significantly reduce esophageal thermal injury by 83.4%. Esophageal protection is important as esophageal injury has a high mortality rate to those that sustain this injury although the overall incidence is low. Rottner et al. discuss a much smaller study on esophageal cooling and the limitations of this study are also discussed.
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Affiliation(s)
- Lisa Wm Leung
- Cardiology Clinical Academic Group, St George's NHS Foundation Trust , London, UK
| | - Mark M Gallagher
- Cardiology Clinical Academic Group, St George's NHS Foundation Trust , London, UK
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Mercado-Montoya M, Bonfanti N, Gundert E, Drewry AM, Bedimo R, Kostov V, Kostov K, Shah S, Kulstad E. The Use of Core Warming as a Treatment for Coronavirus Disease 2019 (COVID-19): an Initial Mathematical Model. JOURNAL OF CARDIAC ARRHYTHMIAS 2020. [DOI: 10.24207/jca.v33i1.3382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background: Increasing data suggest that elevated body temperature may be helpful in resolving a variety of diseases, including sepsis, acute respiratory distress syndrome (ARDS), and viral illnesses. SARS-CoV-2, which causes coronavirus disease 2019 (COVID-19), may be more temperature sensitive than other coronaviruses, particularly with respect to the binding affinity of its viral entry via the ACE2 receptor. A mechanical provision of elevated temperature focused in a body region of high viral activity in patients undergoing mechanical ventilation may offer a therapeutic option that avoids arrhythmias seen with some pharmaceutical treatments. We investigated the potential to actively provide core warming to the lungs of patients with a commercially available heat transfer device via mathematical modeling, and examine the influence of blood perfusion on temperature using this approach. Methods: Using the software Comsol Multiphysics, we modeled and simulated heat transfer in the body from an intraesophageal warming device, taking into account the airflow from patient ventilation. The simulation was focused on heat transfer and warming of the lungs and performed on a simplified geometry of an adult human body and airway from the pharynx to the lungs. Results: The simulations were run over a range of values for blood perfusion rate, which was a parameter expected to have high influence in overall heat transfer, since the heat capacity and density remain almost constant. The simulation results show a temperature distribution which agrees with the expected clinical experience, with the skin surface at a lower temperature than the rest of the body due to convective cooling in a typical hospital environment. The highest temperature in this case is the device warming water temperature, and that heat diffuses by conduction to the nearby tissues, including the air flowing in the airways. At the range of blood perfusion investigated, maximum lung temperature ranged from 37.6°C to 38.6°C. Conclusions: The provision of core warming via commercially available technology currently utilized in the intensive care unit, emergency department, and operating room can increase regional temperature of lung tissue and airway passages. This warming may offer an innovative approach to treating infectious diseases from viral illnesses such as COVID-19, while avoiding the arrhythmogenic complications of currently used pharmaceutical treatments.
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Affiliation(s)
- Marcela Mercado-Montoya
- Universidad de Antioquia – Engineering Faculty – Bioengineering Department – Medellín, Colombia
| | - Nathaniel Bonfanti
- UT Southwestern Medical Center – Departments of Emergency Medicine and Anesthesia/Critical Care – Dallas (TX), USA
| | - Emily Gundert
- UT Southwestern Medical Center – Departments of Emergency Medicine and Anesthesia/Critical Care – Dallas (TX), USA
| | - Anne Meredith Drewry
- Washington University – School of Medicine – Department of Anesthesiology – St. Louis (MO), USA
| | - Roger Bedimo
- UT Southwestern Medical CenterVA North Texas Health Care System – UT Southwestern Medical Center – Dallas (TX), USA
| | - Victor Kostov
- Walter Payton College Preparatory High School – Chicago (IL), USA
| | | | - Shailee Shah
- Illinois Institute of Technology – Department of Bioengineering – Chicago (IL), USA
| | - Erik Kulstad
- UT Southwestern Medical Center – Department of Emergency Medicine – Dallas (TX), USA
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