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Lee D, Lee B, Jeung K, Jung Y. The association between serum free fatty acid levels and neurological outcomes in out-of-hospital cardiac arrest patients: A prospective observational study. Medicine (Baltimore) 2024; 103:e38772. [PMID: 38968533 PMCID: PMC11224856 DOI: 10.1097/md.0000000000038772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 06/10/2024] [Indexed: 07/07/2024] Open
Abstract
Free fatty acids (FFA) are a known risk factor in the development of sudden cardiac death. However, the relationship between FFA and the outcome of out-of-hospital cardiac arrest (OHCA) patients remains unclear. We aimed to examine the association between FFA and neurological outcomes in OHCA patients. This prospective observational study included adult (≥18 years) OHCA patients between February 2016 and December 2022. We measured serial FFA levels within 1 hour after ROSC and at 6, 12, 24, 48, and 72 hours after the return of spontaneous circulation (ROSC). The primary outcome was neurological outcome at 6 months. A poor neurological outcome was defined by cerebral performance categories 3, 4, and 5. A total of 147 patients were included. Of them, 104 (70.7%) had poor neurological outcomes, whereby the median FFA levels within 1 hour after ROSC (0.72 vs 1.01 mol/L), at 6 hours (1.19 vs 1.90 mol/L), 12 hours (1.20 vs 1.66 mol/L), and 24 hours (1.20 vs 1.95 mol/L) after ROSC were significantly lower than in good outcome group. The FFA levels at 6 hours (odds ratio, 0.583; 95% confidence interval, 0.370-0.919; P = .020), and 12 hours (odds ratio, 0.509; 95% confidence interval, 0.303-0.854; P = .011) after ROSC were independently associated with poor neurological outcomes. The lower FFA levels at 6 hours and 12 hours after ROSC were associated with poor neurological outcomes in patients with OHCA. FFA may reflect oxidative metabolism as well as oxidative stress.
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Affiliation(s)
- Donghun Lee
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Byungkook Lee
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Kyungwoon Jeung
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Yonghun Jung
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
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2
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Preuß S, Multmeier J, Stenzel W, Major S, Ploner CJ, Storm C, Nee J, Leithner C, Endisch C. Survival, but not the severity of hypoxic-ischemic encephalopathy, is associated with higher mean arterial blood pressure after cardiac arrest: a retrospective cohort study. Front Cardiovasc Med 2024; 11:1337344. [PMID: 38774664 PMCID: PMC11106407 DOI: 10.3389/fcvm.2024.1337344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 04/15/2024] [Indexed: 05/24/2024] Open
Abstract
Background This study investigates the association between the mean arterial blood pressure (MAP), vasopressor requirement, and severity of hypoxic-ischemic encephalopathy (HIE) after cardiac arrest (CA). Methods Between 2008 and 2017, we retrospectively analyzed the MAP 200 h after CA and quantified the vasopressor requirements using the cumulative vasopressor index (CVI). Through a postmortem brain autopsy in non-survivors, the severity of the HIE was histopathologically dichotomized into no/mild and severe HIE. In survivors, we dichotomized the severity of HIE into no/mild cerebral performance category (CPC) 1 and severe HIE (CPC 4). We investigated the regain of consciousness, causes of death, and 5-day survival as hemodynamic confounders. Results Among the 350 non-survivors, 117 had histopathologically severe HIE while 233 had no/mild HIE, without differences observed in the MAP (73.1 vs. 72.0 mmHg, pgroup = 0.639). Compared to the non-survivors, 211 patients with CPC 1 and 57 patients with CPC 4 had higher MAP values that showed significant, but clinically non-relevant, MAP differences (81.2 vs. 82.3 mmHg, pgroup < 0.001). The no/mild HIE non-survivors (n = 54), who regained consciousness before death, had higher MAP values compared to those with no/mild HIE (n = 179), who remained persistently comatose (74.7 vs. 69.3 mmHg, pgroup < 0.001). The no/mild HIE non-survivors, who regained consciousness, required fewer vasopressors (CVI 2.1 vs. 3.6, pgroup < 0.001). Independent of the severity of HIE, the survivors were weaned faster from vasopressors (CVI 1.0). Conclusions Although a higher MAP was associated with survival in CA patients treated with a vasopressor-supported MAP target above 65 mmHg, the severity of HIE was not. Awakening from coma was associated with less vasopressor requirements. Our results provide no evidence for a MAP target above the current guideline recommendations that can decrease the severity of HIE.
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Affiliation(s)
- Sandra Preuß
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Cardiology and Angiology, Charité Campus Mitte, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jan Multmeier
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
- Ada Health GmbH, Berlin, Germany
| | - Werner Stenzel
- Department of Neuropathology, Charité Campus Mitte, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Sebastian Major
- Center for Stroke Research, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph J. Ploner
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Storm
- Department of Nephrology and Intensive Care Medicine, Cardiac Arrest Center of Excellence Berlin, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jens Nee
- Department of Nephrology and Intensive Care Medicine, Cardiac Arrest Center of Excellence Berlin, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Leithner
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Endisch
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
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Taira T, Inoue A, Okamoto H, Maekawa K, Hifumi T, Sakamoto T, Kuroda Y, Suga M, Nishimura T, Ijuin S, Ishihara S. Fluid balance during acute phase extracorporeal cardiopulmonary resuscitation and outcomes in OHCA patients: a retrospective multicenter cohort study. Clin Res Cardiol 2024:10.1007/s00392-024-02444-z. [PMID: 38635032 DOI: 10.1007/s00392-024-02444-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 03/26/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVE The association between fluid balance and outcomes in patients who underwent out-of-hospital cardiac arrest (OHCA) and received extracorporeal cardiopulmonary resuscitation (ECPR) remains unknown. We aimed to examine the above relationship during the first 24 h following intensive care unit (ICU) admission. METHODS We performed a secondary analysis of the SAVE-J II study, a retrospective multicenter study involving OHCA patients aged ≥ 18 years treated with ECPR between 2013 and 2018 and who received fluid therapy following ICU admission. Fluid balance was calculated based on intravenous fluid administration, blood transfusion, and urine output. The primary outcome was in-hospital mortality. The secondary outcomes included unfavorable outcome (cerebral performance category scores of 3-5 at discharge), acute kidney injury (AKI), and need for renal replacement therapy (RRT). RESULTS Overall, 959 patients met our inclusion criteria. In-hospital mortality was 63.6%, and the proportion of unfavorable outcome at discharge was 82.0%. The median fluid balance in the first 24 h following ICU admission was 3673 mL. Multivariable analysis revealed that fluid balance was significantly associated with in-hospital mortality (odds ratio (OR), 1.04; 95% confidence interval (CI), 1.02-1.06; p < 0.001), unfavorable outcome (OR, 1.03; 95% CI, 1.01-1.06; p = 0.005), AKI (OR, 1.04; 95% CI, 1.02-1.05; p < 0.001), and RRT (OR, 1.05; 95% CI, 1.03-1.07; p < 0.001). CONCLUSIONS Excessive positive fluid balance in the first day following ICU admission was associated with in-hospital mortality, unfavorable outcome, AKI, and RRT in ECPR patients. Further investigation is warranted.
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Affiliation(s)
- Takuya Taira
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, 1-3-1 Wakinohamakaigandori, Chuo-Ku, Kobe, Hyogo, 651-0073, Japan
- Faculty of Medicine, Graduate School of Medicine, Kagawa University, Takamatsu, Kagawa, Japan
| | - Akihiko Inoue
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, 1-3-1 Wakinohamakaigandori, Chuo-Ku, Kobe, Hyogo, 651-0073, Japan.
| | - Hiroshi Okamoto
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Kunihiko Maekawa
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, 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
- Faculty of Medicine, Graduate School of Medicine, Kagawa University, Takamatsu, Kagawa, Japan
| | - Masafumi Suga
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, 1-3-1 Wakinohamakaigandori, Chuo-Ku, Kobe, Hyogo, 651-0073, Japan
| | - Takeshi Nishimura
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, 1-3-1 Wakinohamakaigandori, Chuo-Ku, Kobe, Hyogo, 651-0073, Japan
| | - Shinichi Ijuin
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, 1-3-1 Wakinohamakaigandori, Chuo-Ku, Kobe, Hyogo, 651-0073, Japan
| | - Satoshi Ishihara
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, 1-3-1 Wakinohamakaigandori, Chuo-Ku, Kobe, Hyogo, 651-0073, Japan
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Nikolovski SS, Lazic AD, Fiser ZZ, Obradovic IA, Tijanic JZ, Raffay V. Recovery and Survival of Patients After Out-of-Hospital Cardiac Arrest: A Literature Review Showcasing the Big Picture of Intensive Care Unit-Related Factors. Cureus 2024; 16:e54827. [PMID: 38529434 PMCID: PMC10962929 DOI: 10.7759/cureus.54827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2024] [Indexed: 03/27/2024] Open
Abstract
As an important public health issue, out-of-hospital cardiac arrest (OHCA) requires several stages of high quality medical care, both on-field and after hospital admission. Post-cardiac arrest shock can lead to severe neurological injury, resulting in poor recovery outcome and increased risk of death. These characteristics make this condition one of the most important issues to deal with in post-OHCA patients hospitalized in intensive care units (ICUs). Also, the majority of initial post-resuscitation survivors have underlying coronary diseases making revascularization procedure another crucial step in early management of these patients. Besides keeping myocardial blood flow at a satisfactory level, other tissues must not be neglected as well, and maintaining mean arterial pressure within optimal range is also preferable. All these procedures can be simplified to a certain level along with using targeted temperature management methods in order to decrease metabolic demands in ICU-hospitalized post-OHCA patients. Additionally, withdrawal of life-sustaining therapy as a controversial ethical topic is under constant re-evaluation due to its possible influence on overall mortality rates in patients initially surviving OHCA. Focusing on all of these important points in process of managing ICU patients is an imperative towards better survival and complete recovery rates.
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Affiliation(s)
- Srdjan S Nikolovski
- Pathology and Laboratory Medicine, Cardiovascular Research Institute, Loyola University Chicago Health Science Campus, Maywood, USA
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Aleksandra D Lazic
- Emergency Center, Clinical Center of Vojvodina, Novi Sad, SRB
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Zoran Z Fiser
- Emergency Medicine, Department of Emergency Medicine, Novi Sad, SRB
| | - Ivana A Obradovic
- Anesthesiology, Resuscitation, and Intensive Care, Sveti Vračevi Hospital, Bijeljina, BIH
| | - Jelena Z Tijanic
- Emergency Medicine, Municipal Institute of Emergency Medicine, Kragujevac, SRB
| | - Violetta Raffay
- School of Medicine, European University Cyprus, Nicosia, CYP
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
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5
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Smith D, Kenigsberg BB. Management of Patients After Cardiac Arrest. Crit Care Clin 2024; 40:57-72. [PMID: 37973357 DOI: 10.1016/j.ccc.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Cardiac arrest remains a significant cause of morbidity and mortality, although contemporary care now enables potential survival with good neurologic outcome. The core acute management goals for survivors of cardiac arrest are to provide organ support, sustain adequate hemodynamics, and evaluate the underlying cause of the cardiac arrest. In this article, the authors review the current state of knowledge and clinical intensive care unit practice recommendations for patients after cardiac arrest, particularly focusing on important areas of uncertainty, such as targeted temperature management, neuroprognostication, coronary evaluation, and hemodynamic targets.
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Affiliation(s)
- Damien Smith
- Department of Medicine, MedStar Washington Hospital Center, 110 Irving Street Northwest, Washington, DC 20010, USA
| | - Benjamin B Kenigsberg
- Department of Critical Care, MedStar Washington Hospital Center, 110 Irving Street Northwest, Washington, DC 20010, USA; Division of Cardiology, MedStar Washington Hospital Center, 110 Irving Street Northwest, Washington, DC 20010, USA.
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6
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Bertini P, Marabotti A, Paternoster G, Landoni G, Sangalli F, Peris A, Bonizzoli M, Scolletta S, Franchi F, Rubino A, Nocci M, Castellani Nicolini N, Guarracino F. Regional Cerebral Oxygen Saturation to Predict Favorable Outcome in Extracorporeal Cardiopulmonary Resuscitation: A Systematic Review and Meta-Analysis. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00006-X. [PMID: 36759264 DOI: 10.1053/j.jvca.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/17/2022] [Accepted: 01/05/2023] [Indexed: 01/11/2023]
Abstract
OBJECTIVE This systematic review and meta-analysis aimed to investigate the role of regional cerebral oxygen saturation (rSO2) in predicting survival and neurologic outcomes after extracorporeal cardiopulmonary resuscitation (ECPR). DESIGN The study authors performed a systematic review and meta-analysis of all available literature. SETTING The authors searched relevant databases (Pubmed, Medline, Embase) for studies measuring precannulation rSO2 in patients undergoing ECPR and reporting mortality and/or neurologic outcomes. PARTICIPANTS The authors included both in-hospital and out-of-hospital cardiac arrest patients receiving ECPR. They identified 3 observational studies, including 245 adult patients. INTERVENTIONS The authors compared patients with a low precannulation rSO2 (≤15% or 16%) versus patients with a high (>15% or 16%) precannulation rSO2. In addition, the authors carried out subgroup analyses on out-of-hospital cardiac arrest (OHCA) patients. MEASUREMENTS AND MAIN RESULTS A high precannulation rSO2 was associated with an overall reduced risk of mortality in ECPR recipients (98 out of 151 patients [64.9%] in the high rSO2 group, v 87 out of 94 patients [92.5%] in the low rSO2 group, risk differences [RD] -0.30; 95% CI -0.47 to -0.14), and in OHCA (78 out of 121 patients [64.5%] v 82 out of 89 patients [92.1%], RD 0.30; 95% CI -0.48 to -0.12). A high precannulation rSO2 also was associated with a significantly better neurologic outcome in the overall population (42 out of 151 patients [27.8%] v 2 out of 94 patients [2.12%], RD 0.22; 95% CI 0.13-0.31), and in OHCA patients (33 out of 121 patients [27.3%] v 2 out of 89 patients [2.25%] RD 0.21; 95% CI 0.11-0.30). CONCLUSIONS A low rSO2 before starting ECPR could be a predictor of mortality and survival with poor neurologic outcomes.
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Affiliation(s)
- Pietro Bertini
- Cardiothoracic and Vascular Anaesthesia and Intensive Care, Department of Anaesthesia and Critical Care Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Alberto Marabotti
- Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy; Intensive Care Unit and Regional, ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Gianluca Paternoster
- Division of Cardiac Resuscitation, Cardiovascular Anesthesia and Intensive Care, San Carlo Hospital, Potenza, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
| | - Fabio Sangalli
- Anesthesia and Intensive Care, ASST Valtellina e Alto Lario, Milan, Italy
| | - Adriano Peris
- Intensive Care Unit and Regional, ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Manuela Bonizzoli
- Intensive Care Unit and Regional, ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Sabino Scolletta
- Department of Emergency-Urgency and Organ Transplantation, Anesthesia and Intensive Care, University Hospital of Siena, Siena, Italy
| | - Federico Franchi
- Department of Medical Science, Surgery and Neurosciences, Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, University of Siena, Siena, Italy
| | - Antonio Rubino
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Matteo Nocci
- Health Science Department, Section of Anesthesia and Critical Care - Department of Anesthesia and Critical Care Azienda Ospedaliero-Universitaria Careggi - Università di Firenze, Florence, Italy
| | | | - Fabio Guarracino
- Cardiothoracic and Vascular Anaesthesia and Intensive Care, Department of Anaesthesia and Critical Care Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
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7
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McGuigan PJ, Giallongo E, Blackwood B, Doidge J, Harrison DA, Nichol AD, Rowan KM, Shankar-Hari M, Skrifvars MB, Thomas K, McAuley DF. The effect of blood pressure on mortality following out-of-hospital cardiac arrest: a retrospective cohort study of the United Kingdom Intensive Care National Audit and Research Centre database. Crit Care 2023; 27:4. [PMID: 36604745 PMCID: PMC9817239 DOI: 10.1186/s13054-022-04289-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/20/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Hypotension following out-of-hospital cardiac arrest (OHCA) may cause secondary brain injury and increase mortality rates. Current guidelines recommend avoiding hypotension. However, the optimal blood pressure following OHCA is unknown. We hypothesised that exposure to hypotension and hypertension in the first 24 h in ICU would be associated with mortality following OHCA. METHODS We conducted a retrospective analysis of OHCA patients included in the Intensive Care National Audit and Research Centre Case Mix Programme from 1 January 2010 to 31 December 2019. Restricted cubic splines were created following adjustment for important prognostic variables. We report the adjusted odds ratio for associations between lowest and highest mean arterial pressure (MAP) and systolic blood pressure (SBP) in the first 24 h of ICU care and hospital mortality. RESULTS A total of 32,349 patients were included in the analysis. Hospital mortality was 56.2%. The median lowest and highest MAP and SBP were similar in survivors and non-survivors. Both hypotension and hypertension were associated with increased mortality. Patients who had a lowest recorded MAP in the range 60-63 mmHg had the lowest associated mortality. Patients who had a highest recorded MAP in the range 95-104 mmHg had the lowest associated mortality. The association between SBP and mortality followed a similar pattern to MAP. CONCLUSIONS We found an association between hypotension and hypertension in the first 24 h in ICU and mortality following OHCA. The inability to distinguish between the median blood pressure of survivors and non-survivors indicates the need for research into individualised blood pressure targets for survivors following OHCA.
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Affiliation(s)
- Peter J McGuigan
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK.
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK.
| | - Elisa Giallongo
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK
| | - James Doidge
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, UK
| | - David A Harrison
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, UK
| | - Alistair D Nichol
- University College Dublin Clinical Research Centre, St Vincent's University Hospital, Dublin, Ireland
- The Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
| | - Kathryn M Rowan
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, UK
| | - Manu Shankar-Hari
- Centre for Inflammation Research, Institute of Regeneration and Repair, University of Edinburgh, Edinburgh, UK
- Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki, Helsinki, Finland
- Helsinki University Hospital, Helsinki, Finland
| | - Karen Thomas
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, UK
| | - Danny F McAuley
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK
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8
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da Silva Menezes Jr A, Braga AL, de Souza Cruvinel V. Prevalence, Outcomes, and Risk Factors for Cardiorespiratory Arrest in the Intensive Care Unit: An Observational Study. Indian J Crit Care Med 2022; 26:704-709. [PMID: 35836636 PMCID: PMC9237152 DOI: 10.5005/jp-journals-10071-24201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Cardiorespiratory arrest is defined as an abrupt halt in the cardiac mechanical activity that is accompanied by the loss of a detectable pulse, the cessation of breathing, and the loss of consciousness. The aim of this study is to create a clinical–epidemiological profile of patients who experienced cardiorespiratory arrest and were admitted to the intensive care unit to evaluate the associated factors and their impact on the prognosis of these patients. Patients and methods From January to December 2019, the medical records of 135 patients who received cardiopulmonary resuscitation were reviewed for this cross-sectional observational study. The information was collected according to the Utstein model. Results A low return of spontaneous circulation of 22.2% was observed, with a predominance of females (53.3%) and older patients (68.9%), multiple comorbidities at admission (68.4%), and asystole as the predominant rhythm. Female sex and age >60 years were statistically significant (p = 0.017), as was the association between sex and comorbidities (p = 0.036), with heart disease being the most prevalent in females (p = 0.036). Conclusion In this study, even though the resuscitation maneuver time (start of resuscitation following arrest) was very short and the defibrillation was performed promptly, there was a high prevalence of cardiac arrest and low survival rates after cardiopulmonary resuscitation. How to cite this article Menezes da Silva A, Braga AL, Cruvinel de Souza V. Prevalence, Outcomes, and Risk Factors for Cardiorespiratory Arrest in the Intensive Care Unit: An Observational Study. Indian J Crit Care Med 2022;26(6):704–709.
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Affiliation(s)
- Antônio da Silva Menezes Jr
- Department of Medicine, Faculty of Medicine, Pontifical Catholic University of Goiás (PUC-GO), Goiânia, Goiás, Brazil
- Antônio da Silva Menezes Jr, Department of Medicine, Faculty of Medicine, Pontifical Catholic University of Goiás (PUC-GO), Goiânia, Goiás, Brazil, Phone: +(062) 982711177, e-mail:
| | - Angélica L Braga
- Department of Medicine, Faculty of Medicine, Pontifical Catholic University of Goiás (PUC-GO), Goiânia, Goiás, Brazil
| | - Viviane de Souza Cruvinel
- Department of Medicine, Faculty of Medicine, Pontifical Catholic University of Goiás (PUC-GO), Goiânia, Goiás, Brazil
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Düring J, Annborn M, Dankiewicz J, Dupont A, Forsberg S, Friberg H, Kern KB, May TL, McPherson J, Patel N, Seder DB, Stammet P, Sunde K, Søreide E, Ullén S, Nielsen N. Influence of circulatory shock at hospital admission on outcome after out-of-hospital cardiac arrest. Sci Rep 2022; 12:8293. [PMID: 35585159 PMCID: PMC9117194 DOI: 10.1038/s41598-022-12310-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 05/09/2022] [Indexed: 01/27/2023] Open
Abstract
Hypotension after cardiac arrest could aggravate prolonged hypoxic ischemic encephalopathy. The association of circulatory shock at hospital admission with outcome after cardiac arrest has not been well studied. The objective of this study was to investigate the independent association of circulatory shock at hospital admission with neurologic outcome, and to evaluate whether cardiovascular comorbidities interact with circulatory shock. 4004 adult patients with out-of-hospital cardiac arrest enrolled in the International Cardiac Arrest Registry 2006-2017 were included in analysis. Circulatory shock was defined as a systolic blood pressure below 90 mmHg and/or medical or mechanical supportive measures to maintain adequate perfusion during hospital admission. Primary outcome was cerebral performance category (CPC) dichotomized as good, (CPC 1-2) versus poor (CPC 3-5) outcome at hospital discharge. 38% of included patients were in circulatory shock at hospital admission, 32% had good neurologic outcome at hospital discharge. The adjusted odds ratio for good neurologic outcome in patients without preexisting cardiovascular disease with circulatory shock at hospital admission was 0.60 [0.46-0.79]. No significant interaction was detected with preexisting comorbidities in the main analysis. We conclude that circulatory shock at hospital admission after out-of-hospital cardiac arrest is independently associated with poor neurologic outcome.
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Affiliation(s)
- Joachim Düring
- Department of Clinical Sciences, Anesthesia & Intensive Care, Lund University, Skåne University Hospital, Malmö, Sweden.
| | - Martin Annborn
- Department of Clinical Sciences Lund, Anesthesia & Intensive Care, Lund University, Helsingborg Hospital, Helsingborg, Sweden
| | - Josef Dankiewicz
- Department of Clinical Sciences, Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Allison Dupont
- Department of Cardiology, Northside Cardiovascular Institute, Atlanta, GA, USA
| | - Sune Forsberg
- Department of Intensive Care, Norrtälje Hospital, Karolinska Institute, Norrtälje, Sweden
- Center for Resuscitation Science, Karolinska Institute, Stockholm, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anesthesia & Intensive Care, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Karl B Kern
- Division of Cardiology Department of Medicine, University of Arizona, Tucson, AZ, USA
| | - Teresa L May
- Department of Critical Care Services, Maine Medical Center, Portland, ME, USA
| | | | - Nainesh Patel
- Department of Cardiology, Lehigh Valley Health Network, Allentown, PA, USA
| | - David B Seder
- Division of Cardiology Department of Medicine, University of Arizona, Tucson, AZ, USA
| | - Pascal Stammet
- Department of Intensive Care Medicine, Centre Hospitalier de Luxembourg, Luxembourg City, Luxembourg
- Faculty of Science, Technology and Medicine, University of Luxembourg, Esch-sur-Alzette, Luxembourg
| | - Kjetil Sunde
- Department of Anesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Eldar Søreide
- Critical Care and Anesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Susann Ullén
- Clinical Studies Sweden- Forum South, Skåne University Hospital, Lund, Sweden
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Anesthesia & Intensive Care, Lund University, Helsingborg Hospital, Helsingborg, Sweden
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10
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Langeland H, Bergum D, Løberg M, Bjørnstad K, Skaug TR, Nordseth T, Klepstad P, Skjærvold NK. Characteristics of circulatory failure after out-of-hospital cardiac arrest: a prospective cohort study. Open Heart 2022; 9:openhrt-2021-001890. [PMID: 35046124 PMCID: PMC8772457 DOI: 10.1136/openhrt-2021-001890] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/31/2021] [Indexed: 12/02/2022] Open
Abstract
Background Circulatory failure after out-of-hospital cardiac arrest (OHCA) as part of the postcardiac arrest syndrome (PCAS) is believed to be caused by an initial myocardial depression that later subsides into a superimposed vasodilatation. However, the relative contribution of myocardial dysfunction and systemic inflammation has not been established. Our objective was to describe the macrocirculatory and microcirculatory failure in PCAS in more detail. Methods We included 42 comatose patients after OHCA where circulatory variables were invasively monitored from admission until day 5. We measured the development in cardiac power output (CPO), stroke work (SW), aortic elastance, microcirculatory metabolism, inflammatory and cardiac biomarkers and need for vasoactive medications. We used survival analysis and Cox regression to assess time to norepinephrine discontinuation and negative fluid balance, stratified by inflammatory and cardiac biomarkers. Results CPO, SW and oxygen delivery increased during the first 48 hours. Although the estimated afterload fell, the blood pressure was kept above 65 mmHg with a diminishing need for norepinephrine, indicating a gradually re-established macrocirculatory homoeostasis. Time to norepinephrine discontinuation was longer for patients with higher pro-brain natriuretic peptide concentration (HR 0.45, 95% CI 0.21 to 0.96), while inflammatory biomarkers and other cardiac biomarkers did not predict the duration of vasoactive pressure support. Markers of microcirculatory distress, such as lactate and venous-to-arterial carbon dioxide difference, were normalised within 24 hours. Conclusion The circulatory failure was initially characterised by reduced CPO and SW, however, microcirculatory and macrocirculatory homoeostasis was restored within 48 hours. We found that biomarkers indicating acute heart failure, and not inflammation, predicted longer circulatory support with norepinephrine. Taken together, this indicates an early and resolving, rather than a late and emerging vasodilatation. Trial registration NCT02648061.
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Affiliation(s)
- Halvor Langeland
- Department of Anesthesiology and Intensive Care Medicine, St. Olav's University Hospital, Trondheim, Norway .,Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Daniel Bergum
- Department of Anesthesiology and Intensive Care Medicine, St. Olav's University Hospital, Trondheim, Norway
| | - Magnus Løberg
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway.,Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Knut Bjørnstad
- Department of Cardiology, St. Olav's University Hospital, Trondheim, Norway
| | - Thomas R Skaug
- Department of Cardiology, St. Olav's University Hospital, Trondheim, Norway
| | - Trond Nordseth
- Department of Anesthesiology and Intensive Care Medicine, St. Olav's University Hospital, Trondheim, Norway.,Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Pål Klepstad
- Department of Anesthesiology and Intensive Care Medicine, St. Olav's University Hospital, Trondheim, Norway.,Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Nils Kristian Skjærvold
- Department of Anesthesiology and Intensive Care Medicine, St. Olav's University Hospital, Trondheim, Norway.,Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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11
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Effects of early hemodynamics, oxygen metabolism, and lactate dynamics on prognosis of post-cardiac arrest syndrome. Chin Med J (Engl) 2021; 135:344-346. [PMID: 34759220 PMCID: PMC8812616 DOI: 10.1097/cm9.0000000000001807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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12
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Wilcox C, Choi CW, Cho SM. Brain injury in extracorporeal cardiopulmonary resuscitation: translational to clinical research. JOURNAL OF NEUROCRITICAL CARE 2021. [DOI: 10.18700/jnc.210016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The addition of extracorporeal membrane oxygenation (ECMO) to conventional cardiopulmonary resuscitation (CPR), termed extracorporeal cardiopulmonary resuscitation (ECPR), has significantly improved survival in selected patient populations. Despite this advancement, significant neurological impairment persists in approximately half of survivors. ECPR represents a potential advancement for patients who experience refractory cardiac arrest (CA) due to a reversible etiology and do not regain spontaneous circulation. Important risk factors for acute brain injury (ABI) in ECPR include lack of perfusion, reperfusion, and altered cerebral autoregulation. The initial hypoxic-ischemic injury caused by no-flow and low-flow states after CA and during CPR is compounded by reperfusion, hyperoxia during ECMO support, and nonpulsatile blood flow. Additionally, ECPR patients are at risk for Harlequin syndrome with peripheral cannulation, which can lead to preferential perfusion of cerebral vessels with deoxygenated blood. Lastly, the oxygenator membrane is prothrombotic and requires systemic anticoagulation. The two competing phenomena result in thrombus formation, hemolysis, and thrombocytopenia, increasing the risk of ischemic and hemorrhagic ABI. In addition to clinical studies, we assessed available ECPR animal models to identify the mechanisms underlying ABI at the cellular level. Standardized multimodal neurological monitoring may facilitate early detection of and intervention for ABI. With the increasing use of ECPR, it is critical to understand the pathophysiology of ABI, its prevention, and the management strategies for improving the outcomes of ECPR. Translational and clinical research focusing on acute ABI immediately after ECMO cannulation and its short- and long-term neurological outcomes are warranted.
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13
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Between-hospital variability in organ donation after resuscitation from out-of-hospital cardiac arrest. Resuscitation 2021; 167:372-379. [PMID: 34363855 DOI: 10.1016/j.resuscitation.2021.07.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 07/15/2021] [Accepted: 07/22/2021] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Survival and recovery after out-of-hospital cardiac arrest (OHCA) varies between hospitals, with better outcomes associated with high-volume and specialty care. We evaluated if there is a similar relationship with organ donation after OHCA. METHODS We studied a cohort of adults resuscitated from OHCA from 2010 to 2018, treated at one of 112 hospitals served by a regional organ procurement organization (OPO). We obtained hospital-level characteristics from Centers for Medicare and Medicaid Services and Health Resources and Services Administration and obtained patients' clinical information from the OPO health record. We excluded patients with no potential to donate on initial referral. Our primary exposure was treatment at a high-volume hospital (defined >500 eligible cases during the study period) and our primary outcomes were suitability to donate after full medical evaluation, successful organ procurement and organ transplantation. We used mixed effects models to quantify between-hospital variability in the primary outcomes RESULTS: Overall, 9,792 patients were included and 796 (8%) were organ donors. We identified significant between-hospital variation in odds of donation (median odds ratio 1.64 [95% CI 1.42 - 2.02]). Hospital volume explained the greatest proportion of variability. High volume centers had a higher proportion of referrals with potential to donate (16.9 vs 12.2%), actual donation (10.3 vs 6.2%), and successful transplantation (9.4 vs 5.7%). Overall, 2032/7763 (26%) of recovered transplantable organs in this region were procured from OHCA patients. CONCLUSION High volume centers are more likely to refer and procure transplantable organs from patients with non-survivable OHCA.
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14
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. Postreanimationsbehandlung. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00892-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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15
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Kim YM, Jeung KW, Kim WY, Park YS, Oh JS, You YH, Lee DH, Chae MK, Jeong YJ, Kim MC, Ha EJ, Hwang KJ, Kim WS, Lee JM, Cha KC, Chung SP, Park JD, Kim HS, Lee MJ, Na SH, Kim ARE, Hwang SO. 2020 Korean Guidelines for Cardiopulmonary Resuscitation. Part 5. Post-cardiac arrest care. Clin Exp Emerg Med 2021; 8:S41-S64. [PMID: 34034449 PMCID: PMC8171174 DOI: 10.15441/ceem.21.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 03/07/2021] [Accepted: 03/19/2021] [Indexed: 12/20/2022] Open
Affiliation(s)
- Young-Min Kim
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Kyung Woon Jeung
- Department of Emergency Medicine, Chonnam National University College of Medicine, Gwangju, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, Ulsan University College of Medicine, Seoul, Korea
| | - Yoo Seok Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Joo Suk Oh
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Yeon Ho You
- Department of Emergency Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Dong Hoon Lee
- Department of Emergency Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Minjung Kathy Chae
- Department of Emergency Medicine, Ajou University College of Medicine, Suwon, Korea
| | - Yoo Jin Jeong
- Department of Emergency Medicine, Chonnam National University College of Medicine, Gwangju, Korea
| | - Min Chul Kim
- Department of Internal Medicine, Chonnam National University College of Medicine, Gwangju, Korea
| | - Eun Jin Ha
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyoung Jin Hwang
- Department of Neurology, Kyung Hee University College of Medicine, Seoul, Korea
| | - Won-Seok Kim
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jae Myung Lee
- Department of General Surgery, Korea University College of Medicine, Seoul, Korea
| | - Kyoung-Chul Cha
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - June Dong Park
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Mi Jin Lee
- Department of Emergency Medicine, Kyoungbook University College of Medicine, Daegu, Korea
| | - Sang-Hoon Na
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Ai-Rhan Ellen Kim
- Department of Pediatrics, Ulsan University College of Medicine, Seoul, Korea
| | - Sung Oh Hwang
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - on behalf of the Steering Committee of 2020 Korean Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Chonnam National University College of Medicine, Gwangju, Korea
- Department of Emergency Medicine, Asan Medical Center, Ulsan University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Chungnam National University College of Medicine, Daejeon, Korea
- Department of Emergency Medicine, Chung-Ang University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Ajou University College of Medicine, Suwon, Korea
- Department of Internal Medicine, Chonnam National University College of Medicine, Gwangju, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Neurology, Kyung Hee University College of Medicine, Seoul, Korea
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Department of General Surgery, Korea University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Kyoungbook University College of Medicine, Daegu, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Pediatrics, Ulsan University College of Medicine, Seoul, Korea
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16
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care. Intensive Care Med 2021; 47:369-421. [PMID: 33765189 PMCID: PMC7993077 DOI: 10.1007/s00134-021-06368-4] [Citation(s) in RCA: 459] [Impact Index Per Article: 153.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/08/2021] [Indexed: 12/13/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation and organ donation.
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Affiliation(s)
- Jerry P. Nolan
- University of Warwick, Warwick Medical School, Coventry, CV4 7AL UK
- Royal United Hospital, Bath, BA1 3NG UK
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
- Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W. Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC), Université Catholique de Louvain, Brussels, Belgium
- Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Division of Health Sciences, Warwick Medical School, University of Warwick, Room A108, Coventry, CV4 7AL UK
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Véronique R. M. Moulaert
- Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Markus B. Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB UK
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17
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Mariero Olasveengen T, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care. Resuscitation 2021; 161:220-269. [PMID: 33773827 DOI: 10.1016/j.resuscitation.2021.02.012] [Citation(s) in RCA: 358] [Impact Index Per Article: 119.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation, and organ donation.
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Affiliation(s)
- Jerry P Nolan
- University of Warwick, Warwick Medical School, Coventry CV4 7AL, UK; Royal United Hospital, Bath, BA1 3NG, UK.
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy; Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W Böttiger
- University Hospital of Cologne, Kerpener Straße 62, D-50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC) Université Catholique de Louvain, Brussels, Belgium; Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Room A108, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Gisela Lilja
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden
| | - Véronique R M Moulaert
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB, UK
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18
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Connolly M, Lekoubou A, Bishu KG, Ovbiagele B. Sudden cardiac arrest in epilepsy patients undergoing continuous video electroencephalogram monitoring: The national inpatient sample. Epilepsy Res 2020; 168:106487. [PMID: 33120303 DOI: 10.1016/j.eplepsyres.2020.106487] [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: 04/26/2020] [Revised: 08/16/2020] [Accepted: 10/17/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To examine the relationship between epilepsy and sudden cardiac arrest (SCA) and identify clinical and healthcare system related predictors of SCA in patients with a discharge diagnosis of epilepsy undergoing continuous video EEG (cVEEG) monitoring. METHODS The national inpatient sample was used as data source to identify adults (18 years and older) with a primary discharge diagnosis of epilepsy who were at some point during their hospitalization on cVEEG monitoring. We applied a logistic regression model to identify independent patient-related and hospital/healthcare system-related factors associated with SCA. RESULTS A total of weighted 10,059 (0.71 %) patients with epilepsy on cVEEG had a secondary discharge diagnosis of SCA. The main independent factors associated with SCA were the presence of any of the following secondary discharge diagnoses: paroxysmal arrhythmia (OR: 2.29, 95 %CI: 1.96-2.66), myocardial infarction (OR: 3.78, 95 %CI: 2.83-5.05), congestive heart failure (OR: 2.27, 95 %CI: 1.93-2.62), and anoxic brain injury (OR: 57.6, 95 %CI: 50.83-67.27). There was no association between refractory epilepsy and SCA (OR: 0.99, 95 %CI: 0.51-1.93). CONCLUSION SCA is a rare event occurring in < 1% of patients with epilepsy undergoing cVEEG monitoring in the United States. Key independent contributors to occurrence of SCA are presence of select cardiovascular conditions and anoxic brain injury.
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Affiliation(s)
- Mary Connolly
- Department of Neurology, Penn State University, Hershey Medical Center, Hershey, PA, USA
| | - Alain Lekoubou
- Department of Neurology, Penn State University, Hershey Medical Center, Hershey, PA, USA.
| | - Kinfe G Bishu
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA; Section of Health Systems Research and Policy, Medical University of South Carolina, Charleston, SC, USA
| | - Bruce Ovbiagele
- Department of Neurology, University of California, San Francisco, USA
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19
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Panchal AR, Bartos JA, Cabañas JG, Donnino MW, Drennan IR, Hirsch KG, Kudenchuk PJ, Kurz MC, Lavonas EJ, Morley PT, O’Neil BJ, Peberdy MA, Rittenberger JC, Rodriguez AJ, Sawyer KN, Berg KM, Arafeh J, Benoit JL, Chase M, Fernandez A, de Paiva EF, Fischberg BL, Flores GE, Fromm P, Gazmuri R, Gibson BC, Hoadley T, Hsu CH, Issa M, Kessler A, Link MS, Magid DJ, Marrill K, Nicholson T, Ornato JP, Pacheco G, Parr M, Pawar R, Jaxton J, Perman SM, Pribble J, Robinett D, Rolston D, Sasson C, Satyapriya SV, Sharkey T, Soar J, Torman D, Von Schweinitz B, Uzendu A, Zelop CM, Magid DJ. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S366-S468. [DOI: 10.1161/cir.0000000000000916] [Citation(s) in RCA: 371] [Impact Index Per Article: 92.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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20
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Babini G, Ameloot K, Skrifvars MB. Cardiac function after cardiac arrest: what do we know? Minerva Anestesiol 2020; 87:358-367. [PMID: 32959631 DOI: 10.23736/s0375-9393.20.14574-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Postcardiac arrest myocardial dysfunction (PCAMD) is a frequent complication faced during post-resuscitation care that adversely impacts survival and neurological outcome. Both mechanical and electrical factors contribute to the occurrence of PCAMD. Prearrest ventricular function, the cause of cardiac arrest, global ischemia, resuscitation factors, ischemia/reperfusion injury and post-resuscitation treatments contribute to the severity of PCMAD. The pathophysiology of PCAMD is complex and include myocytes energy failure, impaired contractility, cardiac edema, mitochondrial damage, activation of inflammatory pathways and the coagulation cascade, persistent ischemic injury and myocardial stiffness. Hypotension and low cardiac output with vasopressor/inotropes need are frequent after resuscitation. However, clinical, hemodynamic and laboratory signs of shock are frequently altered by cardiac arrest pathophysiology and post-resuscitation treatment, potentially being misleading and not fully reflecting the severity of postcardiac arrest syndrome. Even if validated criteria are lacking, an extensive hemodynamic evaluation is useful to define a "benign" and a "malign" form of myocardial dysfunction and circulatory shock, potentially having treatment and prognostic implications. Cardiac output is frequently decreased after cardiac arrest, particularly in patients treated with target temperature management (TTM); however, it is not independently associated with outcome. Sinus bradycardia during TTM seems independently associated with survival and good neurological outcome, representing a promising prognostic indicator. Higher mean arterial pressure (MAP) seems to be associated with improved survival and cerebral function after cardiac arrest; however, two recent randomized clinical trials failed to replicate these results. Recommendations on hemodynamic optimization are relatively poor and are largely based on general principle of intensive care medicine.
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Affiliation(s)
- Giovanni Babini
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Department of Emergency Medicine and Services, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Koen Ameloot
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium.,Department of Cardiology, University Hospitals Leuven, Leuven, Belgium.,Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
| | - Markus B Skrifvars
- Department of Anesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital, University of Helsinki, Helsinki, Finland -
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21
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Association Between Intravenous Fluid Resuscitation and Hospital Mortality in Post Cardiac Arrest Patients: A Retrospective Study. Shock 2020; 55:224-229. [PMID: 32769815 DOI: 10.1097/shk.0000000000001617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess the role for intravenous fluid (IVF) resuscitation in the postarrest state. Primary outcome was survival to hospital discharge and 30-day mortality. Secondary outcomes were associations with amount of vasopressor use and mechanical ventilation days. DESIGN Retrospective study design. SETTING Single-center tertiary hospital in Philadelphia, Pennsylvania. PATIENTS All patients admitted to the intensive care unit between 2018 and 2019. INTERVENTIONS Patients were divided into two groups based on amount of IVF received within 24 h <30 mL/kg (restricted) and over 30 mL/kg (liberal). MEASUREMENTS AND MAIN RESULTS A total of 264 patients were included in the study, with 200 included in the restrictive (<30 mL/kg) group and 64 included in the liberal (>30 mg/kg) group. There was no difference in 30-day mortality between the two groups with 146 (73%) deaths in the restrictive groups and 44 (69%) deaths in the liberal group (P = 0.53). There was also no significant difference between those who survived to hospital discharge in the liberal and restrictive groups on Kaplan-Meier analysis (Log-rank = 1.476 P = 0.224). However, there was a significant difference between restrictive and liberal groups with the duration of mechanical ventilation (4 ± 6 days vs. 6 ± 9 days; P = 0.03) and in the rates of two or more vasopressor use (38% vs. 59%; P = 0.002). End-stage renal disease (ESRD) (OR = 2.39; P = 0.03) and volume of fluids in mL/kg/24 h (OR = 1.025; P < 0.0001) were independently associated with higher vasopressor need. Volume of fluid in mL/kg/24 h (P = 0.01), ESRD (P = 0.015), and chronic obstructive pulmonary disease (P = 0.04) were significantly associated with duration of mechanical ventilation, even after adjusting for demographic factors, comorbidities, and mortality. CONCLUSIONS A liberal strategy of IVF used in resuscitation after cardiac arrest is not associated with higher mortality. However, it predicts higher vasopressor use and duration of mechanical ventilation.
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Kuroda Y, Kawakita K. Targeted temperature management for postcardiac arrest syndrome. JOURNAL OF NEUROCRITICAL CARE 2020. [DOI: 10.18700/jnc.200001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Wang Q, Miao P, Modi HR, Garikapati S, Koehler RC, Thakor NV. Therapeutic hypothermia promotes cerebral blood flow recovery and brain homeostasis after resuscitation from cardiac arrest in a rat model. J Cereb Blood Flow Metab 2019; 39:1961-1973. [PMID: 29739265 PMCID: PMC6775582 DOI: 10.1177/0271678x18773702] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Laboratory and clinical studies have demonstrated that therapeutic hypothermia (TH), when applied as soon as possible after resuscitation from cardiac arrest (CA), results in better neurological outcome. This study tested the hypothesis that TH would promote cerebral blood flow (CBF) restoration and its maintenance after return of spontaneous circulation (ROSC) from CA. Twelve Wistar rats resuscitated from 7-min asphyxial CA were randomized into two groups: hypothermia group (7 H, n = 6), treated with mild TH (33-34℃) immediately after ROSC and normothermia group (7 N, n = 6,37.0 ± 0.5℃). Multiple parameters including mean arterial pressure, CBF, electroencephalogram (EEG) were recorded. The neurological outcomes were evaluated using electrophysiological (information quantity, IQ, of EEG) methods and a comprehensive behavior examination (neurological deficit score, NDS). TH consistently promoted better CBF restoration approaching the baseline levels in the 7 H group as compared with the 7 N group. CBF during the first 5-30 min post ROSC of the two groups was 7 H:90.5% ± 3.4% versus 7 N:76.7% ± 3.5% (P < 0.01). Subjects in the 7 H group showed significantly better IQ scores after ROSC and better NDS scores at 4 and 24 h. Early application of TH facilitates restoration of CBF back to baseline levels after CA, which in turn results in the restoration of brain electrical activity and improved neurological outcome.
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Affiliation(s)
- Qihong Wang
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Peng Miao
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA.,Institute of Biomedical Engineering, School of Communication and Information Engineering, Shanghai University, Shanghai, China
| | - Hiren R Modi
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Sahithi Garikapati
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Raymond C Koehler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Nitish V Thakor
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA.,Department of Neurology, Johns Hopkins University, Baltimore, MD, USA.,Singapore Institute for Neurotechnology (SINAPSE), National University of Singapore, Singapore, Singapore
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Development and performance of a novel vasopressor-driven mortality prediction model in septic shock. Ann Intensive Care 2018; 8:112. [PMID: 30467807 PMCID: PMC6250607 DOI: 10.1186/s13613-018-0459-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 11/16/2018] [Indexed: 12/14/2022] Open
Abstract
Background Vasoactive medications are essential in septic shock, but are not fully incorporated into current mortality prediction risk scores. We sought to develop a novel mortality prediction model for septic shock incorporating quantitative vasoactive medication usage. Methods Quantitative vasopressor use was calculated in a cohort of 5352 septic shock patients and compared using norepinephrine equivalents (NEE), cumulative vasopressor index and the vasoactive inotrope score models. Having best discrimination prediction, log10NEE was selected for further development of a novel prediction model for 28-day and 1-year mortality via backward stepwise logistic regression. This model termed ‘MAVIC’ (Mechanical ventilation, Acute Physiology And Chronic Health Evaluation-III, Vasopressors, Inotropes, Charlson comorbidity index) was then compared to Acute Physiology And Chronic Health Evaluation-III (APACHE-III) and Sequential Organ Failure Assessment (SOFA) scores in an independent validation cohort for its accuracy in predicting 28-day and 1-year mortality. Measurements and main results The MAVIC model was superior to the APACHE-III and SOFA scores in its ability to predict 28-day mortality (area under receiver operating characteristic curve [AUROC] 0.73 vs. 0.66 and 0.60) and 1-year mortality (AUROC 0.74 vs. 0.66 and 0.60), respectively. Conclusions The incorporation of quantitative vasopressor usage into a novel ‘MAVIC’ model results in superior 28-day and 1-year mortality risk prediction in a large cohort of patients with septic shock.
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Abstract
The post-cardiac arrest syndrome is a highly inflammatory state characterized by organ dysfunction, systemic ischemia and reperfusion injury, and persistent precipitating pathology. Early critical care should focus on identifying and treating arrest etiology and minimizing further injury to the brain and other organs by optimizing perfusion, oxygenation, ventilation, and temperature. Patients should be treated with targeted temperature management, although the exact temperature goal is not clear. No earlier than 72 hours after rewarming, prognostication using a multimodal approach should inform discussions with families regarding likely neurologic outcome.
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Affiliation(s)
- Amy C Walker
- Department of Emergency Medicine, University of Washington, Harborview Medical Center, 325 9th Avenue, Box 359702, Seattle, WA 98104, USA
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington, Harborview Medical Center, 325 9th Avenue, Box 359702, Seattle, WA 98104, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Harborview Medical Center, 325 9th Avenue, Box 359702, Seattle, WA 98104, USA.
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Abstract
Cardiac arrest is the most common cause of death in North America. An organized bundle of neurocritical care interventions can improve chances of survival and neurological recovery in patients who are successfully resuscitated from cardiac arrest. Therefore, resuscitation following cardiac arrest was chosen as an Emergency Neurological Life Support protocol. Key aspects of successful early post-arrest management include: prevention of secondary brain injury; identification of treatable causes of arrest in need of emergent intervention; and, delayed neurological prognostication. Secondary brain injury can be attenuated through targeted temperature management (TTM), avoidance of hypoxia and hypotension, avoidance of hyperoxia, hyperventilation or hypoventilation, and treatment of seizures. Most patients remaining comatose after resuscitation from cardiac arrest should undergo TTM. Treatable precipitants of arrest that require emergent intervention include, but are not limited to, acute coronary syndrome, intracranial hemorrhage, pulmonary embolism and major trauma. Accurate neurological prognostication is generally not appropriate for several days after cardiac arrest, so early aggressive care should never be limited based on perceived poor neurological prognosis.
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Affiliation(s)
- Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Iroquois Building, Suite 400A, 3600 Forbes Avenue, Pittsburgh, PA, 15213, USA.
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Kees H Polderman
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Duration of Untreated Cardiac Arrest and Clinical Relevance of Animal Experiments: The Relationship Between the “No-Flow” Duration and the Severity of Post-Cardiac Arrest Syndrome in a Porcine Model. Shock 2018; 49:205-212. [DOI: 10.1097/shk.0000000000000914] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Iordanova B, Li L, Clark RSB, Manole MD. Alterations in Cerebral Blood Flow after Resuscitation from Cardiac Arrest. Front Pediatr 2017; 5:174. [PMID: 28861407 PMCID: PMC5561008 DOI: 10.3389/fped.2017.00174] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 07/28/2017] [Indexed: 01/07/2023] Open
Abstract
Greater than 50% of patients successfully resuscitated from cardiac arrest have evidence of neurological disability. Numerous studies in children and adults, as well as in animal models have demonstrated that cerebral blood flow (CBF) is impaired after cardiac arrest. Stages of cerebral perfusion post-resuscitation include early hyperemia, followed by hypoperfusion, and finally either resolution of normal blood flow or protracted hyperemia. At the level of the microcirculation the blood flow is heterogeneous, with areas of no flow, low flow, and increased flow. CBF directed therapies in animal models of cardiac arrest improved neurological outcome, and therefore, the alterations in CBF after cardiac arrest likely contribute to the development of hypoxic ischemic encephalopathy. Current intensive care after cardiac arrest is centered upon maintaining systemic oxygenation, normal blood pressure values for age, maintaining general homeostasis, and avoiding hyperthermia. Assessment of CBF and oxygenation is not routinely performed after cardiac arrest. Currently available and underutilized techniques to assess cerebral perfusion include transcranial doppler, near-infrared spectroscopy, and arterial spin labeling magnetic resonance imaging. Limited clinical studies established the role of CBF and oxygenation monitoring in prognostication after cardiac arrest and few studies suggest that guiding critical care post-resuscitation to mean arterial pressures above the minimal autoregulatory range might improve outcome. Important knowledge gaps thus remain in cerebral monitoring and CBF and oxygen goal-directed therapies post-resuscitation from cardiac arrest.
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Affiliation(s)
- Bistra Iordanova
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States
| | - Lingjue Li
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, United States
| | - Robert S B Clark
- Safar Center for Resuscitation Research, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, United States.,Safar Center for Resuscitation Research, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Mioara D Manole
- Safar Center for Resuscitation Research, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, United States
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What's New In Shock, June 2016? Shock 2016; 45:577-9. [DOI: 10.1097/shk.0000000000000614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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