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Sanak T, Putowski M, Dąbrowski M, Kwinta A, Zawisza K, Morajda A, Puślecki M. CALL TO ECLS-Acronym for Reporting Patients for Extracorporeal Cardiopulmonary Resuscitation Procedure from Prehospital Setting to Destination Centers. Healthcare (Basel) 2024; 12:1613. [PMID: 39201171 PMCID: PMC11353528 DOI: 10.3390/healthcare12161613] [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: 06/24/2024] [Revised: 08/05/2024] [Accepted: 08/12/2024] [Indexed: 09/02/2024] Open
Abstract
The acronym CALL TO ECLS has been proposed as a potential tool to support decision-making in critical communication moments when qualifying a patient for the ECPR procedure. The aim of this study is to assess the accuracy of the acronym and validate its content. Validation is crucial to ensure that the acronym is theoretically correct and includes the necessary information that must be conveyed by EMS during the qualification of a patient with out-of-hospital cardiac arrest for ECMO. A survey was conducted using the LimeSurvey platform through the Survey Research System of the Jagiellonian University Medical College over a 6-month period (from December 2022 to May 2023). Usefulness, importance, clarity, and unambiguity were rated on a 4-point Likert scale, from 1 (not useful, not important, unclear, ambiguous) to 4 (useful, important, clear, unambiguous). On the 4-point scale, the Content Validity Index (I-CVI) was calculated as the percentage of subject matter experts who rated the criterion as having a level of importance/clarity/validity/uniqueness of 3 or 4. The Scale-level Content Validity Index (S-CVI) based on the average method was computed as the average of I-CVI scores (S-CVI-AVE) for all considered criteria (protocol). The number of fully completed surveys by experts was 35, and partial completion was obtained in 63 cases. All criteria were deemed significant/useful, with I-CVI coefficients ranging from 0.87 to 0.97. Similarly, the importance of all criteria was confirmed, as all I-CVI coefficients were greater than 0.78 (ranging from 0.83 to 0.97). The average I-CVI score for the ten considered criteria in terms of usefulness/significance and importance exceeded 0.9, indicating high validity of the tool/protocol/acronym. Based on the survey results and analysis of responses provided by experts, a second version was created, incorporating additional explanations. In Criterion 10, an explanation was added-"Signs of life"-during conventional cardiopulmonary resuscitation (ROSC, motor response during CPR). It has been shown that the acronym CALL TO ECLS, according to experts, is accurate and contains the necessary content, and can serve as a system to facilitate communication between the pre-hospital environment and specialized units responsible for qualifying patients for the ECPR.
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Affiliation(s)
- Tomasz Sanak
- Faculty of Health Sciences, Jagiellonian University Medical College, 31-008 Cracow, Poland
- Department of Anesthesiology and Intensive Care, University Hospital in Cracow, 30-688 Cracow, Poland
| | - Mateusz Putowski
- Faculty of Health Sciences, Jagiellonian University Medical College, 31-008 Cracow, Poland
- Department of Anesthesiology and Intensive Care, University Hospital in Cracow, 30-688 Cracow, Poland
- Collegium Medicum, Jan Kochanowski University, 25-317 Kielce, Poland
| | - Marek Dąbrowski
- Department of Medical Education, Poznan University of Medical Sciences, 60-806 Poznan, Poland
| | - Anna Kwinta
- Department of Anesthesiology and Intensive Care, University Hospital in Cracow, 30-688 Cracow, Poland
- Department of Anesthesiology and Intensive Care, Jagiellonian University Medical College, 31-501 Cracow, Poland
| | - Katarzyna Zawisza
- Epidemiology and Preventive Medicine, Jagiellonian University Medical College, 31-034 Cracow, Poland
| | - Andrzej Morajda
- Department of Anesthesiology and Intensive Care, University Hospital in Cracow, 30-688 Cracow, Poland
| | - Mateusz Puślecki
- Department of Medical Rescue, Poznan University of Medical Sciences, 60-608 Poznan, Poland
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, 61-848 Poznan, Poland
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Usman S, Daloya J, Khan MJ, Haseeb S, Patel H, Mustafa S, Pantic D. Intermittent hemodialysis as a rewarming strategy for severe hypothermia in patients without renal failure: a case report. BMC Anesthesiol 2024; 24:284. [PMID: 39127621 DOI: 10.1186/s12871-024-02664-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 07/30/2024] [Indexed: 08/12/2024] Open
Abstract
This case report highlights the effective use of intermittent hemodialysis (IHD) in warming a 71-year-old female patient with severe hypothermia who presented with a rectal temperature of 25 °C and signs of hemodynamic instability. The patient, found unconscious after prolonged exposure to cold exacerbated by alcohol consumption, initially showed some improvement in core temperature through active external rewarming methods. However, soon, her temperature plateaued at 27 °C. Patient was deemed unsuitable for extracorporeal membrane oxygenation (ECMO) or cardiopulmonary bypass (CPB) due to her age, and urgent IHD was initiated. This approach resulted in a stable increase in core temperature at approximately 2.0 °C/hr, along with normalization of lactic acidosis, creatinine phosphokinase, and correction of electrolyte imbalances, culminating in her full recovery and discharge after seven days in the hospital.After reviewing this case alongside similar ones from before, this case report highlights the efficacy and safety of IHD as an efficient, readily available, and less invasive method for rewarming moderate to severe hypothermic patients who are hemodynamically unstable patients but do not have cardiac arrest or renal dysfunction. IHD is especially useful when less invasive cooling devices (Artic Sun/ CoolGard) are not available or more invasive extracorporeal life support options (ECMO/ CPB) are either not indicated or unavailable. IHD can also help improve concurrent electrolyte imbalances and/or toxin buildup. The report further emphasizes the necessity of monitoring for potential complications, such as post-dialysis hypophosphatemia and rebound hyperkalemia, following successful rewarming.
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Affiliation(s)
- Shaheryar Usman
- Mather Hospital, Northwell Health, 75 N Country Rd, Port Jefferson, NY, 11777, USA.
| | - Jordan Daloya
- Mather Hospital, Northwell Health, 75 N Country Rd, Port Jefferson, NY, 11777, USA
| | | | - Shahan Haseeb
- Mather Hospital, Northwell Health, 75 N Country Rd, Port Jefferson, NY, 11777, USA
| | - Himani Patel
- Mather Hospital, Northwell Health, 75 N Country Rd, Port Jefferson, NY, 11777, USA
| | - Saleem Mustafa
- Mather Hospital, Northwell Health, 75 N Country Rd, Port Jefferson, NY, 11777, USA
| | - Dorjan Pantic
- Division of Intensive Care Medicine, Mather Hospital, Northwell Health, Port Jefferson, NY, USA
- Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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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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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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Podsiadło P, Smoleń A, Brožek T, Kosiński S, Balik M, Hymczak H, Cools E, Walpoth B, Nowak E, Dąbrowski W, Miazgowski B, Witt-Majchrzak A, Jędrzejczak T, Reszka K, Segond N, Debaty G, Dudek M, Górski S, Darocha T. Extracorporeal Rewarming Is Associated With Increased Survival Rate in Severely Hypothermic Patients With Preserved Spontaneous Circulation. ASAIO J 2023; 69:749-755. [PMID: 37039862 DOI: 10.1097/mat.0000000000001935] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023] Open
Abstract
Treatment recommendations for rewarming patients in severe accidental hypothermia with preserved spontaneous circulation have a weak evidence due to the absence of randomized clinical trials. We aimed to compare the outcomes of extracorporeal versus less-invasive rewarming of severely hypothermic patients with preserved spontaneous circulation. We conducted a multicenter retrospective study. The patient population was compiled based on data from the HELP Registry, the International Hypothermia Registry, and a literature review. Adult patients with a core temperature <28°C and preserved spontaneous circulation were included. Patients who underwent extracorporeal rewarming were compared with patients rewarmed with less-invasive methods, using a matched-pair analysis. The study population consisted of 50 patients rewarmed extracorporeally and 85 patients rewarmed with other, less-invasive methods. Variables significantly associated with survival included: lower age; outdoor cooling circumstances; higher blood pressure; higher PaCO 2 ; higher BE; higher HCO 3 ; and the absence of comorbidities. The survival rate was higher in patients rewarmed extracorporeally ( p = 0.049). The relative risk of death was twice as high in patients rewarmed less invasively. Based on our data, we conclude that patients in severe accidental hypothermia with circulatory instability can benefit from extracorporeal rewarming without an increased risk of complications.
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Affiliation(s)
- Paweł Podsiadło
- From the Department of Emergency Medicine, Jan Kochanowski University, Kielce, Poland
| | - Agata Smoleń
- Department of Epidemiology and Clinical Research Methodology, Medical University of Lublin, Poland
| | - Tomáš Brožek
- Department of Anaesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Sylweriusz Kosiński
- Faculty of Health Sciences, Jagiellonian University Medical College, Kraków, Poland
| | - Martin Balik
- Department of Anaesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Hubert Hymczak
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Kraków University, Kraków, Poland
| | - Evelien Cools
- Department of Acute Medicine, Division of Anaesthesiology, University Hospitals, Geneva, Switzerland
| | - Beat Walpoth
- Emeritus. Department of Cardiovascular Surgery, University Hospitals of Geneva, Switzerland
| | - Ewelina Nowak
- Institute of Health Sciences, Jan Kochanowski University, Kielce, 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
| | - Anna Witt-Majchrzak
- Department of Cardiac Surgery Provincial Specialist Hospital, Olsztyn, Poland
| | - Tomasz Jędrzejczak
- Department of Cardiosurgery, Pomeranian Medical University in Szczecin, Poland
| | - Kacper Reszka
- Department of Anaesthesiology and Intensive Care, University Hospital, Łódź, Poland
| | - Nicolas Segond
- Univ. Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, CHU Grenoble Alpes, TIMC, Grenoble, France
| | - Guillaume Debaty
- Univ. Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, CHU Grenoble Alpes, TIMC, Grenoble, France
| | - Michał Dudek
- Department of Emergency Medicine, Faculty of Health Sciences, University of Bielsko-Biała, Poland
| | - Stanisław Górski
- Department of Medical Education, Jagiellonian University Medical College, Kraków, Poland
| | - Tomasz Darocha
- Department of Anaesthesiology and Intensive Care, Medical University of Silesia, Katowice, Poland
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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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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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8
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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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9
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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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10
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Filseth OM, Kondratiev T, Sieck GC, Tveita T. Functional recovery after accidental deep hypothermic cardiac arrest: Comparison of different cardiopulmonary bypass rewarming strategies. Front Physiol 2022; 13:960652. [PMID: 36134333 PMCID: PMC9483155 DOI: 10.3389/fphys.2022.960652] [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: 06/03/2022] [Accepted: 08/01/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction: Using a porcine model of accidental immersion hypothermia and hypothermic cardiac arrest (HCA), the aim of the present study was to compare effects of different rewarming strategies on CPB on need for vascular fluid supply, level of cardiac restitution, and cerebral metabolism and pressures. Materials and Methods: Totally sixteen healthy, anesthetized castrated male pigs were immersion cooled to 20°C to induce HCA, maintained for 75 min and then randomized into two groups: 1) animals receiving CPB rewarming to 30°C followed by immersion rewarming to 36°C (CPB30, n = 8), or 2) animals receiving CPB rewarming to 36°C (CPB36, n = 8). Measurements of cerebral metabolism were collected using a microdialysis catheter. After rewarming to 36°C, surviving animals in both groups were further warmed by immersion to 38°C and observed for 2 h. Results: Survival rate at 2 h after rewarming was 5 out of 8 animals in the CPB30 group, and 8 out of 8 in the CPB36 group. All surviving animals displayed significant acute cardiac dysfunction irrespective of rewarming method. Differences between groups in CPB exposure time or rewarming rate created no differences in need for vascular volume supply, in variables of cerebral metabolism, or in cerebral pressures and blood flow. Conclusion: As 3 out of 8 animals did not survive weaning from CPB at 30°C, early weaning gave no advantages over weaning at 36°C. Further, in surviving animals, the results showed no differences between groups in the need for vascular volume replacement, nor any differences in cerebral blood flow or pressures. Most prominent, after weaning from CPB, was the existence of acute cardiac failure which was responsible for the inability to create an adequate perfusion irrespective of rewarming strategy.
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Affiliation(s)
- Ole Magnus Filseth
- Anesthesia and Critical Care Research Group, Faculty of Health Sciences, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
- Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
- Emergency Medical Services, University Hospital of North Norway, Tromsø, Norway
| | - Timofei Kondratiev
- Anesthesia and Critical Care Research Group, Faculty of Health Sciences, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Gary C. Sieck
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, United States
| | - Torkjel Tveita
- Anesthesia and Critical Care Research Group, Faculty of Health Sciences, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
- Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, United States
- *Correspondence: Torkjel Tveita,
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11
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Filseth OM, Hermansen SE, Kondratiev T, Sieck GC, Tveita T. Cooling to Hypothermic Circulatory Arrest by Immersion vs. Cardiopulmonary Bypass (CPB): Worse Outcome After Rewarming in Immersion Cooled Pigs. Front Physiol 2022; 13:862729. [PMID: 35431978 PMCID: PMC9008231 DOI: 10.3389/fphys.2022.862729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 02/25/2022] [Indexed: 12/04/2022] Open
Abstract
Introduction Cooling by cardiopulmonary bypass (CPB) to deep hypothermic cardiac arrest (HCA) for cardiac surgical interventions, followed by CPB-rewarming is performed on a routine basis with relatively low mortality. In contrast, victims of deep accidental hypothermia rewarmed with CPB generally have a much worse prognosis. Thus, we have developed an intact pig model to compare effects on perfusion pressures and global oxygen delivery (DO2) during immersion cooling versus cooling by CPB. Further, we compared the effects of CPB-rewarming between groups, to restitute cardiovascular function, brain blood flow, and brain metabolism. Materials and Methods Total sixteen healthy, anesthetized juvenile (2–3 months) castrated male pigs were randomized in a prospective, open placebo-controlled experimental study to immersion cooling (IMMc, n = 8), or cooling by CPB (CPBc, n = 8). After 75 minutes of deep HCA in both groups, pigs were rewarmed by CPB. After weaning from CPB surviving animals were observed for 2 h before euthanasia. Results Survival rates at 2 h after completed rewarming were 4 out of 8 in the IMMc group, and 8 out of 8 in the CPBc group. Compared with the CPBc-group, IMMc animals showed significant reduction in DO2, mean arterial pressure (MAP), cerebral perfusion pressure, and blood flow during cooling below 25°C as well as after weaning from CPB after rewarming. After rewarming, brain blood flow returned to control in CPBc animals only, and brain micro dialysate-data showed a significantly increase in the lactate/pyruvate ratio in IMMc vs. CPBc animals. Conclusion Our data indicate that, although global O2 consumption was independent of DO2, regional ischemic damage may have taken place during cooling in the brain of IMMc animals below 25°C. The need for prolonged extracorporeal membrane oxygenation (ECMO) should be considered in all victims of accidental hypothermic arrest that cannot be weaned from CPB immediately after rewarming.
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Affiliation(s)
- Ole Magnus Filseth
- Anesthesia and Critical Care Research Group, Faculty of Health Sciences, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
- Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
- Emergency Medical Services, University Hospital of North Norway, Tromsø, Norway
| | - Stig Eggen Hermansen
- Cardiothoracic Research Group, Faculty of Health Sciences, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
- Cardiothoracic and Respiratory Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Timofei Kondratiev
- Anesthesia and Critical Care Research Group, Faculty of Health Sciences, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Gary C. Sieck
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine & Science, Rochester, MN, United States
| | - Torkjel Tveita
- Anesthesia and Critical Care Research Group, Faculty of Health Sciences, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
- Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine & Science, Rochester, MN, United States
- *Correspondence: Torkjel Tveita,
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12
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Bjertnæs LJ, Næsheim TO, Reierth E, Suborov EV, Kirov MY, Lebedinskii KM, Tveita T. Physiological Changes in Subjects Exposed to Accidental Hypothermia: An Update. Front Med (Lausanne) 2022; 9:824395. [PMID: 35280892 PMCID: PMC8904885 DOI: 10.3389/fmed.2022.824395] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/28/2022] [Indexed: 12/01/2022] Open
Abstract
Background Accidental hypothermia (AH) is an unintended decrease in body core temperature (BCT) to below 35°C. We present an update on physiological/pathophysiological changes associated with AH and rewarming from hypothermic cardiac arrest (HCA). Temperature Regulation and Metabolism Triggered by falling skin temperature, Thyrotropin-Releasing Hormone (TRH) from hypothalamus induces release of Thyroid-Stimulating Hormone (TSH) and Prolactin from pituitary gland anterior lobe that stimulate thyroid generation of triiodothyronine and thyroxine (T4). The latter act together with noradrenaline to induce heat production by binding to adrenergic β3-receptors in fat cells. Exposed to cold, noradrenaline prompts degradation of triglycerides from brown adipose tissue (BAT) into free fatty acids that uncouple metabolism to heat production, rather than generating adenosine triphosphate. If BAT is lacking, AH occurs more readily. Cardiac Output Assuming a 7% drop in metabolism per °C, a BCT decrease of 10°C can reduce metabolism by 70% paralleled by a corresponding decline in CO. Consequently, it is possible to maintain adequate oxygen delivery provided correctly performed cardiopulmonary resuscitation (CPR), which might result in approximately 30% of CO generated at normal BCT. Liver and Coagulation AH promotes coagulation disturbances following trauma and acidosis by reducing coagulation and platelet functions. Mean prothrombin and partial thromboplastin times might increase by 40-60% in moderate hypothermia. Rewarming might release tissue factor from damaged tissues, that triggers disseminated intravascular coagulation. Hypothermia might inhibit platelet aggregation and coagulation. Kidneys Renal blood flow decreases due to vasoconstriction of afferent arterioles, electrolyte and fluid disturbances and increasing blood viscosity. Severely deranged renal function occurs particularly in the presence of rhabdomyolysis induced by severe AH combined with trauma. Conclusion Metabolism drops 7% per °C fall in BCT, reducing CO correspondingly. Therefore, it is possible to maintain adequate oxygen delivery after 10°C drop in BCT provided correctly performed CPR. Hypothermia may facilitate rhabdomyolysis in traumatized patients. Victims suspected of HCA should be rewarmed before being pronounced dead. Rewarming avalanche victims of HCA with serum potassium > 12 mmol/L and a burial time >30 min with no air pocket, most probably be futile.
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Affiliation(s)
- Lars J. Bjertnæs
- Department of Clinical Medicine, Faculty of Health Sciences, Anesthesia and Critical Care Research Group, University of Tromsø, UiT The Arctic University of Norway, Tromsø, Norway
- Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
| | - Torvind O. Næsheim
- Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, Faculty of Health Sciences, Cardiovascular Research Group, University of Tromsø, UiT The Arctic University of Norway, Tromsø, Norway
| | - Eirik Reierth
- Science and Health Library, University of Tromsø, UiT The Arctic University of Norway, Tromsø, Norway
| | - Evgeny V. Suborov
- The Nikiforov Russian Center of Emergency and Radiation Medicine, St. Petersburg, Russia
| | - Mikhail Y. Kirov
- Department of Anesthesiology and Intensive Care, Northern State Medical University, Arkhangelsk, Russia
| | - Konstantin M. Lebedinskii
- Department of Anesthesiology and Intensive Care, North-Western State Medical University named after I.I. Mechnikov, St. Petersburg, Russia
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Torkjel Tveita
- Department of Clinical Medicine, Faculty of Health Sciences, Anesthesia and Critical Care Research Group, University of Tromsø, UiT The Arctic University of Norway, Tromsø, Norway
- Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
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13
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Swol J, Darocha T, Paal P, Brugger H, Podsiadło P, Kosiński S, Puślecki M, Ligowski M, Pasquier M. Extracorporeal Life Support in Accidental Hypothermia with Cardiac Arrest-A Narrative Review. ASAIO J 2022; 68:153-162. [PMID: 34261875 PMCID: PMC8797003 DOI: 10.1097/mat.0000000000001518] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Severely hypothermic patients, especially suffering cardiac arrest, require highly specialized treatment. The most common problems affecting the recognition and treatment seem to be awareness, logistics, and proper planning. In severe hypothermia, pathophysiologic changes occur in the cardiovascular system leading to dysrhythmias, decreased cardiac output, decreased central nervous system electrical activity, cold diuresis, and noncardiogenic pulmonary edema. Cardiac arrest, multiple organ dysfunction, and refractory vasoplegia are indicative of profound hypothermia. The aim of these narrative reviews is to describe the peculiar pathophysiology of patients suffering cardiac arrest from accidental hypothermia. We describe the good chances of neurologic recovery in certain circumstances, even in patients presenting with unwitnessed cardiac arrest, asystole, and the absence of bystander cardiopulmonary resuscitation. Guidance on patient selection, prognostication, and treatment, including extracorporeal life support, is given.
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Affiliation(s)
- Justyna Swol
- From the Deparment of Respiratory Medicine, Allergology and Sleep Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Tomasz Darocha
- Department of Anesthesiology and Intensive Care, Severe Accidental Hypothermia Center, Medical University of Silesia, Katowice, Poland
| | - Peter Paal
- Department of Anesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Hermann Brugger
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - Paweł Podsiadło
- Department of Emergency Medicine, Jan Kochanowski University, Kielce, Poland
| | - Sylweriusz Kosiński
- Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Mateusz Puślecki
- Department of Medical Rescue, Poznan University of Medical Sciences, Poznan, Poland
- Departmentf Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Marcin Ligowski
- Departmentf Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Mathieu Pasquier
- Emergency Department, Lausanne University Hospital, Lausanne, Switzerland
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14
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Takauji S, Hayakawa M. Intensive care with extracorporeal membrane oxygenation rewarming in accident severe hypothermia (ICE-CRASH) study: a protocol for a multicentre prospective, observational study in Japan. BMJ Open 2021; 11:e052200. [PMID: 34711600 PMCID: PMC8557292 DOI: 10.1136/bmjopen-2021-052200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Accidental hypothermia (AH) is a rare but critical disease, leading to death in severe cases. In recent decades, extracorporeal membrane oxygenation (ECMO) has been successfully used to rewarm hypothermic patients with cardiac arrest or circulation instability. However, data on the efficacy of rewarming using ECMO for patients with AH are limited. Therefore, a large-scale, multicentre, prospective study is warranted. The primary objective of this study will be to clarify the effectiveness of rewarming using ECMO for patients with AH. Our secondary objectives will be to compare the incidence of adverse effects between ECMO rewarming and non-ECMO rewarming and to identify the most appropriate management of ECMO for AH. METHODS AND ANALYSES The Intensive Care with ExtraCorporeal membrane oxygenation Rewarming in Accidentally Severe Hypothermia study is taking place in 35 tertiary emergency medical facilities in Japan. The inclusion criteria are patients ≥18 years old with a body temperature ≤32°C. We will include patients with AH who present to the emergency department from December 2019 to March 2022. The research personnel at each hospital will collect several variables, including patient demographics, rewarming method, ECMO data and complications. Our primary outcome is to compare the 28-day survival rate between the ECMO and non-ECMO (other treatments) groups among patients with severe AH. Our secondary outcomes are to compare the following values between the ECMO and non-ECMO groups: length of stay in the intensive-care unit and complications. Furthermore, in patients with cardiac arrest, the Cerebral Performance Category score at discharge will be compared between both groups. ETHICS AND DISSEMINATION This study received research ethics approval from Asahikawa Medical University (18194 and 19115). The study was approved by the institutional review board of each hospital, and the requirement for informed consent was waived due to the observational nature of the study. TRIAL REGISTRATION NUMBER UMIN000036132.
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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
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15
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Tveita T, Sieck GC. Physiological Impact of Hypothermia: The Good, the Bad and the Ugly. Physiology (Bethesda) 2021; 37:69-87. [PMID: 34632808 DOI: 10.1152/physiol.00025.2021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Hypothermia is defined as a core body temperature of < 35°C, and as body temperature is reduced the impact on physiological processes can be beneficial or detrimental. The beneficial effect of hypothermia enables circulation of cooled experimental animals to be interrupted for 1-2 h without creating harmful effects, while tolerance of circulation arrest in normothermia is between 4 and 5 min. This striking difference has attracted so many investigators, experimental as well as clinical, to this field, and this discovery was fundamental for introducing therapeutic hypothermia in modern clinical medicine in the 1950's. Together with the introduction of cardiopulmonary bypass, therapeutic hypothermia has been the cornerstone in the development of modern cardiac surgery. Therapeutic hypothermia also has an undisputed role as a protective agent in organ transplantation and as a therapeutic adjuvant for cerebral protection in neonatal encephalopathy. However, the introduction of therapeutic hypothermia for organ protection during neurosurgical procedures or as a scavenger after brain and spinal trauma has been less successful. In general, the best neuroprotection seems to be obtained by avoiding hyperthermia in injured patients. Accidental hypothermia occurs when endogenous temperature control mechanisms are incapable of maintaining core body temperature within physiologic limits and core temperature becomes dependent on ambient temperature. During hypothermia spontaneous circulation is considerably reduced and with deep and/or prolonged cooling, circulatory failure may occur, which may limit safe survival of the cooled patient. Challenges that limit safe rewarming of accidental hypothermia patients include cardiac arrhythmias, uncontrolled bleeding, and "rewarming shock".
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Affiliation(s)
- Torkjel Tveita
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.,Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
| | - Gary C Sieck
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, United States
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16
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Takauji S, Hifumi T, Saijo Y, Yokobori S, Kanda J, Kondo Y, Hayashida K, Shimazaki J, Moriya T, Yagi M, Yamaguchi J, Okada Y, Okano Y, Kaneko H, Kobayashi T, Fujita M, Shimizu K, Yokota H. Accidental hypothermia: characteristics, outcomes, and prognostic factors-A nationwide observational study in Japan (Hypothermia study 2018 and 2019). Acute Med Surg 2021; 8:e694. [PMID: 34567577 PMCID: PMC8448583 DOI: 10.1002/ams2.694] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/06/2021] [Accepted: 08/28/2021] [Indexed: 12/25/2022] Open
Abstract
Aim This study describes the clinical characteristics and outcomes as well as the prognostic factors of patients with accidental hypothermia (AH) using Japan’s nationwide registry data. Methods The Hypothermia study 2018 and 2019, which included patients aged 18 years or older with a body temperature of 35°C or less, was a multicenter registry conducted at 87 and 89 institutions throughout Japan, with data collected from December 2018 to February 2019 and December 2019 to February 2020, respectively. Results In total, 1363 patients were enrolled in the registry, of which 1194 were analyzed in this study. The median (interquartile range) age was 79 (68–87) years, and the median (interquartile range) body temperature at the emergency department was 30.8°C (28.4–33.6°C). Forty‐three percent of patients with AH had a mild condition, 35.2% moderate, and 21.9% severe. AH occurred in an indoor setting in 73.4% and was caused by acute medical illness in 49.3% of patients. A total of 101 (8.5%) patients suffered from cardiopulmonary arrest on arrival at the hospital. The overall 30‐day mortality rate was 24.5%, the median (interquartile range) intensive care unit stay was 4 (2–7) days, and the median (interquartile range) hospital stay was 13 (4–27) days. In the multivariable logistic analysis, the prognostic factors were age (≥75 years old), male, activities of daily living (needing total assistance), cause of AH (trauma, alcohol), Glasgow Coma Scale score, and potassium level (>5.5 mEq/L). Conclusion The mortality rate of AH was 24.5% in Japan. The prognostic factors developed in this study may be useful for the early prediction, prevention, and awareness of severe AH.
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Affiliation(s)
- Shuhei Takauji
- Department of Emergency Medicine Asahikawa Medical University Hospital Asahikawa Japan.,Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan
| | - Toru Hifumi
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan.,Department of Emergency and Critical Care Medicine St. Luke's International Hospital Tokyo Japan
| | - Yasuaki Saijo
- Department of Social Medicine Asahikawa Medical University Asahikawa Japan
| | - Shoji Yokobori
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan.,Department of Emergency and Critical Care Medicine Nippon Medical School Tokyo Japan
| | - Jun Kanda
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan.,Department of Emergency Medicine Teikyo University Hospital Tokyo Japan
| | - Yutaka Kondo
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan.,Department of Emergency and Critical Care Medicine Juntendo University Urayasu Hospital Urayasu Japan
| | - Kei Hayashida
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan.,Department of Emergency Medicine North Shore University Hospital Northwell Health System Manhasset NY USA
| | - Junya Shimazaki
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan.,Department of Traumatology and Acute Critical Medicine Osaka University Graduate School Osaka Japan
| | - Takashi Moriya
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan.,Department of Emergency and Critical Care Medicine Jichi Medical University Saitama Medical Center Omiya Japan
| | - Masaharu Yagi
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan.,Department of Emergency, Disaster and Critical Care Medicine Showa University School of Medicine Tokyo Japan
| | - Junko Yamaguchi
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan.,Department of Acute Medicine Nihon University School of Medicine Tokyo Japan
| | - Yohei Okada
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan.,Department of Primary Care and Emergency Medicine Graduate School of Medicine Kyoto University Kyoto Japan
| | - Yuichi Okano
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan.,Department of Emergency Medicine Japanese Red Cross Kumamoto Hospital Kumamoto Japan
| | - Hitoshi Kaneko
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan.,Emergency and Critical Care Center Tokyo Metropolitan Tama Medical Center Tokyo Japan
| | - Tatsuho Kobayashi
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan.,Department of Emergency and Critical Care Medicine Aizu Chuo Hospital Aizu Wakamatsu Japan
| | - Motoki Fujita
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan.,Advanced Medical Emergency and Critical Care Center Yamaguchi University Hospital Ube Japan
| | - Keiki Shimizu
- Emergency and Critical Care Center Tokyo Metropolitan Tama Medical Center Tokyo Japan
| | - Hiroyuki Yokota
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan.,Department of Emergency and Critical Care Medicine Nippon Medical School Tokyo Japan
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17
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Nilsen JH, Schanche T, Valkov S, Mohyuddin R, Haaheim B, Kondratiev TV, Næsheim T, Sieck GC, Tveita T. Effects of rewarming with extracorporeal membrane oxygenation to restore oxygen transport and organ blood flow after hypothermic cardiac arrest in a porcine model. Sci Rep 2021; 11:18918. [PMID: 34556695 PMCID: PMC8460815 DOI: 10.1038/s41598-021-98044-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 08/26/2021] [Indexed: 02/08/2023] Open
Abstract
We recently documented that cardiopulmonary resuscitation (CPR) generates the same level of cardiac output (CO) and mean arterial pressure (MAP) during both normothermia (38 °C) and hypothermia (27 °C). Furthermore, continuous CPR at 27 °C provides O2 delivery (ḊO2) to support aerobic metabolism throughout a 3-h period. The aim of the present study was to investigate the effects of extracorporeal membrane oxygenation (ECMO) rewarming to restore ḊO2 and organ blood flow after prolonged hypothermic cardiac arrest. Eight male pigs were anesthetized and immersion cooled to 27 °C. After induction of hypothermic cardiac arrest, CPR was started and continued for a 3-h period. Thereafter, the animals were rewarmed with ECMO. Organ blood flow was measured using microspheres. After cooling with spontaneous circulation to 27 °C, MAP and CO were initially reduced to 66 and 44% of baseline, respectively. By 15 min after the onset of CPR, there was a further reduction in MAP and CO to 42 and 25% of baseline, respectively, which remained unchanged throughout the rest of 3-h CPR. During CPR, ḊO2 and O2 uptake (V̇O2) fell to critical low levels, but the simultaneous small increase in lactate and a modest reduction in pH, indicated the presence of maintained aerobic metabolism. Rewarming with ECMO restored MAP, CO, ḊO2, and blood flow to the heart and to parts of the brain, whereas flow to kidneys, stomach, liver and spleen remained significantly reduced. CPR for 3-h at 27 °C with sustained lower levels of CO and MAP maintained aerobic metabolism sufficient to support ḊO2. Rewarming with ECMO restores blood flow to the heart and brain, and creates a "shockable" cardiac rhythm. Thus, like continuous CPR, ECMO rewarming plays a crucial role in "the chain of survival" when resuscitating victims of hypothermic cardiac arrest.
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Affiliation(s)
- Jan Harald Nilsen
- grid.10919.300000000122595234Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, 9037 Tromsø, Norway ,grid.420120.50000 0004 0481 3017Department of Research and Education, Norwegian Air Ambulance Foundation, 1441 Drøbak, Norway ,grid.412244.50000 0004 4689 5540Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, 9038 Tromsø, Norway
| | - Torstein Schanche
- grid.10919.300000000122595234Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, 9037 Tromsø, Norway ,grid.66875.3a0000 0004 0459 167XDepartment of Physiology & Biomedical Engineering, Mayo Clinic, Rochester, MN USA
| | - Sergei Valkov
- grid.10919.300000000122595234Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, 9037 Tromsø, Norway
| | - Rizwan Mohyuddin
- grid.10919.300000000122595234Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, 9037 Tromsø, Norway
| | - Brage Haaheim
- grid.10919.300000000122595234Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, 9037 Tromsø, Norway
| | - Timofei V. Kondratiev
- grid.10919.300000000122595234Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, 9037 Tromsø, Norway
| | - Torvind Næsheim
- grid.412244.50000 0004 4689 5540Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, 9038 Tromsø, Norway
| | - Gary C. Sieck
- grid.66875.3a0000 0004 0459 167XDepartment of Physiology & Biomedical Engineering, Mayo Clinic, Rochester, MN USA
| | - Torkjel Tveita
- grid.10919.300000000122595234Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, 9037 Tromsø, Norway ,grid.412244.50000 0004 4689 5540Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, 9038 Tromsø, Norway ,grid.66875.3a0000 0004 0459 167XDepartment of Physiology & Biomedical Engineering, Mayo Clinic, Rochester, MN USA
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18
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Bjertnæs LJ, Hindberg K, Næsheim TO, Suborov EV, Reierth E, Kirov MY, Lebedinskii KM, Tveita T. Rewarming From Hypothermic Cardiac Arrest Applying Extracorporeal Life Support: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2021; 8:641633. [PMID: 34055829 PMCID: PMC8155640 DOI: 10.3389/fmed.2021.641633] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 03/04/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction: This systematic review and meta-analysis aims at comparing outcomes of rewarming after accidental hypothermic cardiac arrest (HCA) with cardiopulmonary bypass (CPB) or/and extracorporeal membrane oxygenation (ECMO). Material and Methods: Literature searches were limited to references with an abstract in English, French or German. Additionally, we searched reference lists of included papers. Primary outcome was survival to hospital discharge. We assessed neurological outcome, differences in relative risks (RR) of surviving, as related to the applied rewarming technique, sex, asphyxia, and witnessed or unwitnessed HCA. We calculated hypothermia outcome prediction probability score after extracorporeal life support (HOPE) in patients in whom we found individual data. P < 0.05 considered significant. Results: Twenty-three case observation studies comprising 464 patients were included in a meta-analysis comparing outcomes of rewarming with CPB or/and ECMO. One-hundred-and-seventy-two patients (37%) survived to hospital discharge, 76 of 245 (31%) after CPB and 96 of 219 (44 %) after ECMO; 87 and 75%, respectively, had good neurological outcomes. Overall chance of surviving was 41% higher (P = 0.005) with ECMO as compared with CPB. A man and a woman had 46% (P = 0.043) and 31% (P = 0.115) higher chance, respectively, of surviving with ECMO as compared with CPB. Avalanche victims had the lowest chance of surviving, followed by drowning and people losing consciousness in cold environments. Assessed by logistic regression, asphyxia, unwitnessed HCA, male sex, high initial body temperature, low pH and high serum potassium (s-K+) levels were associated with reduced chance of surviving. In patients displaying individual data, overall mean predictive surviving probability (HOPE score; n = 134) was 33.9 ± 33.6% with no significant difference between ECMO and CPB-treated patients. We also surveyed 80 case reports with 96 victims of HCA, who underwent resuscitation with CPB or ECMO, without including them in the meta-analysis. Conclusions: The chance of surviving was significantly higher after rewarming with ECMO, as compared to CPB, and in patients with witnessed compared to unwitnessed HCA. Avalanche victims had the lowest probability of surviving. Male sex, high initial body temperature, low pH, and high s-K+ were factors associated with low surviving chances.
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Affiliation(s)
- Lars J. Bjertnæs
- Anesthesia and Critical Care Research Group, University of Tromsø (UiT), The Arctic University of Norway, Tromsø, Norway
| | - Kristian Hindberg
- K. G. Jebsen Thrombosis Research and Expertise Center, University of Tromsø (UiT), The Arctic University of Norway, Tromsø, Norway
| | - Torvind O. Næsheim
- Cardiovascular Research Group, Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø (UiT), The Arctic University of Norway, Tromsø, Norway
| | - Evgeny V. Suborov
- The Nikiforov Russian Federation Center of Emergency and Radiation Medicine, St. Petersburg, Russia
| | - Eirik Reierth
- Science and Health Library, University of Tromsø, The Arctic University of Norway, Tromsø, Norway
| | - Mikhail Y. Kirov
- Department of Anesthesiology and Intensive Care, Northern State Medical University, Arkhangelsk, Russia
| | - Konstantin M. Lebedinskii
- Department of Anesthesiology and Intensive Care, North-Western State Medical University Named After I. I. Mechnikov, St. Petersburg, Russia
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Torkjel Tveita
- Anesthesia and Critical Care Research Group, University of Tromsø (UiT), The Arctic University of Norway, Tromsø, Norway
- Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
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19
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Podsiadło P, Smoleń A, Kosiński S, Hymczak H, Waligórski S, Witt-Majchrzak A, Drobiński D, Nowak E, Barteczko-Grajek B, Toczek K, Skowronek R, Darocha T. Impact of rescue collapse on mortality rate in severe accidental hypothermia: A matched-pair analysis. Resuscitation 2021; 164:108-113. [PMID: 33930504 DOI: 10.1016/j.resuscitation.2021.04.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/26/2021] [Accepted: 04/14/2021] [Indexed: 11/29/2022]
Abstract
AIM To assess the impact of the occurrence of cardiac arrest associated with initial management on the outcome of severely hypothermic patients who were rewarmed with Extracorporeal Life Support (ECLS). METHODS We collected the individual data of patients in a state of severe accidental hypothermia who were found with spontaneous circulation and rewarmed with ECLS, from cardiac surgery departments. Patients were divided into two groups: those with a subsequent cardiac arrest (RC group); and those with the retained circulation (HT3 group), and compared by using a matched-pair analysis. The mortality rates and the neurological status in survivors were compared as the main outcomes. The difference in the risk of death between the HT3 and RC groups was calculated. RESULTS A total of 124 patients were included into the study: 45 in the HT3 group and 79 in the RC group. The matched cohorts consisted of 45 HT3 patients and 45 RC patients. The mortality rate in both groups was 24% and 49% (p = 0.02) respectively; the relative risk of death was 2.0 (p = 0.02). ICU length of stay was significantly longer in the RC group (p < 0.001). Factors associated with survival in the HT3 group included patient age, rewarming rate, and blood BE; while in the RC group, patient age and lactate concentration. CONCLUSIONS The occurrence of rescue collapse is linked to a doubling of the risk of death in severely hypothermic patients. Procedures which are known as potential triggers of rescue collapse should be performed with special attention, including in conscious patients.
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Affiliation(s)
- Paweł Podsiadło
- Institute of Medical Sciences, Jan Kochanowski University, Kielce, Poland
| | - Agata Smoleń
- Department of Epidemiology and Clinical Research Methodology, Medical University of Lublin, Poland
| | - Sylweriusz Kosiński
- Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Hubert Hymczak
- Department of Anaesthesiology and Intensive Care, John Paul II Hospital, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland
| | - Szymon Waligórski
- Department of Cardiosurgery, Pomeranian Medical University, Szczecin, Poland
| | - Anna Witt-Majchrzak
- Department of Cardiac Surgery Provincial Specialist Hospital, Olsztyn, Poland
| | - Dominik Drobiński
- Cardiosurgery Clinic and Department of Cardiac Anaesthesia, Central Clinical Hospital of the Ministry of the Interior and Administration, Warsaw, Poland
| | - Ewelina Nowak
- Institute of Health Sciences, Jan Kochanowski University, Kielce, Poland
| | - Barbara Barteczko-Grajek
- Department and Clinic of Anaesthesiology and Intensive Care, Wrocław Medical University, Wrocław, Poland
| | - Krzysztof Toczek
- Department of Cardiac Surgery, 4th Military Hospital, Wrocław, Poland
| | - Radomir Skowronek
- Department of Cardiac Surgery, Regional Specialist Hospital, Grudziądz, Poland
| | - Tomasz Darocha
- Department of Anaesthesiology and Intensive Care, Medical University of Silesia, Katowice, Poland.
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20
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Rasmussen JM, Cogbill TH, Borgert AJ, Frankki SM, Kallies KJ, Roberts JC, Cullinane DC, Renier C, Woehrle T, Eyer SD, Zein Eddine SB, Beckman M, Waller CJ. Epidemiology, Management, and Outcomes of Accidental Hypothermia: A Multicenter Study of Regional Care. Am Surg 2020; 88:1062-1070. [PMID: 33375834 DOI: 10.1177/0003134820984869] [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: 11/16/2022]
Abstract
BACKGROUND Hypothermia is an uncommon, potentially life-threatening condition. We hypothesized (1) advanced rewarming techniques were more frequent with increased hypothermia severity, (2) active rewarming is increasingly performed with smaller intravascular catheters and decreased cardiopulmonary bypass, and (3) mortality was associated with age, hypothermia severity, and type. METHODS Trauma patients with temperatures <35°C at 4 ACS-verified trauma centers in Wisconsin and Minnesota from 2006 to 2016 were reviewed. Statistical analysis included chi-square and Fisher's exact tests. A P value < .05 was considered significant. RESULTS 337 patients met inclusion criteria; primary hypothermia was identified in 127 (38%), secondary in 113 (34%), and mixed primary/secondary in 96 (28%) patients. Hypothermia was mild in 69%, moderate in 26%, and severe in 5% of patients. Intravascular rewarming catheter was the most frequent advanced modality (2%), used increasingly since 2014. Advanced techniques were used for primary (12%) vs. secondary (0%) and mixed (5%) (P = .0002); overall use increased with hypothermia severity but varied by institution. Dysrhythmia, acute kidney injury, and frostbite risk worsened with hypothermia severity (P < .0001, P = .031, and P < .0001, respectively). Mortality was greatest in patients with mixed hypothermia (39%, P = .0002) and age >65 years (33%, P = .03). Thirty-day mortality rates were similar among severe, moderate, and mild hypothermia (P = .44). CONCLUSION Advanced rewarming techniques were used more frequently in severe and primary hypothermia but varied among institutions. Advanced rewarming was less common in mixed hypothermia; mortality was highest in this subgroup. Reliance on smaller intravascular catheters for advanced rewarming increased over time. Given inconsistencies in management, implementation of guidelines for hypothermia management appears necessary.
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Affiliation(s)
- Jessica M Rasmussen
- Department of Medical Education, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Thomas H Cogbill
- Department of General Surgery, Gundersen Health System, La Crosse, WI, USA
| | - Andrew J Borgert
- Department of Medical Research, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Susan M Frankki
- Department of Medical Research, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Kara J Kallies
- Department of Medical Research, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Jennifer C Roberts
- Department of Surgery, Marshfield Clinic Health System, Marshfield, WI, USA
| | - Daniel C Cullinane
- Department of Surgery, Marshfield Clinic Health System, Marshfield, WI, USA
| | - Colleen Renier
- Department of Trauma Surgery, Essentia Health St Mary's Medical Center, Essentia Institute of Rural Health, Duluth, MN, USA
| | - Theo Woehrle
- Department of Trauma Surgery, Essentia Health St Mary's Medical Center, Essentia Institute of Rural Health, Duluth, MN, USA
| | - Steven D Eyer
- Department of Trauma Surgery, Essentia Health St Mary's Medical Center, Essentia Institute of Rural Health, Duluth, MN, USA
| | - Savo Bou Zein Eddine
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Marshall Beckman
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Christine J Waller
- Department of General Surgery, Gundersen Health System, La Crosse, WI, USA
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21
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Sip M, Puslecki M, Dabrowski M, Klosiewicz T, Zalewski R, Ligowski M, Goszczynska E, Paprocki C, Grygier M, Lesiak M, Jemielity M, Perek B. Extended cardiopulmonary resuscitation: from high fidelity simulation scenario to the first clinical applications in Poznan out-of-hospital cardiac arrest program. Perfusion 2020; 37:46-55. [PMID: 33325325 DOI: 10.1177/0267659120981811] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND The outcomes of out-of-hospital cardiac arrest (OHCA) patients are poor. In some OHCA cases, the reason is potentially reversible cardiac or aortic disease. It was suggested previously that high-quality cardiopulmonary resuscitation (CPR) followed by extracorporeal membrane oxygenation (ECMO) support may improve the grave prognosis of OHCA. However, extended CPR (ECPR) with ECMO application is an extremely invasive and cutting-edge procedure. The purpose of this article is to describe how high-fidelity medical simulation as a safe tool enabled implementation of the complex, multi-stage ECPR procedure. METHOD A high fidelity simulation of OHCA in street conditions was prepared and carried out as part of a ECPR procedure implemented in an in-hospital area. The simulation tested communication and collaboration of several medical teams from the pre-hospital to in-hospital phases along with optimal use of equipment in management of a sudden cardiac arrest (SCA) patient. RESULTS The critical and weak points of an earlier created scenario were collected into a simulation scenario checklist of ECPR algorithm architecture. A few days later, two ECPR procedures followed by cardiologic interventions for OHCA patients (one pulmonary artery embolectomy for acute pulmonary thrombosis and one percutaneous coronary artery angioplasty with drug eluting stent implantation for acute occlusion of the left anterior descending artery), were performed for the first time in Poland. The protocol was activated five times in the first 2 months of the POHCA Program. CONCLUSION High fidelity medical simulation in real-life conditions was confirmed to be a safe, useful tool to test and then implement the novel and complex medical procedures. It enabled to find, analyze and solve the weakest points of the earlier developed theoretical protocol and eventually succeed in clinical application of complete ECPR procedure.
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Affiliation(s)
- Maciej Sip
- Department of Medical Rescue, Poznan University of Medical Sciences, Poznan, Poland.,Polish Society of Medical Simulation, Slupca, Poland
| | - Mateusz Puslecki
- Department of Medical Rescue, Poznan University of Medical Sciences, Poznan, Poland.,Polish Society of Medical Simulation, Slupca, Poland.,Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Wielkopolskie, Poland
| | - Marek Dabrowski
- Polish Society of Medical Simulation, Slupca, Poland.,Department of Medical Education, Poznan University of Medical Sciences, Poznan, Wielkopolskie, Poland
| | - Tomasz Klosiewicz
- Department of Medical Rescue, Poznan University of Medical Sciences, Poznan, Poland.,Polish Society of Medical Simulation, Slupca, Poland
| | - Radoslaw Zalewski
- Department of Medical Rescue, Poznan University of Medical Sciences, Poznan, Poland.,Polish Society of Medical Simulation, Slupca, Poland
| | - Marcin Ligowski
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Wielkopolskie, Poland
| | - Ewa Goszczynska
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Wielkopolskie, Poland
| | | | - Marek Grygier
- First Department of Cardiology, Poznan University of Medical Sciences, Poznan, Wielkopolskie, Poland
| | - Maciej Lesiak
- First Department of Cardiology, Poznan University of Medical Sciences, Poznan, Wielkopolskie, Poland
| | - Marek Jemielity
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Wielkopolskie, Poland
| | - Bartłomiej Perek
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Wielkopolskie, Poland
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22
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Oi M, Maruhashi T, Yamamoto D, Kurihara Y, Koizumi H, Asari Y. Intravascular treatment for ruptured facial artery aneurysm via percutaneous cardiopulmonary support device: A case report. Clin Case Rep 2020; 8:1202-1205. [PMID: 32695357 PMCID: PMC7364082 DOI: 10.1002/ccr3.2869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/11/2020] [Accepted: 03/20/2020] [Indexed: 11/15/2022] Open
Abstract
Even in cases of cardiac arrest caused by hemorrhagic shock, when reliable control of the bleeding source is possible, ECPR may be an effective treatment option if anticoagulant therapy is well-managed and is withdrawn early.
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Affiliation(s)
- Marina Oi
- Department of Emergency and Critical Care MedicineKitasato University School of MedicineSagamiharaJapan
| | - Takaaki Maruhashi
- Department of Emergency and Critical Care MedicineKitasato University School of MedicineSagamiharaJapan
| | - Daisuke Yamamoto
- Department of NeurosurgeryKitasato University School of MedicineSagamiharaJapan
| | - Yutaro Kurihara
- Department of Emergency and Critical Care MedicineKitasato University School of MedicineSagamiharaJapan
| | - Hiroyuki Koizumi
- Department of NeurosurgeryKitasato University School of MedicineSagamiharaJapan
| | - Yasushi Asari
- Department of Emergency and Critical Care MedicineKitasato University School of MedicineSagamiharaJapan
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23
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Watanabe M, Matsuyama T, Morita S, Ehara N, Miyamae N, Okada Y, Jo T, Sumida Y, Okada N, Nozawa M, Tsuruoka A, Fujimoto Y, Okumura Y, Kitamura T, Ohta B. Impact of rewarming rate on the mortality of patients with accidental hypothermia: analysis of data from the J-Point registry. Scand J Trauma Resusc Emerg Med 2019; 27:105. [PMID: 31771645 PMCID: PMC6880476 DOI: 10.1186/s13049-019-0684-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 11/11/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Accidental hypothermia (AH) is defined as an involuntary decrease in core body temperature to < 35 °C. The management of AH has been progressing over the last few decades, and numerous techniques for rewarming have been validated. However, little is known about the association between rewarming rate (RR) and mortality in patients with AH. METHOD This was a multicentre chart review study of patients with AH visiting the emergency department of 12 institutions in Japan from April 2011 to March 2016 (Japanese accidental hypothermia network registry, J-Point registry). We retrospectively registered patients using the International Classification of Diseases, Tenth Revision code T68: 'hypothermia'. We excluded patients whose body temperatures were unknown or ≥ 35 °C, who could not be rewarmed, whose rewarmed temperature or rewarming time was unknown, those aged < 18 years, or who or whose family members had refused to join the registry. RR was calculated based on the body temperature on arrival at the hospital, time of arrival at the hospital, the documented temperature during rewarming, and time of the temperature documentation. RR was classified into the following five groups: ≥2.0 °C/h, 1.5-< 2.0 °C/h, 1.0-< 1.5 °C/h, 0.5-< 1.0 °C/h, and < 0.5 °C/h. The primary outcome of this study was in-hospital mortality. The association between RR and in-hospital mortality was evaluated using multivariate logistic regression analysis. RESULT During the study, 572 patients were registered in the J-Point registry, and 481 patients were included in the analysis. The median body temperature on arrival to the hospital was 30.7 °C (interquartile range [IQR], 28.2 °C-32.4 °C), and the median RR was 0.85 °C/h (IQR, 0.53 °C/h-1.31 °C/h). The in-hospital mortality rates were 19.3% (11/57), 11.1% (4/36), 14.4% (15/104), 20.1% (35/175), and 34.9% (38/109) in the ≥2.0 °C/h, 1.5-< 2.0 °C/h, 1.0-< 1.5 °C/h, 0.5-< 1.0 °C/h, and < 0.5 °C/h groups, respectively. Multivariate regression analysis revealed that in-hospital mortality rate increased with each 0.5 °C/h decrease in RR (adjusted odds ratio, 1.49; 95% confidence interval, 1.15-1.94; Ptrend < 0.01). CONCLUSION This study showed that slower RR is independently associated with in-hospital mortality.
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Affiliation(s)
- Makoto Watanabe
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan.
| | - Sachiko Morita
- Senri Critical Care Medical Center, Saiseikai Senri Hospital, Suita, Japan
| | - Naoki Ehara
- Department of Emergency, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Nobuyoshi Miyamae
- Department of Emergency Medicine, Rakuwa-kai Otowa Hospital, Kyoto, Japan
| | - Yohei Okada
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Society Kyoto Daini Red Cross Hospital, Kyoto, Japan
| | - Takaaki Jo
- Department of Emergency Medicine, Uji-Tokushukai Medical Center, Uji, Japan
| | - Yasuyuki Sumida
- Department of Emergency Medicine, North Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nobunaga Okada
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan.,Department of Emergency and Critical Care Medicine, National Hospital Organization, Kyoto Medical Centre, Kyoto, Japan
| | - Masahiro Nozawa
- Department of Emergency and Critical Care Medicine, Saiseikai Shiga Hospital, Ritto, Japan
| | - Ayumu Tsuruoka
- Department of Emergency and Critical Care Medicine, Kidney and Cardiovascular Center, Kyoto Min-iren Chuo Hospital, Kyoto, Japan.,Emergency and Critical Care Medical Center, Osaka City General Hospital, Osaka, Japan
| | - Yoshihiro Fujimoto
- Department of Emergency, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Yoshiki Okumura
- Department of Emergency Medicine, Fukuchiyama City Hospital, Fukuchiyama, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Bon Ohta
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan
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24
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Ohbe H, Isogai S, Jo T, Matsui H, Fushimi K, Yasunaga H. Extracorporeal membrane oxygenation improves outcomes of accidental hypothermia without vital signs: A nationwide observational study. Resuscitation 2019; 144:27-32. [DOI: 10.1016/j.resuscitation.2019.08.041] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 08/17/2019] [Accepted: 08/25/2019] [Indexed: 10/26/2022]
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25
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Murakami T, Yoshida T, Kurokochi A, Takamatsu K, Teranishi Y, Shigeta K, Tamaki S, Morita S, Mizuno R, Oya M. Accidental Hypothermia Treated by Hemodialysis in the Acute Phase: Three Case Reports and a Review of the Literature. Intern Med 2019; 58:2743-2748. [PMID: 31178478 PMCID: PMC6794177 DOI: 10.2169/internalmedicine.1945-18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Accidental hypothermia is defined as a core body temperature <35°C. Even with the use of multiple active rewarming methods, it has a high mortality rate. No standard treatment strategy for moderate or severe hypothermia in the absence of cardiac arrest has yet been established. We herein report three patients with severe or moderate accidental hypothermia who were treated by hemodialysis in the acute phase. This case report with a literature review describes the usefulness of hemodialysis for the treatment of moderate and severe accidental hypothermia without cardiac arrest.
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Affiliation(s)
| | - Tadashi Yoshida
- Apheresis and Dialysis Center, Keio University School of Medicine, Japan
| | - Arata Kurokochi
- Department of Internal Medicine, Keio University School of Medicine, Japan
| | | | - Yu Teranishi
- Department of Urology, Keio University School of Medicine, Japan
| | - Keisuke Shigeta
- Department of Urology, Keio University School of Medicine, Japan
| | - Satoshi Tamaki
- Department of Urology, Keio University School of Medicine, Japan
- Apheresis and Dialysis Center, Keio University School of Medicine, Japan
| | - Shinya Morita
- Department of Urology, Keio University School of Medicine, Japan
- Apheresis and Dialysis Center, Keio University School of Medicine, Japan
| | - Ryuichi Mizuno
- Department of Urology, Keio University School of Medicine, Japan
| | - Mototsugu Oya
- Department of Urology, Keio University School of Medicine, Japan
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26
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Ting DK, Brown DJA. Use of extracorporeal life support for active rewarming in a hypothermic, nonarrested patient with multiple trauma. CMAJ 2019; 190:E718-E721. [PMID: 29891476 DOI: 10.1503/cmaj.180117] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Daniel K Ting
- Department of Emergency Medicine (Ting), University of British Columbia, Kelowna, BC; Department of Emergency Medicine (Brown), University of British Columbia, Vancouver BC
| | - Douglas J A Brown
- Department of Emergency Medicine (Ting), University of British Columbia, Kelowna, BC; Department of Emergency Medicine (Brown), University of British Columbia, Vancouver BC
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27
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Balik M, Porizka M, Matousek V, Brestovansky P, Svobodova E, Flaksa M, Rulisek J, Mlejnsky F, Hodkova G, Grus T, Vobruba V, Belohlavek J. Management of accidental hypothermia: an established extracorporeal membrane oxygenation centre experience. Perfusion 2019; 34:74-81. [DOI: 10.1177/0267659119830551] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Data on management of severe accidental hypothermia published from an established high-volume extracorporeal membrane oxygenation centre are scarce. Methods: A total of 28 patients with intravesical temperature lower than 28°C on admission were either treated with veno-arterial extracorporeal membrane oxygenation or rewarmed conservatively. Results: A total of 10 patients rewarmed on veno-arterial extracorporeal membrane oxygenation (age: 37 ± 12.6 years) and 18 conservatively (age: 55.2 ± 11.2 years) were collected over a course of 5 years. The dominant cause was alcohol intoxication with exposure to cold (39%), 12 patients were resuscitated prior to admission. The admission temperature in the extracorporeal membrane oxygenation group (23.8 ± 2.6°C) was lower than in the non–extracorporeal membrane oxygenation group (26.0 ± 1.5°C, p = 0.01). The peripheral percutaneous veno-arterial extracorporeal membrane oxygenation was always cannulated in malignant arrhythmias causing refractory cardiac arrest. The typical extracorporeal membrane oxygenation blood flow was 3-4 L/minute and sweep gas flow 2 L/minute, the median extracorporeal membrane oxygenation duration was 48.3 (28.1-86.7) hours. The median rates of rewarming did not differ (0.41 (0.35-0.7)°C/hour in extracorporeal membrane oxygenation and 0.77 (0.54-0.98)°C/hour in non–extracorporeal membrane oxygenation, p = 0.46) as well as the admission arterial lactate, pH and potassium. Their development was not different between the groups except for higher pH between the third and ninth hour of rewarming in the extracorporeal membrane oxygenation group. The hospital mortality was 10% in the extracorporeal membrane oxygenation group and 11.1% in the non–extracorporeal membrane oxygenation group with the median last Glasgow Coma Scale 15 and Cerebral Performance Score 1. Conclusion: Veno-arterial extracorporeal membrane oxygenation for severe hypothermia shows promising outcome data collected in an extracorporeal membrane oxygenation/extracorporeal cardiopulmonary resuscitation centre located in a European urban area. Except for presence of refractory cardiac arrest, the established hypothermia-related prognostic indicators did not differ between patients in need for extracorporeal membrane oxygenation and those rewarmed without extracorporeal membrane oxygenation.
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Affiliation(s)
- Martin Balik
- Department of Anaesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Michal Porizka
- Department of Anaesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Vojtech Matousek
- Department of Anaesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Petr Brestovansky
- Department of Anaesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Eva Svobodova
- Department of Anaesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Marek Flaksa
- Department of Anaesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Jan Rulisek
- Department of Anaesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Frantisek Mlejnsky
- Perfusion Unit, Department of Cardiovascular Surgery, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Gabriela Hodkova
- Perfusion Unit, Department of Cardiovascular Surgery, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Tomas Grus
- Department of Cardiovascular Surgery, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Vaclav Vobruba
- Department of Pediatrics, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Jan Belohlavek
- 2nd Department of Internal Medicine – Department of Cardiovascular Medicine, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
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Avellanas Chavala ML, Ayala Gallardo M, Soteras Martínez Í, Subirats Bayego E. Management of accidental hypothermia: A narrative review. Med Intensiva 2019; 43:556-568. [PMID: 30683520 DOI: 10.1016/j.medin.2018.11.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 11/16/2018] [Accepted: 11/24/2018] [Indexed: 01/25/2023]
Abstract
A narrative review is presented on the diagnosis, treatment and management of accidental hypothermia. Although all these processes form a continuum, for descriptive purposes in this manuscript the recommendations are organized into the prehospital and in-hospital settings. At prehospital level, it is advised to: a) perform high-quality cardiopulmonary resuscitation for cardiac arrest patients, regardless of body temperature; b) establish measures to minimize further cooling; c) initiate rewarming; d) prevent rescue collapse and continued cooling (afterdrop); and (e) select the appropriate hospital based on the clinical and hemodynamic situation of the patient. Extracorporeal life support has revolutionized rewarming of the hemodynamically unstable victim or patients suffering cardiac arrest, with survival rates of up to 100%. The new evidences indicate that the management of accidental hypothermia has evolved favorably, with substantial improvement of the final outcomes.
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Affiliation(s)
- M L Avellanas Chavala
- Unidad de Medicina Intensiva, Hospital General San Jorge, Huesca, España; Unidad Funcional de Congelaciones y Patologías de Montaña, Hospital General San Jorge, Huesca, España; Máster en Medicina de Urgencia y Rescate en Montaña, Universidad de Zaragoza, Zaragoza, España.
| | | | - Í Soteras Martínez
- Servicio de Urgencias; Hospital de Cerdanya, Puigcerdà, Gerona, España; Facultad de Medicina, Universidad de Girona, Gerona, España
| | - E Subirats Bayego
- Hospital de Cerdanya, Puigcerdà, Gerona, España; Facultad de Medicina, Universidad de Girona, Gerona, España
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Mazur P, Kosiński S, Podsiadło P, Jarosz A, Przybylski R, Litiwnowicz R, Piątek J, Konstanty-Kalandyk J, Gałązkowski R, Darocha T. Extracorporeal membrane oxygenation for accidental deep hypothermia-current challenges and future perspectives. Ann Cardiothorac Surg 2019; 8:137-142. [PMID: 30854323 DOI: 10.21037/acs.2018.10.12] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The incidence of accidental hypothermia (core temperature ≤35 °C) is difficult to estimate, as the affected population is heterogeneous. Both temperature and clinical presentation should be considered while determining severity, which is difficult in a prehospital setting. Extracorporeal rewarming is advocated for all Swiss Staging System class IV (hypothermic cardiac arrest) and class III (hypothermic cardiac instability) patients. Veno-arterial extracorporeal membrane oxygenation (ECMO) is the method of choice, as it not only allows a gradual, controlled increase of core body temperature, but also provides respiratory and hemodynamic support during the unstable period of rewarming and reperfusion. This poses difficulties with the coordination of patient management, as usually only cardiac referral centers can deliver such advanced treatment. Further special considerations apply to subgroups of patients, including drowning or avalanche victims. The principle of ECMO implantation in severely hypothermic patients is no different from any other indication, although establishing vascular access in a timely manner during ongoing resuscitation and maintaining adequate flow may require modification of the operating technique, as well as aggressive fluid resuscitation. Further studies are needed in order to determine the optimal rewarming rate and flow that would favor brain and lung protection. Recent analysis shows an overall survival rate of 40.3%, while additional prognostic factors are being sought for determining those patients in whom the treatment is futile. New cannulas, along with ready-to-use ECMO sets, are being developed that would enable easy, safe and efficient out-reach ECMO implantation, thus shortening resuscitation times. Moreover, national guidelines for the management of accidental hypothermia are needed in order that all patients that would benefit from extracorporeal rewarming would be provided with such treatment. In this perspective article, we discuss burning problems in ECMO therapy in hypothermic patients, outlining the important research goals to improve the outcomes.
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Affiliation(s)
- Piotr Mazur
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Cracow, Poland.,Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland
| | - Sylweriusz Kosiński
- Faculty of Health Sciences, Jagiellonian University Medical College, Cracow, Poland
| | - Paweł Podsiadło
- Emergency Medicine Department, Jan Kochanowski University, Kielce, Poland
| | - Anna Jarosz
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Cracow, Poland
| | - Roman Przybylski
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Cracow, Poland
| | - Radosław Litiwnowicz
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Cracow, Poland
| | - Jacek Piątek
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Cracow, Poland
| | - Janusz Konstanty-Kalandyk
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Cracow, Poland.,Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland
| | - Robert Gałązkowski
- Department of Emergency Medical Services, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Darocha
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Silesia, Katowice, Poland
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30
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Kosiński S, Darocha T, Czerw A, Paal P, Pasquier M, Krawczyk P, Drwiła R, Gałązkowski R. Cost-utility of extracorporeal membrane oxygenation rewarming in accidentally hypothermic patients-A single-centre retrospective study. Acta Anaesthesiol Scand 2018; 62:1105-1111. [PMID: 29687446 DOI: 10.1111/aas.13137] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 01/22/2018] [Accepted: 04/01/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has become the treatment of choice for severely hypothermic patients in cardiac arrest or acute cardiac failure. Highly specialized ECMO centres have been established, however, no centre has ever reported the costs of extracorporeal rewarming. The aim of this study was to assess the costs of the treatment of patients in Swiss Stage III and IV rewarmed with veno-arterial ECMO. METHODS A retrospective exploratory cohort study analysed twenty-nine consecutive patients treated for hypothermia in the Severe Accidental Hypothermia Centre in Cracow, Poland. The main outcome parameters were the overall and specific costs of the ICU treatment of patients rewarmed with veno-arterial ECMO. The secondary outcome parameter was cost utility, determined by the costs involved for every year of life gained. Costs were processed using the bottom-up method and classified into six categories. Survivors were followed up after 1 year. RESULTS The mean cost of VA-ECMO was $5133 USD, which equalled 35% of all ICU expenditures ($14 668 USD). One year after discharge, 13 of 29 patients were still alive (45%). The overall gain of life of the thirteen 1-year survivors was 28 years, while the mean cost related to treatment with VA-ECMO for each year of life gained was 1138 USD. CONCLUSIONS In this study, the costs of VA-ECMO rewarming and intensive care treatment per patient were substantially lower than in other studies reporting ECMO and intensive care treatment of other causes.
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Affiliation(s)
- S Kosiński
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Hospital, Zakopane, Poland
| | - T Darocha
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Silesia, Katowice, Poland
| | - A Czerw
- Department of Public Health, Medical University of Warsaw, Warsaw, Poland
- National Institute of Public Health - National Institute of Hygiene, Warsaw, Poland
| | - P Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitaller Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
- Barts Heart Centre, William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - M Pasquier
- Emergency Service, University Hospital Centre, Lausanne, Switzerland
| | - P Krawczyk
- Department of Anaesthesiology and Intensive Care, John Paul II Hospital, Medical College of Jagiellonian University, Krakow, Poland
| | - R Drwiła
- Department of Anaesthesiology and Intensive Care, John Paul II Hospital, Medical College of Jagiellonian University, Krakow, Poland
| | - R Gałązkowski
- Department of Emergency Medical Services, Medical University of Warsaw, Warsaw, Poland
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31
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Paal P, Rauch S. Indoor accidental hypothermia in the elderly: an emerging lethal entity in the 21st century. Emerg Med J 2018; 35:667-668. [PMID: 30158146 DOI: 10.1136/emermed-2018-207804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 08/14/2018] [Accepted: 08/15/2018] [Indexed: 11/03/2022]
Affiliation(s)
- Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital Teaching Hospital of the Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Simon Rauch
- Institute of Mountain Emergency Medicine, EURAC research, Bolzano, Italy.,Department of Anaesthesiology, University Hospital LMU, Munich, Germany.,Department of Sports Science, Medical Section, University of Innsbruck, Innsbruck, Austria
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32
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Saczkowski RS, Brown DJ, Abu-Laban RB, Fradet G, Schulze CJ, Kuzak ND. Prediction and risk stratification of survival in accidental hypothermia requiring extracorporeal life support: An individual patient data meta-analysis. Resuscitation 2018; 127:51-57. [DOI: 10.1016/j.resuscitation.2018.03.028] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 03/16/2018] [Accepted: 03/20/2018] [Indexed: 10/17/2022]
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33
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Singer B, Reynolds JC, Lockey DJ, O'Brien B. Pre-hospital extra-corporeal cardiopulmonary resuscitation. Scand J Trauma Resusc Emerg Med 2018; 26:21. [PMID: 29587810 PMCID: PMC5870373 DOI: 10.1186/s13049-018-0489-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 03/14/2018] [Indexed: 11/10/2022] Open
Abstract
Survival from out-of-hospital cardiac arrest (OHCA) has remained low despite advances in resuscitation science. Hospital-based extra-corporeal cardiopulmonary resuscitation (ECPR) is a novel use of an established technology that provides greater blood flow and oxygen delivery during cardiac arrest than closed chest compressions. Hospital-based ECPR is currently offered to selected OHCA patients in specialized centres. The interval between collapse and restoration of circulation is inversely associated with good clinical outcomes after ECPR. Pre-hospital delivery of ECPR concurrent with conventional resuscitation is one approach to shortening this interval and improving outcomes after OHCA. This article examines the background and rationale for pre-hospital ECPR; summarises the findings of a literature search for published evidence; and considers candidate selection, logistics, and complications for this complex intervention.
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Affiliation(s)
- Ben Singer
- St Bartholomew's Hospital and Barts Heart Centre, Barts Health NHS Trust, London, UK. .,The Blizard Institute, Queen Mary University, London, UK. .,William Harvey Research Institute, Queen Mary University, London, UK.
| | - Joshua C Reynolds
- Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - David J Lockey
- The Blizard Institute, Queen Mary University, London, UK
| | - Ben O'Brien
- St Bartholomew's Hospital and Barts Heart Centre, Barts Health NHS Trust, London, UK.,William Harvey Research Institute, Queen Mary University, London, UK.,Outcomes Research Consortium, Cleveland, OH, USA
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34
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Abstract
Accidental hypothermia causes profound changes to the body's physiology. After an initial burst of agitation (e.g., 36-37°C), vital functions will slow down with further cooling, until they vanish (e.g. <20-25°C). Thus, a deeply hypothermic person may appear dead, but may still be able to be resuscitated if treated correctly. The hospital use of minimally invasive rewarming for nonarrested, otherwise healthy patients with primary hypothermia and stable vital signs has the potential to substantially decrease morbidity and mortality for these patients. Extracorporeal life support (ECLS) has revolutionized the management of hypothermic cardiac arrest, with survival rates approaching 100%. Hypothermic patients with risk factors for imminent cardiac arrest (i.e., temperature <28°C, ventricular arrhythmia, systolic blood pressure <90 mmHg), and those who have already arrested, should be transferred directly to an ECLS center. Cardiac arrest patients should receive continuous cardiopulmonary resuscitation (CPR) during transfer. If prolonged transport is required or terrain is difficult, mechanic CPR can be helpful. Intermittent CPR may be appropriate in hypothermic arrest when continuous CPR is impossible. Modern postresuscitation care should be implemented following hypothermic arrest. Structured protocols should be in place to optimize prehospital triage, transport, and treatment as well as in-hospital management, including detailed criteria and protocols for the use of ECLS and postresuscitation care.
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Affiliation(s)
- Peter Paal
- Department of Anaesthesia and Intensive Care Medicine, Hospitallers Brothers Hospital, Salzburg, Austria.
| | - Hermann Brugger
- Institute of Mountain Emergency Medicine, EURAC Research, Bolzano, Italy
| | - Giacomo Strapazzon
- Institute of Mountain Emergency Medicine, EURAC Research, Bolzano, Italy
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35
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Podsiadło P, Darocha T, Kosiński S, Sałapa K, Ziętkiewicz M, Sanak T, Turner R, Brugger H. Severe Hypothermia Management in Mountain Rescue: A Survey Study. High Alt Med Biol 2017; 18:411-416. [PMID: 28968162 PMCID: PMC5743028 DOI: 10.1089/ham.2017.0090] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Podsiadło, Paweł, Tomasz Darocha, Sylweriusz Kosiński, Kinga Sałapa, Mirosław Ziętkiewicz, Tomasz Sanak, Rachel Turner, and Hermann Brugger. Severe hypothermia management in mountain rescue: A survey study. High Alt Med Biol 18:411–416, 2017. Introduction: Severe hypothermia is a rare but demanding medical emergency. Although mortality is high, if well managed, the neurological outcome of survivors can be excellent. The aim of the study was to assess whether mountain rescue teams (MRTs) are able to meet the guidelines in the management of severe hypothermia, regarding their equipment and procedures. Methods: Between August and December 2016, an online questionnaire, with 24 questions to be completed using Google Forms, was sent to 123 MRTs in 27 countries. Results: Twenty-eight MRTs from 10 countries returned the completed questionnaire. Seventy-five percent of MRTs reportedly provide advanced life support (ALS) on-site and 89% are regularly trained in hypothermia management. Thirty-two percent of MRTs transport hypothermic patients in cardiac arrest to the nearest hospital instead of an Extracorporeal Life Support facility; 39% are equipped with mechanical chest compression devices; 36% measure core body temperature on-site and no MRT is equipped with a device to measure serum potassium concentration on-site in avalanche victims. Conclusions: Most MRTs are regularly trained in the treatment of severe hypothermia and provide ALS. The majority are not equipped to follow standard procedural guidelines for the treatment of severely hypothermic patients, especially with cardiac arrest. However, the low response rate—23% (28/123)—could have induced a bias.
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Affiliation(s)
- Paweł Podsiadło
- 1 Polish Society for Mountain Medicine and Rescue , Szczyrk, Poland .,2 Polish Medical Air Rescue , Warsaw, Poland
| | - Tomasz Darocha
- 2 Polish Medical Air Rescue , Warsaw, Poland .,3 Department of Anaesthesiology and Intensive Care, Medical University of Silesia , Katowice, Poland
| | - Sylweriusz Kosiński
- 4 Department of Anesthesiology and Intensive Care, Pulmonary Hospital , Zakopane, Poland .,5 Tatra Mountain Rescue Service , Zakopane, Poland
| | - Kinga Sałapa
- 6 Department of Bioinformatics and Telemedicine, Jagiellonian University Medical College , Kraków, Poland
| | - Mirosław Ziętkiewicz
- 7 Department of Anaesthesiology and Intensive Care, Jagiellonian University Medical College , Kraków, Poland
| | - Tomasz Sanak
- 8 Department of Disaster Medicine and Emergency Care, Jagiellonian University Medical College , Kraków, Poland
| | - Rachel Turner
- 9 EURAC Institute of Mountain Emergency Medicine , Bolzano, Italy
| | - Hermann Brugger
- 9 EURAC Institute of Mountain Emergency Medicine , Bolzano, Italy .,10 Medical University of Innsbruck , Innsbruck, Austria
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36
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Clinical course and prognostic factors of patients in severe accidental hypothermia with circulatory instability rewarmed with veno-arterial ECMO - an observational case series study. Scand J Trauma Resusc Emerg Med 2017; 25:46. [PMID: 28464863 PMCID: PMC5414327 DOI: 10.1186/s13049-017-0388-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 04/25/2017] [Indexed: 11/10/2022] Open
Abstract
Background Recently, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has become the rewarming treatment of choice in hypothermic cardiac arrest. The detailed indications for extracorporeal rewarming in non-arrested, severely hypothermic patients with circulatory instability have not been established yet. The primary purpose of the study was a preliminary analysis of all aspects of the treatment process, as well as initial identification of mortality risk factors within the group of severely hypothermic patients, treated with arteriovenous extracorporeal membrane oxygenation (VA-ECMO). The secondary aim of the study was to evaluate efficacy of VA-ECMO in initial 6-h period of treatment Methods From July 2013 to June 2016, thirty one hypothermic patients were accepted for extracorporeal rewarming at Severe Accidental Hypothermia Center, Cracow. Thirteen patients were identified with circulatory instability and were enrolled in the study. The evaluation took into account patients’ condition on admission, the course of therapy, and changes in laboratory and hemodynamic parameters. Results Nine out of 13 analyzed patients survived (69%). Patients who died were older, had lower both systolic and diastolic pressure, and had increased creatinine an potassium levels on admission. In surviving patients, arterial blood gases parameters (pH, BE, HCO3) and lactates would normalize more quickly. Their potassium level was lower on admission as well. The values of the core temperature on admission were comparable. Although normothermia was achieved in 92% of patients, none of them had been weaned-off VA-ECMO in the first 6 h of treatment. Discussion and Conclusions In our preliminary study more pronounced markers of cardiocirculatory instability and organ hypoperfusion were observed in non-survivors. Future studies on indications to extracorporeal rewarming in severely hypothermic, non-arrested patients should focus on the extent of hemodynamic disturbances. Short term (<6 h) treatment in severe hypothermic, non-arrested patients seems to be not clinically appropriate.
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Hatam EM, Cameron A, Petsikas D, Messenger D, Ball IM. A Case of Severe Accidental Hypothermia Successfully Treated with Cardiopulmonary Bypass. Clin Pract Cases Emerg Med 2017; 1:33-36. [PMID: 29849406 PMCID: PMC5965436 DOI: 10.5811/cpcem.2016.11.32919] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 10/24/2016] [Accepted: 11/12/2016] [Indexed: 11/21/2022] Open
Abstract
After missing for seven days, a 34-year-old female was found with a rectal temperature of 19.8oC. Instead of attempting aggressive rewarming in the emergency department she was directly transferred to the operating room for extracorporeal rewarming. She received cardiopulmonary bypass (CPB) for 66 minutes at an initial warming rate of 12oC/ hour and warmed to 36.2oC. Her postoperative course was complicated by sepsis, which eventually led to bilateral below-knee amputations after refusing antibiotics. She was discharged 22 days after admission, with full neurologic recovery. This remarkable case highlights the emerging role of CPB as the definitive therapy for severe accidental hypothermia.
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Affiliation(s)
- Erfun M Hatam
- Western University, Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Andrew Cameron
- University of Toronto, Department of Emergency Medicine, Toronto, Ontario, Canada
| | - Dimitri Petsikas
- Queen's University, Kingston General Hospital, Division of Cardiac Surgery, Kingston, Ontario, Canada
| | - David Messenger
- Queen's University, Department of Emergency Medicine & Critical Care Medicine, Kingston, Ontario, Canada
| | - Ian M Ball
- Western University, Department of Epidemiology and Biostatistics, Division of Critical Care Medicine, London, Ontario, Canada
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38
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Outcome After Rewarming From Accidental Hypothermia by Use of Extracorporeal Circulation. Ann Thorac Surg 2016; 103:920-925. [PMID: 27692232 DOI: 10.1016/j.athoracsur.2016.06.093] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 06/20/2016] [Accepted: 06/27/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Accidental hypothermia with arrested circulation remains a condition associated with high mortality. In our institution, extracorporeal circulation (ECC) rewarming has been the cornerstone in treating such patients since 1987. We here explore characteristics and outcomes of this treatment, to identify significant merits and challenges from 3 decades of experience in ECC rewarming. METHODS Sixty-nine patients rewarmed by ECC during the period from December 1987 to December 2015 were analyzed. One patient was excluded from the analyses because of combined traumatic cerebral injury. The analysis was focused on patient characteristics, treatment procedures, and outcomes were focused. Survivors were evaluated according to the cerebral performance categories scale. Simple statistics with nonparametric tests and χ2 tests were used. Median value and range are reported. RESULTS Median age was 30 years (minimum 1.5, maximum 76), and the cause of accidental hypothermia was cold exposure (27.9%), avalanche (5.9%), and immersion/submersion accidents (66.2%). Eighteen patients survived (26.5%). The survival rate did not improve during the years. Survivors had lower serum potassium (p = 0.002), higher pH (p = 0.03), lower core temperature (p = 0.02), and shorter cardiopulmonary resuscitation time (p = 0.001), but ranges were wide. Although suspected primary hypoxia and hypothermia were associated with lower survival, we observed a 10.5% survival of these victims. Sixteen survivors had good outcome (cerebral performance category 1 or 2), whereas 2 patients with suspected primary hypoxia survived with severe cerebral disability (cerebral performance category 3). CONCLUSIONS Despite extended experience with ECC rewarming, improved handling strategies, and intensive care, no overall improvement in survival was observed. Good outcome was observed even among patients with a dismal prognosis.
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39
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Paal P, Gordon L, Strapazzon G, Brodmann Maeder M, Putzer G, Walpoth B, Wanscher M, Brown D, Holzer M, Broessner G, Brugger H. Accidental hypothermia-an update : The content of this review is endorsed by the International Commission for Mountain Emergency Medicine (ICAR MEDCOM). Scand J Trauma Resusc Emerg Med 2016; 24:111. [PMID: 27633781 PMCID: PMC5025630 DOI: 10.1186/s13049-016-0303-7] [Citation(s) in RCA: 163] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 09/07/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND This paper provides an up-to-date review of the management and outcome of accidental hypothermia patients with and without cardiac arrest. METHODS The authors reviewed the relevant literature in their specialist field. Summaries were merged, discussed and approved to produce this narrative review. RESULTS The hospital use of minimally-invasive rewarming for non-arrested, otherwise healthy, patients with primary hypothermia and stable vital signs has the potential to substantially decrease morbidity and mortality for these patients. Extracorporeal life support (ECLS) has revolutionised the management of hypothermic cardiac arrest, with survival rates approaching 100 % in some cases. Hypothermic patients with risk factors for imminent cardiac arrest (temperature <28 °C, ventricular arrhythmia, systolic blood pressure <90 mmHg), and those who have already arrested, should be transferred directly to an ECLS-centre. Cardiac arrest patients should receive continuous cardiopulmonary resuscitation (CPR) during transfer. If prolonged transport is required or terrain is difficult, mechanical CPR can be helpful. Delayed or intermittent CPR may be appropriate in hypothermic arrest when continuous CPR is impossible. Modern post-resuscitation care should be implemented following hypothermic arrest. Structured protocols should be in place to optimise pre-hospital triage, transport and treatment as well as in-hospital management, including detailed criteria and protocols for the use of ECLS and post-resuscitation care. CONCLUSIONS Based on new evidence, additional clinical experience and clearer management guidelines and documentation, the treatment of accidental hypothermia has been refined. ECLS has substantially improved survival and is the treatment of choice in the patient with unstable circulation or cardiac arrest.
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Affiliation(s)
- Peter Paal
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck University Hospital, Anichstr. 35, 6020 Innsbruck, Austria
- Barts Heart Centre, St Bartholomew’s Hospital, West Smithfield, Barts Health NHS Trust, Queen Mary University of London, KGV Building, Office 10, 1st floor, West Smithfield, London, EC1A 7BE UK
- International Commission of Mountain Emergency Medicine (ICAR MEDCOM), Kloten, Switzerland
| | - Les Gordon
- Department of Anaesthesia, University hospitals, Morecambe Bay Trust, Lancaster, UK
- Langdale Ambleside Mountain Rescue Team, Ambleside, UK
| | - Giacomo Strapazzon
- International Commission of Mountain Emergency Medicine (ICAR MEDCOM), Kloten, Switzerland
- Institute of Mountain Emergency Medicine, EURAC research, Drususallee 1, Bozen/Bolzano, Italy
| | - Monika Brodmann Maeder
- International Commission of Mountain Emergency Medicine (ICAR MEDCOM), Kloten, Switzerland
- Institute of Mountain Emergency Medicine, EURAC research, Drususallee 1, Bozen/Bolzano, Italy
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Gabriel Putzer
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck University Hospital, Anichstr. 35, 6020 Innsbruck, Austria
| | - Beat Walpoth
- Department of Surgery, Cardiovascular Research, Service of Cardiovascular Surgery, University Hospital Geneva, Geneva, Switzerland
| | - Michael Wanscher
- Department of Cardiothoracic Anaesthesia and Intensive Care 4142, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Doug Brown
- International Commission of Mountain Emergency Medicine (ICAR MEDCOM), Kloten, Switzerland
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
| | - Michael Holzer
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Gregor Broessner
- Department of Neurology, Neurologic Intensive Care Unit, Medical University of Innsbruck, Innsbruck, Austria
| | - Hermann Brugger
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck University Hospital, Anichstr. 35, 6020 Innsbruck, Austria
- Institute of Mountain Emergency Medicine, EURAC research, Drususallee 1, Bozen/Bolzano, Italy
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Jarosz A, Kosiński S, Darocha T, Paal P, Gałązkowski R, Hymczak H, Drwiła R. Problems and Pitfalls of Qualification for Extracorporeal Rewarming in Severe Accidental Hypothermia. J Cardiothorac Vasc Anesth 2016; 30:1693-1697. [PMID: 27727083 DOI: 10.1053/j.jvca.2016.05.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Indexed: 11/11/2022]
Abstract
OBJECTIVES When establishing the Severe Hypothermia Treatment Centre, certain problems and pitfalls regarding the qualification for extracorporeal rewarming were encountered. The authors shared their experience and opened a discussion with other centers that deal with severe, accidental hypothermia. DESIGN Retrospective analysis of medical records of all patients examined by the hypothermia coordinator. SETTING Patients consulted and treated by the Severe Hypothermia Treatment Centre. PARTICIPANTS Patients who underwent accidental hypothermia. INTERVENTIONS From July 2013 until January 2016, hypothermia coordinators at the Severe Hypothermia Treatment Centre examined the cases of 152 hypothermic patients. Of those cases, 127 patients were subjected to noninvasive rewarming in referral hospitals and 25 were accepted to the center for extracorporeal rewarming. MEASUREMENTS AND MAIN RESULTS Difficulties that deferred or delayed the implementation of extracorporeal membrane oxygen rewarming were identified and addressed, including low platelet/red blood count, intraperitoneal fluid of unknown origin, abnormal results of head computed tomography, extremes of age, bleeding from the external auditory meatus, inaccuracy of infrared-based thermometers, iatrogenic trauma to the femoral vessels, chronic/terminal comorbidities, poisonings, pregnancy, hypoglycemia, hemodynamic stability despite severe hypothermia, and decontamination protocol. CONCLUSIONS The problems discussed may delay the use of extracorporeal membrane oxygen rewarming in hypothermic patients but should not discourage medical teams from the implementation of extracorporeal rewarming. The prognosis for severe hypothermia is favorable, even with a long resuscitation time and low core temperatures.
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Affiliation(s)
- Anna Jarosz
- Department of Anaesthesiology and Intensive Care, John Paul II Hospital, Collegium Medicum, Jagiellonian University, Krakow, Poland.
| | - Sylweriusz Kosiński
- Department of Anaesthesiology and Intensive Care, Pulmonary Hospital and; Tatra Mountains Rescue Service, Zakopane, Poland
| | - Tomasz Darocha
- Department of Anaesthesiology and Intensive Care, John Paul II Hospital, Collegium Medicum, Jagiellonian University, Krakow, Poland; Polish Medical Air Rescue and
| | - Peter Paal
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Innsbruck, Innsbruck, Austria; Barts Heart Centre, St. Bartholomew's Hospital, Barts Health NHS Trust, Queen Mary University of London, London, United Kingdom; International Commission for Mountain Emergency Medicine (ICAR MEDCOM)
| | - Robert Gałązkowski
- Polish Medical Air Rescue and; Department of Emergency Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Hubert Hymczak
- Department of Anaesthesiology and Intensive Care, John Paul II Hospital, Collegium Medicum, Jagiellonian University, Krakow, Poland
| | - Rafał Drwiła
- Department of Anaesthesiology and Intensive Care, John Paul II Hospital, Collegium Medicum, Jagiellonian University, Krakow, Poland
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Aso S, Matsui H, Fushimi K, Yasunaga H. In-hospital mortality and successful weaning from venoarterial extracorporeal membrane oxygenation: analysis of 5,263 patients using a national inpatient database in Japan. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:80. [PMID: 27044572 PMCID: PMC4820970 DOI: 10.1186/s13054-016-1261-1] [Citation(s) in RCA: 113] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Accepted: 03/08/2016] [Indexed: 12/05/2022]
Abstract
Background The mortality rate of severely ill patients treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) remains unknown because of differences in patient background, clinical settings, and sample sizes between studies. We determined the in-hospital mortality of VA-ECMO patients and the proportion weaned from VA-ECMO using a national inpatient database in Japan. Methods Patients aged ≥19 years who received VA-ECMO during hospitalization for cardiogenic shock, pulmonary embolism, hypothermia, poisoning, or trauma between 1 July 2010 and 31 March 2013 were identified, using The Japanese Diagnosis Procedure Combination national inpatient database. Results The primary outcome was in-hospital mortality and the secondary outcome was the proportion weaned from VA-ECMO. A total of 5263 patients received VA-ECMO during the study period. The majority of patients had cardiogenic shock (n = 4,658). The number of patients weaned from VA-ECMO was 3389 (64.4 %) and in-hospital mortality after weaning from VA-ECMO was 1994 (37.9 %). In-hospital mortality without cardiac arrest in the cardiogenic shock group was significantly lower than that in patients with cardiac arrest (70.5 % vs. 77.1 %, p <0.001). In the multivariable logistic regression including multiple imputation, higher age and greater or smaller body mass index were significantly associated with in-hospital mortality, whereas hospital volume was not associated with such mortality. Conclusions The present nationwide study showed high mortality rates in patients who received VA-ECMO, and in particular in patients with cardiogenic shock and in patients with cardiac arrest. Weaning from VA-ECMO did not necessarily result in survival. Further studies are warranted to clarify risk-adjusted mortality of VA-ECMO using more detailed data on patient background.
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Affiliation(s)
- Shotaro Aso
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
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Patroniti N, Sangalli F, Avalli L. Post-cardiac arrest extracorporeal life support. Best Pract Res Clin Anaesthesiol 2015; 29:497-508. [DOI: 10.1016/j.bpa.2015.09.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 09/17/2015] [Accepted: 09/22/2015] [Indexed: 01/19/2023]
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Outcome after severe accidental hypothermia in the French Alps: A 10-year review. Resuscitation 2015; 93:118-23. [DOI: 10.1016/j.resuscitation.2015.06.013] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 06/08/2015] [Accepted: 06/11/2015] [Indexed: 11/21/2022]
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Dunne B, Christou E, Duff O, Merry C. Extracorporeal-Assisted Rewarming in the Management of Accidental Deep Hypothermic Cardiac Arrest. Heart Lung Circ 2014; 23:1029-35. [DOI: 10.1016/j.hlc.2014.06.011] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Revised: 06/11/2014] [Accepted: 06/12/2014] [Indexed: 10/25/2022]
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Abstracts from the 3rd innsbruck targeted temperature management symposium-a multidisciplinary conference september 21, 2013 vienna, austria. Ther Hypothermia Temp Manag 2014; 3:A1-A14. [PMID: 24834952 DOI: 10.1089/ther.2013.1517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Sawamoto K, Bird SB, Katayama Y, Maekawa K, Uemura S, Tanno K, Narimatsu E. Outcome from severe accidental hypothermia with cardiac arrest resuscitated with extracorporeal cardiopulmonary resuscitation. Am J Emerg Med 2014; 32:320-4. [DOI: 10.1016/j.ajem.2013.12.023] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 12/07/2013] [Accepted: 12/07/2013] [Indexed: 10/25/2022] Open
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Extracorporeal Membrane Oxygenation Strategy in Cardiac Arrest. Resuscitation 2014. [DOI: 10.1007/978-88-470-5507-0_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Paal P, Brown DJA, Brugger H, Boyd J. In hypothermic major trauma patients the appropriate hospital for damage control and rewarming may be life saving. Injury 2013; 44:1665. [PMID: 23856631 DOI: 10.1016/j.injury.2013.06.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 06/16/2013] [Indexed: 02/02/2023]
Affiliation(s)
- Peter Paal
- Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical University, Austria; International Commission of Mountain Emergency Medicine, ICAR MEDCOM, Poland.
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Resource use trends in extracorporeal membrane oxygenation in adults: an analysis of the Nationwide Inpatient Sample 1998-2009. J Thorac Cardiovasc Surg 2013; 148:416-21.e1. [PMID: 24183903 DOI: 10.1016/j.jtcvs.2013.09.033] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 09/02/2013] [Accepted: 09/17/2013] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The study objective was to determine whether significant trends over time have occurred in resource use associated with the use of extracorporeal membrane oxygenation in critically ill adults. METHODS All adult admissions involving extracorporeal membrane oxygenation were examined by using the Nationwide Inpatient Sample database (years 1998-2009). Trends in volume, outcome, and resource use (including hospital charges, length of stay, and charges per day) were analyzed. RESULTS An estimated total of 8753 admissions involved extracorporeal membrane oxygenation over the study period. Overall length of stay was 18.3 ± 1.3 days. Total hospital charges averaged $344,009 ± $30,707 per admission, with average charges per day of $40,588 ± $3099. Cumulative national charges for extracorporeal membrane oxygenation admissions increased significantly from $109.0 million in 1998 to $764.7 million in 2009 (P = .0016). Charges per patient and length of stay also increased significantly (P = .0032 and .0321, respectively). The increasing trend in the number of extracorporeal membrane oxygenation admissions during the study period was not statistically significant (P = .19). The post-cardiotomy group had more favorable outcomes and lower resource use. A shift was observed in the relative case-mix of extracorporeal membrane oxygenation admissions over the study period, with a relative decrease in the post-cardiotomy group and increases in the cardiogenic shock, respiratory failure, and lung transplant groups. CONCLUSIONS These results suggest that dramatic increases in resource use associated with extracorporeal membrane oxygenation are not solely the result of increased volume, but in part are due to a shift toward extracorporeal membrane oxygenation use in patient groups (other than in the post-cardiotomy setting) with greater resource use and worse outcomes.
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Sepehripour AH, Gupta S, Lall KS. When should cardiopulmonary bypass be used in the setting of severe hypothermic cardiac arrest? Interact Cardiovasc Thorac Surg 2013; 17:564-9. [PMID: 23702466 DOI: 10.1093/icvts/ivt208] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
A best evidence topic was written according to a structured protocol. The question addressed was regarding the indication and timing of the use of cardiopulmonary bypass (CPB), following severe hypothermic cardiac arrest. A total of 284 papers were found using the reported searches, of which nine represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Reported measures were survival, rewarming speed, incidence of arrhythmia during rewarming, resolution of full neurological function, long-term neurological function, evidence of damage on neurological imaging and venous metabolic parameters in hypothermic patients. The most recent of the best evidence studies, a retrospective comparative study of 68 patients, demonstrated CPB rewarming to be far superior to conventional methods of rewarming, with mortality rates of 15.8 and 53.3%, respectively. Another study of similar size, comparing CPB with extracorporeal membrane oxygenation (ECMO) for rewarming, revealed superior survival rates with ECMO, 75 vs 34%. A systematic review of 68 patients demonstrated an overall survival of 60%, and 80% of survivors returning to a previous level of activity. Two smaller observational studies reported survival rates of 73.1 and 45.5%, respectively. A retrospective study analysing long-term neurological outcomes of survivors reported normal history and physical examination in 93.3%, normal neurovascular ultrasound in 100%, normal neuropsychological findings in 93.3% and normal brain magnetic resonance imaging in 86.7%. A small comparative study demonstrated a significant survival benefit when CPB was preceded with emergency thoracotomy, internal cardiac massage and warm mediastinal irrigation compared with CPB alone. We conclude that, following deep hypothermic circulatory arrest, the urgent use of cardiopulmonary bypass is widely indicated for rewarming where it has been shown to provide good survival and neurological outcomes far superior in comparison with conventional methods of rewarming.
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Affiliation(s)
- Amir H Sepehripour
- Department of Cardiothoracic Surgery, St. Bartholomew's Hospital, London, UK.
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