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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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Carr JR, Hawkins WA, Newsome AS, Smith SE, Clemmons AB, Bland CM, Branan TN. Fluid Stewardship of Maintenance Intravenous Fluids. J Pharm Pract 2022; 35:769-782. [PMID: 33827313 PMCID: PMC8497650 DOI: 10.1177/08971900211008261] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Despite the frequent use of maintenance intravenous fluids (mIVF) in critically ill patients, limited guidance is available. Notably, fluid overload secondary to mIVF mismanagement is associated with significant adverse patient outcomes. The Four Rights (right drug, right dose, right duration, right patient) construct of fluid stewardship has been proposed for the safe evaluation and use of fluids. The purpose of this evidence-based review is to offer practical insights for the clinician regarding mIVF selection, dosing, and duration in line with the Four Rights of Fluid Stewardship.
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Affiliation(s)
- John R. Carr
- Department of Pharmacy, St. Joseph’s/Candler Health System, Savannah, GA, USA
| | - W. Anthony Hawkins
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Albany, GA, USA
- Department of Pharmacology and Toxicology, Medical College of Georgia at Augusta University, Albany, GA, USA
| | - Andrea Sikora Newsome
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, USA
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
| | - Susan E. Smith
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA, USA
| | - Amber B Clemmons
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, USA
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
| | - Christopher M. Bland
- Department of Pharmacy, St. Joseph’s/Candler Health System, Savannah, GA, USA
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Savannah, GA, USA
| | - Trisha N. Branan
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA, USA
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Matsuzaki M, Matsumoto N, Nagao K, Sawano H, Yokoyama H, Tahara Y, Hase M, Shirai S, Hazui H, Arimoto H, Kashiwase K, Kasaoka S, Motomura T, Kuroda Y, Yasuga Y, Yonemoto N, Nonogi H. Impact of Induced Therapeutic Hypothermia by Intravenous Infusion of Ice-Cold Fluids After Hospital Arrival in Comatose Survivors of Out-of-Hospital Cardiac Arrest With Initial Shockable Rhythm. Circ J 2021; 85:1842-1848. [PMID: 34261843 DOI: 10.1253/circj.cj-20-0793] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The effect of in-hospital rapid cooling by intravenous ice-cold fluids for comatose survivors of out-of-hospital cardiac arrest (OHCA) is unclear. METHODS AND RESULTS From the J-PULSE-HYPO study registry, data for 248 comatose survivors with return of spontaneous circulation (ROSC) who were treated with therapeutic hypothermia (34℃ for 12-72 h) after witnessed shockable OHCA were extracted. Patients were divided into 2 groups by the median collapse-to-ROSC interval (18 min), and then into 2 groups by cooling method (rapid cooling by intravenous ice-cold fluids vs. standard cooling). The primary endpoint was favorable neurological outcome (Cerebral Performance Category of 1 or 2) at 30 days after OHCA. In the whole cohort, the shorter collapse-to-ROSC interval group had significantly higher favorable neurological outcome than the longer collapse-to-ROSC interval group (78.2% vs. 46.8%, P<0.001). In the shorter collapse-to-ROSC interval group, no significant difference was observed in favorable neurological outcome between the 2 cooling groups (rapid cooling group: 79.4% vs. standard cooling group: 77.0%, P=0.75). In the longer collapse-to-ROSC interval group, however, favorable neurological outcome was significant higher in the rapid cooling group than in the standard cooling group (60.7% vs. 33.3%, P<0.01) and the adjusted odds ratio after rapid cooling was 3.069 (95% confidence interval 1.423-6.616, P=0.004). CONCLUSIONS In-hospital rapid cooling by intravenous ice-cold fluids improved neurologically intact survival in comatose survivors whose collapse-to-ROSC interval was delayed over 18 min after shockable OHCA.
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Affiliation(s)
| | | | - Ken Nagao
- Department of Cardiology, Nihon University Hospital
| | - Hirotaka Sawano
- Senri Critical Care Medical Center, Saiseikai Senri Hospital
| | | | | | - Mamoru Hase
- Emergency and Critical Care Center, Sapporo City University Hospital
| | | | - Hiroshi Hazui
- Emergency Medicine, Osaka Mishima Emergency and Critical Care Center
| | - Hideki Arimoto
- Emergency and Critical Care Medical Center, Osaka City General Hospital
| | | | - Shunji Kasaoka
- Disaster Medical Education and Research Center, Kumamoto University Hospital
| | | | - Yasuhiro Kuroda
- Emergency and Critical Care Center, Kagawa University Hospital
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4
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Bridwell RE, Long B, April MD. Does Therapeutic Hypothermia Improve Mortality and Neurologic Outcome in Critically Ill Patients? Ann Emerg Med 2020; 77:374-376. [PMID: 32807541 DOI: 10.1016/j.annemergmed.2020.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Rachel E Bridwell
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, TX
| | - Brit Long
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, TX
| | - Michael D April
- Department of Military Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; 4th Infantry Division, Fort Carson, CO
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Zhang DY, Gao T, Xu RJ, Sun L, Zhang CF, Bai L, Chen W, Liu KY, Zhou Y, Jiao X, Zhang GH, Guo RL, Li JX, Gao Y, Jiao WJ, Tian H. SIRT3 Transfection of Aged Human Bone Marrow-Derived Mesenchymal Stem Cells Improves Cell Therapy-Mediated Myocardial Repair. Rejuvenation Res 2020; 23:453-464. [PMID: 32228121 DOI: 10.1089/rej.2019.2260] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Sirtuin 3 (SIRT3) is a deacetylase important for antioxidant protection, cell longevity, and aging. We hypothesized that SIRT3 improve oxidative resistance of aged cells and improve cell therapy in aged patients. In vitro, the proliferation and oxidative resistance of human mesenchymal stem cells (hMSCs) significantly declined with age. The expression and activity of antioxidant enzymes, including catalase (CAT) and manganese superoxide dismutase (MnSOD), increased after transfection of SIRT3 in hMSCs from older donors (O-hMSCs). The protein level of Forkhead box O3a (FOXO3a) in nucleus increased after SIRT3 overexpression. The antioxidant capacity of O-hMSCs increased after SIRT3 overexpression. 3-Amino-1,2,4-triazole (3-AT, CAT inhibitor) or diethyldithiocarbamate (DETC, SOD inhibitor) that was used to inhibit CAT or SOD activity significantly blocked the antioxidant function of SIRT3. When two inhibitors were used together, the antioxidant function of SIRT3 almost disappeared. Following myocardial infarction and intramyocardial injections of O-hMSCs in rats in vivo, the survival rate of O-hMSCs increased by SIRT3 transfection. The cardiac function of rats was improved after SIRT3-overexpressed O-hMSC transplantation. The infarct size, collagen content, and expression levels of matrix metalloproteinase 2 (MMP2) and MMP9 decreased. Besides, the protein level of vascular endothelial growth factor A and vascular density increased after cell transplantation with SIRT3-modified O-hMSCs. These results indicate that damage resistance of hMSCs decline with age and SIRT3 might protect O-hMSCs against oxidative damage by activating CAT and MnSOD through transferring FOXO3a into nucleus. Meanwhile, the therapeutic effect of aged hMSC transplantation can be improved by SIRT3 overexpression.
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Affiliation(s)
- Dong-Yang Zhang
- Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China.,Future Medical Laboratory, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Tong Gao
- Future Medical Laboratory, The Second Affiliated Hospital of Harbin Medical University, Harbin, China.,Department of Cardiovascular Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Rong-Jian Xu
- Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Lu Sun
- Future Medical Laboratory, The Second Affiliated Hospital of Harbin Medical University, Harbin, China.,Department of Cardiovascular Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Chun-Feng Zhang
- Future Medical Laboratory, The Second Affiliated Hospital of Harbin Medical University, Harbin, China.,Department of Cardiovascular Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Long Bai
- Future Medical Laboratory, The Second Affiliated Hospital of Harbin Medical University, Harbin, China.,Department of Cardiovascular Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Wei Chen
- Future Medical Laboratory, The Second Affiliated Hospital of Harbin Medical University, Harbin, China.,Department of Cardiovascular Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Kai-Yu Liu
- Future Medical Laboratory, The Second Affiliated Hospital of Harbin Medical University, Harbin, China.,Department of Cardiovascular Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yang Zhou
- Future Medical Laboratory, The Second Affiliated Hospital of Harbin Medical University, Harbin, China.,Department of Cardiovascular Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xuan Jiao
- Future Medical Laboratory, The Second Affiliated Hospital of Harbin Medical University, Harbin, China.,Department of Cardiovascular Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Gui-Huan Zhang
- Future Medical Laboratory, The Second Affiliated Hospital of Harbin Medical University, Harbin, China.,Department of Cardiovascular Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Rui-Lin Guo
- The Second Clinical College of Harbin Medical University, Harbin, China
| | - Jing-Xuan Li
- The Second Clinical College of Harbin Medical University, Harbin, China
| | - Ying Gao
- The Second Clinical College of Harbin Medical University, Harbin, China
| | - Wen-Jie Jiao
- Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Hai Tian
- Future Medical Laboratory, The Second Affiliated Hospital of Harbin Medical University, Harbin, China.,Department of Cardiovascular Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
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Kim JG, Shin H, Choi HY, Kim W, Kim J, Moon S, Kim B, Ahn C, Lee J. Prognostic factors for neurological outcomes in Korean targeted temperature management recipients with return of spontaneous circulation after out-of-hospital cardiac arrests: A nationwide observational study. Medicine (Baltimore) 2020; 99:e19581. [PMID: 32282707 PMCID: PMC7440340 DOI: 10.1097/md.0000000000019581] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Targeted temperature management (TTM) is recommended for comatose patients after out-of-hospital cardiac arrests (OHCAs). Even after successful TTM, several factors could influence the neuroprotective effect of TTM. The aim of this study is to identify prognostic factors associated with good neurological outcomes in TTM recipients.This study used nationwide data during 2012 to 2016 to investigate prognostic factors associated with good neurological outcomes in patients who received TTM after the return of spontaneous circulation (ROSC). Multivariate logistic regression analysis was conducted to analyse the factors that may affect the neurological outcomes in the TTM recipients.The study included 1578 eligible patients, comprising 767 with good and 811 with poor neurological outcomes. Multivariable analyses showed that OHCA in public places (OR, 1.599; 95% CI, 1.100-2.323, P = .014), initial shockable rhythms (OR, 1.721; 95% CI, 1.191-2.486, P = .004), pre-hospital ROSCs (OR, 6.748; 95% CI, 4.703-9.682, P < .001), bystander cardiopulmonary resuscitation (CPR) (OR, 1.715; 95% CI, 1.200-2.450, P = .003), and primary coronary interventions (PCIs) (OR, 2.488; 95% CI, 1.639-3.778, P < .001) were statistically significantly associated with good neurological outcomes. Whereas, increase of age (OR, 0.962; 95% CI, 0.950-0.974, P < .001) and conventional cooling (OR, 0.478; 95% CI, 0.255-0.895, P = .021) were statistically significantly associated with poor neurological outcome.This study suggests that being younger, experiencing OHCA in public places, having initial shockable rhythm, pre-hospital ROSC, and bystander CPR, implementing PCIs and applying intravascular or surface cooling devices compared to conventional cooling method could predict good neurological outcomes in post-cardiac arrest patients who received TTM.
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Affiliation(s)
- Jae Guk Kim
- Department of Emergency Medicine, Hallym University College of Medicine
- Department of Emergency Medicine, Graduate School of Medicine, Kangwon National University, Chuncheon
| | - Hyungoo Shin
- Department of Emergency Medicine, Hanyang University College of Medicine, Hanyang University Guri Hospital, Guri
| | - Hyun Young Choi
- Department of Emergency Medicine, Hallym University College of Medicine
| | - Wonhee Kim
- Department of Emergency Medicine, Hallym University College of Medicine
| | - Jihoon Kim
- Department of Thoracic and Cardiovascular Surgery, Hallym University College of Medicine, Chuncheon
| | - Shinje Moon
- Department of Internal Medicine, Hallym University College of Medicine
| | - Bongyoung Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul
| | - Chiwon Ahn
- Department of Emergency Medicine, Armed Force Yangju Hospital, Yangju
| | - Juncheol Lee
- Department of Emergency Medicine, Armed Force Capital Hospital, Seongnam, Republic of Korea
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Kim YS, Cho JH, Shin MC, Park Y, Park CW, Tae HJ, Cho JH, Kim IS, Lee TK, Park YE, Ahn JH, Park JH, Kim DW, Won MH, Lee JC. Effects of regional body temperature variation during asphyxial cardiac arrest on mortality and brain damage in a rat model. J Therm Biol 2019; 87:102466. [PMID: 31999601 DOI: 10.1016/j.jtherbio.2019.102466] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/18/2019] [Accepted: 11/21/2019] [Indexed: 01/19/2023]
Abstract
To date, hypothermia has focused on improving rates of resuscitation to increase survival in patients sustaining cardiac arrest (CA). Towards this end, the role of body temperature in neuronal damage or death during CA needs to be determined. However, few studies have investigated the effect of regional temperature variation on survival rate and neurological outcomes. In this study, adult male rats (12 week-old) were used under the following four conditions: (i) whole-body normothermia (37 ± 0.5 °C) plus (+) no asphyxial CA, (ii) whole-body normothermia + CA, (iii) whole-body hypothermia (33 ± 0.5 °C)+CA, (iv) body hypothermia/brain normothermia + CA, and (v) brain hypothermia/body normothermia + CA. The survival rate after resuscitation was significantly elevated in groups exposed to whole-body hypothermia plus CA and body hypothermia/brain normothermia plus CA, but not in groups exposed to whole-body normothermia combined with CA and brain hypothermia/body normothermia plus CA. However, the group exposed to hypothermia/brain normothermia combined with CA exhibited higher neuroprotective effects against asphyxial CA injury, i.e. improved neurological deficit and neuronal death in the hippocampus compared with those involving whole-body normothermia combined with CA. In addition, neurological deficit and neuronal death in the group of rat exposed to brain hypothermia/body normothermia and CA were similar to those in the rats subjected to whole-body normothermia and CA. In brief, only brain hypothermia during CA was not associated with effective survival rate, neurological function or neuronal protection compared with those under body (but not brain) hypothermia during CA. Our present study suggests that regional temperature in patients during CA significantly affects the outcomes associated with survival rate and neurological recovery.
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Affiliation(s)
- Yoon Sung Kim
- Department of Emergency Medicine, School of Medicine, Kangwon National University, Chuncheon, Gangwon, 24341, Republic of Korea; Department of Emergency Medicine, Samcheok Medical Center, Samcheok, Kangwon, 25920, Republic of Korea
| | - Jun Hwi Cho
- Department of Emergency Medicine, School of Medicine, Kangwon National University, Chuncheon, Gangwon, 24341, Republic of Korea
| | - Myoung-Cheol Shin
- Department of Emergency Medicine, School of Medicine, Kangwon National University, Chuncheon, Gangwon, 24341, Republic of Korea
| | - Yoonsoo Park
- Department of Emergency Medicine, School of Medicine, Kangwon National University, Chuncheon, Gangwon, 24341, Republic of Korea
| | - Chan Woo Park
- Department of Emergency Medicine, School of Medicine, Kangwon National University, Chuncheon, Gangwon, 24341, Republic of Korea
| | - Hyun-Jin Tae
- Bio-Safety Research Institute, College of Veterinary Medicine, Chonbuk National University, Iksan, Chonbuk, 54596, Republic of Korea
| | - Jeong Hwi Cho
- Bio-Safety Research Institute, College of Veterinary Medicine, Chonbuk National University, Iksan, Chonbuk, 54596, Republic of Korea
| | - In-Shik Kim
- Bio-Safety Research Institute, College of Veterinary Medicine, Chonbuk National University, Iksan, Chonbuk, 54596, Republic of Korea
| | - Tae-Kyeong Lee
- Department of Neurobiology, School of Medicine, Kangwon National University, Chuncheon, Gangwon, 24341, Republic of Korea
| | - Young Eun Park
- Department of Neurobiology, School of Medicine, Kangwon National University, Chuncheon, Gangwon, 24341, Republic of Korea
| | - Ji Hyeon Ahn
- Department of Biomedical Science and Research Institute for Bioscience and Biotechnology, Hallym University, Chuncheon, Gangwon, 24252, Republic of Korea
| | - Joon Ha Park
- Department of Anatomy, College of Korean Medicine, Dongguk University, Gyeongju, Gyeongbuk, 38066, Republic of Korea
| | - Dae Won Kim
- Department of Biochemistry and Molecular Biology, Research Institute of Oral Sciences, College of Dentistry, Kangnung-Wonju National University, Gangneung, Gangwon, 25457, Republic of Korea
| | - Moo-Ho Won
- Department of Neurobiology, School of Medicine, Kangwon National University, Chuncheon, Gangwon, 24341, Republic of Korea.
| | - Jae-Chul Lee
- Department of Neurobiology, School of Medicine, Kangwon National University, Chuncheon, Gangwon, 24341, Republic of Korea.
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Assis FR, Bigelow MEG, Chava R, Sidhu S, Kolandaivelu A, Halperin H, Tandri H. Efficacy and Safety of Transnasal CoolStat Cooling Device to Induce and Maintain Hypothermia. Ther Hypothermia Temp Manag 2019; 9:108-117. [PMID: 30234442 PMCID: PMC6588101 DOI: 10.1089/ther.2018.0014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Targeted temperature management (TTM) is recommended as a standard of care for postcardiac arrest patients. Current TTM methods have significant limitations to be used in an ambulatory setting. We investigated the efficacy and safety of a novel noninvasive transnasal evaporative cooling device (CoolStat™). Eleven Yorkshire pigs underwent hypothermia therapy using the CoolStat device. CoolStat induces evaporative cooling by blowing dehumidified ambient air over the nasal turbinates in a unidirectional fashion. CoolStat's efficacy and safety were assessed by applying different cooling strategies (groups A, B and C). In group A (efficacy study; n = 5, TTM for 8 hours), time to achieve brain target temperature (2°C reduction from baseline), and the percentage of time in which the temperature ranged within ±0.5°C after reaching the target temperature were investigated. In the safety assessment (groups B and C), two worst-case therapy situations were reproduced: in group B (n = 3), continuous maximum air flow (65 L/min) was applied without temperature control and, in group C (n = 3), subjects underwent 24-hour TTM (prolonged therapy). Hemodynamic and respiratory parameters, nasal mucosa integrity (endoscopic assessment), and other therapy-related adverse effects were evaluated. Efficacy study: CoolStat cooling therapy successfully induced and sustained managed hypothermia in all subjects. Brain target temperature was achieved in 0.5 ± 0.6 hours and kept within a ±0.5°C range for the therapy duration (99.9% ± 0.1%). All animals completed the safety studies. Maximum air flow (group B) and 24-hour (group C) therapies were well tolerated and no significant damage was observed on nasal mucosa for neither of the groups. CoolStat was able to efficiently induce and maintain hypothermia using unidirectional high flow of dry air into the nostrils of porcine models. CoolStat therapy was well tolerated and no damage to nasal mucosa was observed under either maximum air flow or prolonged therapy.
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Affiliation(s)
- Fabrizio R. Assis
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - M. Emma G. Bigelow
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Raghuram Chava
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sunjeet Sidhu
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Aravindan Kolandaivelu
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Henry Halperin
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Harikrishna Tandri
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Contemporary Management of Increased Intraoperative Intracranial Pressure: Evidence-Based Anesthetic and Surgical Review. World Neurosurg 2019; 129:120-129. [PMID: 31158533 DOI: 10.1016/j.wneu.2019.05.224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 05/26/2019] [Accepted: 05/27/2019] [Indexed: 12/29/2022]
Abstract
Increased intracranial pressure (ICP) is frequently encountered in the neurosurgical setting. A multitude of tactics exists to reduce ICP, ranging from patient position and medications to cerebrospinal fluid diversion and surgical decompression. A vast amount of literature has been published regarding ICP management in the critical care setting, but studies specifically tailored toward the management of intraoperative acute increases in ICP or brain bulk are lacking. Compartmentalizing the intracranial space into blood, brain tissue, and cerebrospinal fluid and understanding the numerous techniques available to affect these individual compartments can guide the surgical team to quickly identify increased brain bulk and respond appropriately. Rapidly instituting measures for brain relaxation in the operating room is essential in optimizing patient outcomes. Knowledge of the efficacy, rapidity, feasibility, and risks of the various available interventions can aid the team to properly tailor their approach to each individual patient. In this article, we present the first evidence-based review of intraoperative management of ICP and brain bulk.
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Kay Bader M, Figueroa SA, Wavra T, Livesay SL, Cahoon WD, Hamilton LA. Clinical Q & A: Translating Therapeutic Temperature Management from Theory to Practice. Ther Hypothermia Temp Manag 2018; 8:245-249. [PMID: 30427772 DOI: 10.1089/ther.2018.29050.mkb] [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
Affiliation(s)
| | - Stephen A Figueroa
- Division of Neurocritical Care, The University of Texas Southwestern Medical Center Dallas, Texas
| | | | - Sarah L Livesay
- Department of Adult and Gerontological Nursing. Rush University, College of Nursing, Chicago, Illinois
| | - William D Cahoon
- Coronary and Cardiothoracic Intensive Care, VCU Health System, Richmond, Virginia
| | - Leslie A Hamilton
- Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Knoxville, Tennessee
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11
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Effects of Intravenous Cold Saline on Hyperthermic Athletes Representative of Large Football Players and Small Endurance Runners. Clin J Sport Med 2018; 28:493-499. [PMID: 29112514 DOI: 10.1097/jsm.0000000000000505] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the cooling effects of intravenous (IV) cold normal (0.9%) saline on hyperthermic athletes. DESIGN Randomized crossover study design. SETTING Controlled research laboratory. PARTICIPANTS Twelve male participants who were representative of a collegiate cross-country (6) and American football (6) population. INTERVENTIONS Participants underwent body composition analysis using a BodPod. They were placed in an environmentally controlled chamber and brought to a Tc of 39.5°C with dynamic exercise. When temperatures were reached, they were treated with either 2 L of cold saline (CS) (4°C) or intravenous room temperature (22°C) saline (RS) over a ∼30-minute period. Tre was measured with a rectal temperature probe every minute during the treatment period. MAIN OUTCOME MEASURES Total ΔTre (ending Tre - starting Tre) and cooling rate (total change in Tre/time) were measured for each condition, and body composition variables calculated included body surface area (BSA), BSA-to-mass ratio (BSA/mass), lean body mass, and body fat percentage (%BF) (P < 0.05). RESULTS Statistically significant differences were found in the total ΔTre and cooling rate between the CS and RS trials. The cooling rate for the CS trials was significantly correlated to mass, BSA, BSA/mass, and %BF. CONCLUSIONS In hyperthermic athletes, core temperature was reduced more effectively using chilled saline during IV infusion. Body composition had a significant impact on overall cooling revealing that the smaller and leaner participants cooled at a greater rate. When indicated, CS infusion could be considered for cooling hyperthermic individuals when other methods are not available.
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12
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Khera R, Humbert A, Leroux B, Nichol G, Kudenchuk P, Scales D, Baker A, Austin M, Newgard CD, Radecki R, Vilke GM, Sawyer KN, Sopko G, Idris AH, Wang H, Chan PS, Kurz MC. Hospital Variation in the Utilization and Implementation of Targeted Temperature Management in Out-of-Hospital Cardiac Arrest. Circ Cardiovasc Qual Outcomes 2018; 11:e004829. [DOI: 10.1161/circoutcomes.118.004829] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Rohan Khera
- Division of Cardiology, UT Southwestern Medical Center, Dallas, TX (R.K.)
| | - Andrew Humbert
- Clinical Trial Center, Department of Biostatistics (A.H., B.L.), University of Washington, Seattle
| | - Brian Leroux
- Clinical Trial Center, Department of Biostatistics (A.H., B.L.), University of Washington, Seattle
| | - Graham Nichol
- Department of Medicine (G.N., P.K.), University of Washington, Seattle
| | - Peter Kudenchuk
- Department of Medicine (G.N., P.K.), University of Washington, Seattle
| | - Damon Scales
- Department of Medicine, University of Toronto, Ontario, Canada (D.S., A.B.)
| | - Andrew Baker
- Department of Medicine, University of Toronto, Ontario, Canada (D.S., A.B.)
| | - Mike Austin
- Department of Emergency Medicine, University of Ottawa, Ontario, Canada (M.A.)
| | - Craig D. Newgard
- Department of Emergency Medicine, Oregon Health & Science University, Portland (C.D.N.)
| | - Ryan Radecki
- Department of Emergency Medicine, Kaiser Permanente Northwest, Portland, OR (R.R.)
| | - Gary M. Vilke
- Department of Emergency Medicine, University of California San Diego, CA (G.M.V.)
| | - Kelly N. Sawyer
- Department of Emergency Medicine, University of Pittsburgh, PA (K.N.S.)
| | - George Sopko
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MA (G.S.)
| | - Ahamed H. Idris
- Departments of Emergency Medicine and Internal Medicine, UT Southwestern Medical Center, Dallas, TX (A.H.I.)
| | - Henry Wang
- Department of Emergency Medicine, University of Texas Health Sciences Center at Houston (H.W.)
| | - Paul S. Chan
- Mid America Heart Institute, Kansas City and the University of Missouri-Kansas City, MO (P.S.C.)
| | - Michael C. Kurz
- Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham (M.C.K.)
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Abstract
Evidence from animal models indicates that lowering temperature by a few degrees can produce substantial neuroprotection. In humans, hypothermia has been found to be neuroprotective with a significant impact on mortality and long-term functional outcome only in cardiac arrest and neonatal hypoxic-ischemic encephalopathy. Clinical trials have explored the potential role of maintaining normothermia and treating fever in critically ill brain injured patients. This review concentrates on basic concepts to understand the physiologic interactions of thermoregulation, effects of thermal modulation in critically ill patients, proposed mechanisms of action of temperature modulation, and practical aspects of targeted temperature management.
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Livesay SL, Hamilton LA, Cahoon WD, Figueroa SA, Lovejoy DG, Baumann JJ, Kupchik N. Clinical Q & A: Translating Therapeutic Temperature Management from Theory to Practice. Ther Hypothermia Temp Manag 2018; 8:181-185. [PMID: 30067455 DOI: 10.1089/ther.2018.29046.mkb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Sarah L Livesay
- 2 Department of Adult and Gerontological Nursing, College of Nursing, Rush University , Chicago, Illinois
| | - Leslie A Hamilton
- 3 University of Tennessee Health Science Center , College of Pharmacy, Knoxville, Tennessee
| | - William D Cahoon
- 4 Coronary and Cardiothoracic Intensive Care, VCU Health System , Richmond, Virginia
| | - Stephen A Figueroa
- 5 Division of Neurocritical Care, The University of Texas Southwestern Medical Center , Dallas, Texas
| | | | - J J Baumann
- 6 UC Health Memorial Hospital , Colorado Springs, Colorado
| | - Nicole Kupchik
- 7 Nicole Kupchik Consulting and Education , Seattle, Washington
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15
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Abstract
Evidence from animal models indicates that lowering temperature by a few degrees can produce substantial neuroprotection. In humans, hypothermia has been found to be neuroprotective with a significant impact on mortality and long-term functional outcome only in cardiac arrest and neonatal hypoxic-ischemic encephalopathy. Clinical trials have explored the potential role of maintaining normothermia and treating fever in critically ill brain injured patients. This review concentrates on basic concepts to understand the physiologic interactions of thermoregulation, effects of thermal modulation in critically ill patients, proposed mechanisms of action of temperature modulation, and practical aspects of targeted temperature management.
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Affiliation(s)
- Fred Rincon
- Division of Critical Care and Neurotrauma, Department of Neurology, Sidney-Kimmel College of Medicine, Thomas Jefferson University, 909 Walnut Street, 3rd Floor, Philadelphia, PA 19107, USA; Division of Critical Care and Neurotrauma, Department of Neurological Surgery, Sidney-Kimmel College of Medicine, Thomas Jefferson University, 909 Walnut Street, 3rd Floor, Philadelphia, PA 19107, USA.
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16
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Abstract
Following return of spontaneous circulation (ROSC) after cardiac arrest, the challenge is to institute measures that ensure a higher likelihood of neurologically intact survival. Regardless of the cause of collapse, multiple organ systems may be affected secondary to post-cardiac arrest syndrome. Interventions required for post-ROSC care are bundled into a care regimen: prompt identification and treatment of the cause of cardiac arrest; and treatment of electrolyte abnormalities. It is also essential to establish definitive airway management to maintain normocapnic ventilation, prevent hyperoxia, and optimise haemodynamic management via judicious intravenous fluids and vasoactive drugs. Targeted temperature management after ROSC confers neuroprotection and leads to improved neurological outcomes. Glycaemic control of blood glucose levels at 6-10 mmol/L, adequate seizure management and measures to optimise neurological functions should be integrated into the care bundle. The interventions outlined can potentially lead to more patients being discharged from hospital alive with good neurological function.
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Affiliation(s)
- Sohil Pothiawala
- Department of Emergency Medicine, Singapore General Hospital, Singapore
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17
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Suppogu N, Panza GA, Kilic S, Gowdar S, Kallur KR, Jayaraman R, Lundbye J, Fernandez AB. The Effects of In-Hospital Intravenous Cold Saline in Postcardiac Arrest Patients Treated with Targeted Temperature Management. Ther Hypothermia Temp Manag 2018; 8:18-23. [DOI: 10.1089/ther.2017.0023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Nissi Suppogu
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Gregory A. Panza
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
- Department of Kinesiology, University of Connecticut, Storrs, Connecticut
| | - Sena Kilic
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Shreyas Gowdar
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Kamala R. Kallur
- Department of Medicine, St. Luke's-Roosevelt Hospital, New York, New York
| | - Ramya Jayaraman
- Department of Medicine, Saint Vincent's Hospital, Bridgeport, Connecticut
| | - Justin Lundbye
- Division of Cardiology, Hospital of Central Connecticut, New Britain, Connecticut
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Lee SH, Youn YN, Chang BC, Joo HC, Lee S, Yoo KJ. Effect of Patient-Prosthesis Mismatch in Aortic Position on Late-Onset Tricuspid Regurgitation and Clinical Outcomes after Double Valve Replacement. Yonsei Med J 2017; 58:968-974. [PMID: 28792140 PMCID: PMC5552651 DOI: 10.3349/ymj.2017.58.5.968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 06/08/2017] [Accepted: 06/27/2017] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Significant late-onset tricuspid regurgitation (TR) is unfortunately common after double valve replacement (DVR); however, its underlying factors remain undefined. We evaluated the effect of aortic patient-prosthesis mismatch (PPM) on late-onset TR and clinical outcomes after DVR. MATERIALS AND METHODS Of the 2392 consecutive patients who underwent aortic valve replacement between January 1990 and May 2014 at our institution, we retrospectively studied 462 patients who underwent DVR (excluding concomitant tricuspid valvular annuloplasty or replacement). Survival and freedom from grade >3 TR were compared between PPM (n=152) and non-PPM (n=310) groups using the Kaplan-Meier method. RESULTS Although the overall survival rates were similar between the two groups at 5 and 10 years (95%, 91% vs. 96%, 93%, p=0.412), grade >3 TR-free survival was significantly lower in the PPM group (98%, 91% vs. 99%, 95%, p=0.014). Small body-surface area, atrial fibrillation, PPM, and subaortic pannus were risk factors for TR progression. However, aortic prosthesis size and trans-valvular pressure gradient were not significant factors for either TR progression or overall survival. CONCLUSION Aortic PPM in DVR, regardless of mitral prosthesis size, was associated with late TR progression, but was not significantly correlated with overall survival. Therefore, we recommend careful echocardiographic follow-up for the early detection of TR progression in patients with aortic PPM in DVR.
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Affiliation(s)
- Seung Hyun Lee
- Division of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Young Nam Youn
- Division of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Chul Chang
- Division of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Chel Joo
- Division of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sak Lee
- Division of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea.
| | - Kyung Jong Yoo
- Division of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
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20
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Wu D, Shi J, Elmadhoun O, Duan Y, An H, Zhang J, He X, Meng R, Liu X, Ji X, Ding Y. Dihydrocapsaicin (DHC) enhances the hypothermia-induced neuroprotection following ischemic stroke via PI3K/Akt regulation in rat. Brain Res 2017; 1671:18-25. [PMID: 28684048 DOI: 10.1016/j.brainres.2017.06.029] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 06/27/2017] [Accepted: 06/28/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Hypothermia has demonstrated neuroprotection following ischemia in preclinical studies while its clinical application is still very limited. The aim of this study was to explore whether combining local hypothermia in ischemic territory achieved by intra-arterial cold infusions (IACIs) with pharmacologically induced hypothermia enhances therapeutic outcomes, as well as the underlying mechanism. METHODS Sprague-Dawley rats were subjected to right middle cerebral artery occlusion (MCAO) for 2h using intraluminal hollow filament. The ischemic rats were randomized to receive: 1) pharmacological hypothermia by intraperitoneal (i.p.) injection of dihydrocapsaicin (DHC); 2) physical hypothermia by IACIs for 10min; or 3) the combined treatments. Extent of brain injury was determined by neurological deficit, infarct volume, and apoptotic cell death at 24h and/or 7d following reperfusion. ATP and ROS levels were measured. Expression of p-Akt, cleaved Caspase-3, pro-apoptotic (AIF, Bax) and anti-apoptotic proteins (Bcl-2, Bcl-xL) was evaluated at 24h. Finally, PI3K inhibitor was used to determine the effect of p-Akt. RESULTS DHC or IACIs each exhibited hypothermic effect and neuroprotection in rat MCAO models. The combination of pharmacological and physical approaches led to a faster and sustained reduction in brain temperatures and improved ischemia-induced injury than either alone (P<0.01). Furthermore, the combination treatment favorably increased the expression of anti-apoptotic proteins and decreased pro-apoptotic protein levels (P<0.01 or 0.05). This neuroprotective effect was largely blocked by p-Akt inhibition, indicating a potential role of Akt pathway in this mechanism (P<0.01 or 0.05). CONCLUSIONS The combination approach is able to enhance the efficiency of hypothermia and efficacy of hypothermia-induced neuroprotection following ischemic stroke. The findings here move us a step closer towards translating this long recognized TH from bench to bedside.
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Affiliation(s)
- Di Wu
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Jingfei Shi
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Beijing, China
| | - Omar Elmadhoun
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Yunxia Duan
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hong An
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jun Zhang
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiaoduo He
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ran Meng
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiangrong Liu
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xunming Ji
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.
| | - Yuchuan Ding
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China; Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
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21
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Yuan W, Wu JY, Zhao YZ, Li J, Li JB, Li ZH, Li CS. Comparison of early sequential hypothermia and delayed hypothermia on neurological function after resuscitation in a swine model. Am J Emerg Med 2017; 35:1645-1652. [PMID: 28521971 DOI: 10.1016/j.ajem.2017.05.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 05/09/2017] [Accepted: 05/10/2017] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND We utilized a porcine cardiac arrest model to compare early sequential hypothermia (ESH) with delayed hypothermia (DH) and no hypothermia (NH) to investigate the different effects on cerebral function after resuscitation. METHODS After return of spontaneous circulation (ROSC), resuscitated 24 pigs divided into three groups. The ESH group implemented early sequential hypothermia immediately, and the DH group implemented delayed hypothermia at 1 h after ROSC. The core temperature, hemodynamic parameters and oxygen metabolism were recorded. Cerebral metabolism variables and neurotransmitter in the extracellular fluid were collected through the microdialysis tubes. The bloods were analyzed for venous jugular bulb oxygen saturation, lactate and neuron specific nolase. The cerebral function was evaluated using the cerebral performance category and neurologic deficit score at 72h after ROSC and cerebral histology in the right posterior frontal lobe were collected. RESULTS ESH reached the target temperature earlier and showed more favorable outcomes of neurological function than DH. Specifically, early sequential hypothermia reduced cerebral oxygen and energy consumption and decreased extracellular accumulation of neurotransmitters after resuscitation and protected the integrity of the BBB during reperfusion. CONCLUSIONS Early sequential hypothermia could increase the protection of neurological function after resuscitation and produce better neurological outcomes. The institutional protocol number: 2010-D-013.
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Affiliation(s)
- Wei Yuan
- Department of Emergency, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China; Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, China
| | - Jun-Yuan Wu
- Department of Emergency, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China; Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, China
| | - Yong-Zhen Zhao
- Department of Emergency, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China; Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, China
| | - Jie Li
- Department of Emergency, Beijing Fu-Xing Hospital, Capital Medical University, Beijing 100038, China
| | - Jie-Bin Li
- Department of Emergency, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Zhen-Hua Li
- Department of Emergency, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Chun-Sheng Li
- Department of Emergency, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China; Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, China.
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22
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Liu P, Yang R, Zuo Z. Application of a novel rectal cooling device in hypothermia therapy after cerebral hypoxia-ischemia in rats. BMC Anesthesiol 2016; 16:77. [PMID: 27613331 PMCID: PMC5017120 DOI: 10.1186/s12871-016-0239-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 08/24/2016] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND A new rectal cooling device for therapeutic hypothermia (TH) therapy is designed and is applied in TH treatment of SD rats with ischemic-hypoxic brain damage. METHODS Healthy adult SD rats (n = 45) were randomly assigned into four groups: the healthy control group (n = 5), the ischemia and hypoxia group (n = 10), the rectal TH cooling group (n = 18), and the ice blanket TH cooling group (n = 11). The rats in the rectal cooling and ice blanket TH groups received 12 h treatment after hypoxic-ischemic brain damage had been established, while those in the ischemia and hypoxia group did not. Taking the start of TH as the zero point, rats were sacrificed after 24 h and the brain and rectum tissues were sampled for histological analysis. RESULTS The TH induction time (37.3 ± 14.7 min) in the rectal cooling group was significantly shorter (F = 4.937, P < 0.05) than that in the ice blanket cooling group (75.6 ± 27.2 min). The HE and NISSL staining results showed that rats in the rectal TH cooling group had significantly decreased (P < 0.01) positive neurons cell count compared to those in ischemia and hypoxia group. In addition, TUNEL staining indicated that the number of apoptotic cells (3.9 ± 1.8 cells / × 400 field) and the apoptosis index (4.4 % ± 1.5) were significantly lower in rectal TH cooling group (P < 0.05) than in ischemia and hypoxia group (23.2 ± 12.1 cells / × 400 field, 26.6 % ± 12.1). Also, no rectal frostbite or inflammatory infiltration was observed in rats in the rectal TH treatment groups. CONCLUSION Our new cooling device realized rapid TH induction in SD rats with ischemic-hypoxic brain damage, inhibited the apoptosis of cells in the hippocampal CAl region, and did not cause histological damage to the rectal tissues.
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Affiliation(s)
- Peng Liu
- Department of PICU, Children’s Hospital of Chongqing Medical University, Chongqing, 400014 China
- Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, 400014 China
| | - Rui Yang
- Department of PICU, Children’s Hospital of Chongqing Medical University, Chongqing, 400014 China
| | - Zelan Zuo
- Department of PICU, Children’s Hospital of Chongqing Medical University, Chongqing, 400014 China
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Prehospital therapeutic hypothermia after out-of-hospital cardiac arrest: a systematic review and meta-analysis. Am J Emerg Med 2016; 34:2209-2216. [PMID: 27658332 DOI: 10.1016/j.ajem.2016.09.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 09/01/2016] [Accepted: 09/03/2016] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The effectiveness and safety of the infusion of ice-cold fluids for prehospital hypothermia in cardiac arrest victims are unclear. This study assessed its effects in adult victims of out-of-hospital cardiac arrest. METHODS An online search of PubMed and Cochrane Library databases was performed. Cooling methods were limited to ice-cold fluid perfusion. Randomized controlled trials were included in this review. The main outcomes were body temperature at hospital arrival, survival to hospital discharge, neurological recovery, incidence of pulmonary edema, and the rate of rearrest. RESULTS Among 1155 citations, 5 studies were included in this meta-analysis. The pooled analysis of these studies revealed no differences in survival to hospital discharge, favorable neurological outcomes, and incidence of pulmonary edema between the treatment group and control group. There were significant differences in body temperature at hospital arrival (I2 = 0.0%, χ2 = 2.58, MD = -0.760, 95% confidence interval = -0.938 to -0.581, P < .001) and the rate of rearrest (I2 = 0.0%, χ2 = 0.69, 95% confidence interval = 1.109 to 1.479, P = .031). CONCLUSIONS Prehospital therapeutic hypothermia induced by intravenous infusion of ice-cold fluids in patients with out-of-hospital cardiac arrest decreased body temperature at hospital arrival but did not improve survival to hospital discharge and favorable neurological outcomes. Ice-cold fluid infusion did not increase the incidence of pulmonary edema but increased the incidence of rearrests.
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Wander PL, Enquobahrie DA, Pritchard CC, McKnight B, Rice K, Christiansen M, Lemaitre RN, Rea T, Siscovick D, Sotoodehnia N. Circulating microRNAs and sudden cardiac arrest outcomes. Resuscitation 2016; 106:96-101. [PMID: 27423422 DOI: 10.1016/j.resuscitation.2016.06.038] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 06/15/2016] [Accepted: 06/24/2016] [Indexed: 10/21/2022]
Abstract
AIM MicroRNAs (miRNAs) have regulatory functions in organs critical in resuscitation from sudden cardiac arrest due to ventricular fibrillation (VF-SCA); therefore, circulating miRNAs may be markers of VF-SCA outcome. METHODS We measured candidate miRNAs (N=45) in plasma using qRT-PCR among participants of a population-based VF-SCA study. Participants were randomly selected cases who died in the field (DF, n=15), died in hospital (DH, n=15), or survived to discharge (DC, n=15), and, age-, sex-, and race-matched controls (n=15). MiRNA levels were compared using ANOVA, t-tests, and fold-changes. RESULTS Mean age of groups ranged from 66.9 to 69.7. Most participants were male (53-67%) and white (67%). Comparing cases to controls, plasma levels of 17 miRNAs expressed in heart, brain, liver, and other tissues (including miR-29c, -34a, -122, -145, -200a, -210, -499-5p, and -663b) were higher and three non-specific miRNAs lower (miR-221, -330-3p, and -9-5p). Among DH or DC compared with DF cases, levels of two miRNAs (liver-specific miR-122 and non-specific miR-205) were higher and two heart-specific miRNAs (miR-208b and -499-5p) lower. Among DC vs. DF cases, levels of three miRNAs (miR-122, and non-specific miR-200a and -205) were higher and four heart-specific miRNAs (miR-133a, -133b, -208b, and -499-5p) lower. Among DC vs. DH cases, levels of two non-specific miRNAs (miR-135a and -9-3p) were lower. CONCLUSIONS Circulating miRNAs expressed in heart, brain, and other tissues differ between VF-SCA cases and controls and are related to resuscitation outcomes. Measurement of miRNAs may clarify mechanisms underlying resuscitation, improve prognostication, and guide development of therapies. Results require replication.
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Affiliation(s)
- P L Wander
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, WA, USA; VA Puget Sound Health Care System, Seattle, WA, USA.
| | - D A Enquobahrie
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - C C Pritchard
- Department of Laboratory Medicine, University of Washington, Seattle, WA, USA
| | - B McKnight
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - K Rice
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - M Christiansen
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, WA, USA
| | - R N Lemaitre
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, WA, USA
| | - T Rea
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, WA, USA; Public Health-Seattle and King County, Emergency Medical Services Division, Seattle, WA, USA
| | - D Siscovick
- New York Academy of Medicine, New York, NY, USA
| | - N Sotoodehnia
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, USA
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Wang B, Wu D, Dornbos III D, Shi J, Ma Y, Zhang M, Liu Y, Chen J, Ding Y, Luo Y, Ji X. Local cerebral hypothermia induced by selective infusion of cold lactated ringer’s: a feasibility study in rhesus monkeys. Neurol Res 2016; 38:545-52. [DOI: 10.1080/01616412.2016.1187827] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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26
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Su Y, Fan L, Zhang Y, Zhang Y, Ye H, Gao D, Chen W, Liu G. Improved Neurological Outcome With Mild Hypothermia in Surviving Patients With Massive Cerebral Hemispheric Infarction. Stroke 2016; 47:457-63. [PMID: 26696645 DOI: 10.1161/strokeaha.115.009789] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 11/16/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Yingying Su
- From the Department of Neurology, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Linlin Fan
- From the Department of Neurology, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Yunzhou Zhang
- From the Department of Neurology, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Yan Zhang
- From the Department of Neurology, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Hong Ye
- From the Department of Neurology, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Daiquan Gao
- From the Department of Neurology, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Weibi Chen
- From the Department of Neurology, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Gang Liu
- From the Department of Neurology, Xuan Wu Hospital, Capital Medical University, Beijing, China
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27
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Kudenchuk PJ, Sandroni C, Drinhaus HR, Böttiger BW, Cariou A, Sunde K, Dworschak M, Taccone FS, Deye N, Friberg H, Laureys S, Ledoux D, Oddo M, Legriel S, Hantson P, Diehl JL, Laterre PF. Breakthrough in cardiac arrest: reports from the 4th Paris International Conference. Ann Intensive Care 2015; 5:22. [PMID: 26380990 PMCID: PMC4573754 DOI: 10.1186/s13613-015-0064-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 08/18/2015] [Indexed: 02/08/2023] Open
Abstract
Jean-Luc Diehl The French Intensive Care Society organized on 5th and 6th June 2014 its 4th "Paris International Conference in Intensive Care", whose principle is to bring together the best international experts on a hot topic in critical care medicine. The 2014 theme was "Breakthrough in cardiac arrest", with many high-quality updates on epidemiology, public health data, pre-hospital and in-ICU cares. The present review includes short summaries of the major presentations, classified into six main chapters: Epidemiology of CA Pre-hospital management Post-resuscitation management: targeted temperature management Post-resuscitation management: optimizing organ perfusion and metabolic parameters Neurological assessment of brain damages Public healthcare.
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Affiliation(s)
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy.
| | - Hendrik R Drinhaus
- Department of Anaesthesiology and Intensive Care Medicine, University of Koeln, Cologne, Germany.
| | - Bernd W Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University of Koeln, Cologne, Germany.
| | - Alain Cariou
- Medical Intensive Care Unit, AP-HP, Cochin Hospital, Paris, France.
- Paris Descartes University and Sorbonne Paris Cité-Medical School and INSERM U970 (Team 4), Cardiovascular Research Center, European Georges Pompidou Hospital, Paris, France.
| | - Kjetil Sunde
- Division of Emergencies and Critical Care, Department of Anaesthesiology, Surgical Intensive Care Unit Ullevål, Oslo University Hospital, Oslo, Norway.
| | - Martin Dworschak
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Vienna General Hospital, Medical University Vienna, Vienna, Austria.
| | - Fabio Silvio Taccone
- Department of Intensive Care, Laboratoire de Recherche Experimentale, Erasme Hospital, Brussels, Belgium.
| | - Nicolas Deye
- Medical Intensive Care Unit, AP-HP, Lariboisière University Hospital, Inserm U942, Paris, France.
| | - Hans Friberg
- Anaesthesiology and Intensive Care Medicine, Skåne University Hospital, Lund University, Lund, Sweden.
| | - Steven Laureys
- Coma Science Group, Cyclotron Research Centre, University of Liège and Liège 2 Department of Neurology, University Hospital of Liège, Liège, Belgium.
| | - Didier Ledoux
- Coma Science Group, Cyclotron Research Centre, University of Liège and Department of Intensive Care Medicine, University Hospital of Liège, Liège, Belgium.
| | - Mauro Oddo
- Department of Intensive Care Medicine, Faculty of Biology and Medicine, CHUV-University Hospital, Lausanne, Switzerland.
| | - Stéphane Legriel
- Intensive Care Unit, Centre Hospitalier de Versailles, Le Chesnay, France.
| | - Philippe Hantson
- Department of Intensive Care, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.
| | - Jean-Luc Diehl
- Medical Intensive Care Unit, AP-HP, European Georges Pompidou Hospital, Paris Descartes University and Sorbonne Paris Cité-Medical School, Paris, France.
| | - Pierre-Francois Laterre
- Department of Intensive Care, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain Brussels, Brussels, Belgium.
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Vargas M, Sutherasan Y, Servillo G, Pelosi P. What is the proper target temperature for out-of-hospital cardiac arrest? Best Pract Res Clin Anaesthesiol 2015; 29:425-34. [PMID: 26670814 DOI: 10.1016/j.bpa.2015.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 09/21/2015] [Indexed: 12/21/2022]
Abstract
The implementation of target temperature management (TTM) or therapeutic hypothermia has been demonstrated in several major studies to be an effective neuroprotective strategy in postresuscitation care after cardiac arrest. Although several landmark studies found the promising results of lower targeted temperature (32-34 °C) in terms of survival and neurological outcomes, recent evidence showed no difference in either survival or long-term neurological outcome when compared with higher targeted temperature (36 °C). Thus, recent data suggest that avoiding hyperpyrexia, rather than cooling "per se," may be considered the main therapeutic target to avoid secondary brain damage after out-of-hospital cardiac arrest. Many questions are still debated about the exact protocol of TTM to be used, including whether temperature control is more beneficial than standard of care without active temperature control, the optimal cooling temperature, patient selection, and duration of cooling. The aim of this review article was to discuss the physiology of hypothermia, available cooling methods, and current evidence about the optimal target temperature and timing of hypothermia.
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Affiliation(s)
- Maria Vargas
- Department of Neuroscience and Reproductive and Odontostomatological, Sciences, University of Naples "Federico II", Naples, Italy.
| | - Yuda Sutherasan
- Division of Pulmonary and Critical Care Unit, Department of Medicine, Ramathibodi Hospital, Mahidol University 270 RAMA VI Road, Bangkok 10400, Thailand.
| | - Giuseppe Servillo
- Department of Neuroscience and Reproductive and Odontostomatological, Sciences, University of Naples "Federico II", Naples, Italy.
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics IRCCS AOU San Martino-IST, Largo Rosanna Benzi 8, Genoa 16131, Italy.
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Callaway CW, Elmer J, Guyette FX, Molyneaux BJ, Anderson KB, Empey PE, Gerstel SJ, Holquist K, Repine MJ, Rittenberger JC. Dexmedetomidine Reduces Shivering during Mild Hypothermia in Waking Subjects. PLoS One 2015; 10:e0129709. [PMID: 26237219 PMCID: PMC4523180 DOI: 10.1371/journal.pone.0129709] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 05/12/2015] [Indexed: 12/20/2022] Open
Abstract
Background and Purpose Reducing body temperature can prolong tolerance to ischemic injury such as stroke or myocardial infarction, but is difficult and uncomfortable in awake patients because of shivering. We tested the efficacy and safety of the alpha-2-adrenergic agonist dexmedetomidine for suppressing shivering induced by a rapid infusion of cold intravenous fluids. Methods Ten subjects received a rapid intravenous infusion of two liters of cold (4°C) isotonic saline on two separate test days, and we measured their core body temperature, shivering, hemodynamics and sedation for two hours. On one test day, fluid infusion was preceded by placebo infusion. On the other test day, fluid infusion was preceded by 1.0 μg/kg bolus of dexmedetomidine over 10 minutes. Results All ten subjects experienced shivering on placebo days, with shivering beginning at a mean (SD) temperature of 36.6 (0.3)°C. The mean lowest temperature after placebo was 36.0 (0.3)°C (range 35.7-36.5°C). Only 3/10 subjects shivered on dexmedetomidine days, and the mean lowest temperature was 35.7 (0.4)°C (range 35.0-36.3°C). Temperature remained below 36°C for the full two hours in 6/10 subjects. After dexmedetomidine, subjects had moderate sedation and a mean 26 (13) mmHg reduction in blood pressure that resolved within 90 minutes. Heart rate declined a mean 23 (11) bpm after both placebo and dexmedetomidine. Dexmedetomidine produced no respiratory depression. Conclusion Dexmedetomidine decreases shivering in normal volunteers. This effect is associated with decreased systolic blood pressure and sedation, but no respiratory depression.
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Affiliation(s)
- Clifton W. Callaway
- Applied Physiology Laboratory, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Jonathan Elmer
- Applied Physiology Laboratory, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Francis X. Guyette
- Applied Physiology Laboratory, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Bradley J. Molyneaux
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Kacey B. Anderson
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Philip E. Empey
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Stacy J. Gerstel
- Applied Physiology Laboratory, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Kate Holquist
- Applied Physiology Laboratory, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Melissa J. Repine
- Applied Physiology Laboratory, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Jon C. Rittenberger
- Applied Physiology Laboratory, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
- * E-mail:
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Abstract
Cardiac arrest afflicts more than 300,000 persons annually in North America alone. Advances in systematic, regimented postresuscitation care have lowered mortality and improved neurologic outcomes in select cohorts of patients over the last decade. Postcardiac arrest care now comprises its own link in the chain of survival. For most patients, high-quality postcardiac arrest care begins in the Emergency Department. This article reviews the evidence and offers treatment strategies for the key components of postcardiac arrest care.
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Affiliation(s)
- Jon C Rittenberger
- Department of Emergency Medicine, University of Pittsburgh, Suite 10028, Forbes Tower, Pittsburgh, PA 15260, USA
| | - Ankur A Doshi
- Department of Emergency Medicine, University of Pittsburgh, Suite 10028, Forbes Tower, Pittsburgh, PA 15260, USA
| | - Joshua C Reynolds
- Department of Emergency Medicine, Michigan State University College of Human Medicine, 15 Michigan Street Northeast, Suite 420, Grand Rapids, MI 49503, USA.
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Imaging Evaluation of Tricuspid Valve: Analysis of Morphology and Function With CT and MRI. AJR Am J Roentgenol 2015; 204:W531-42. [DOI: 10.2214/ajr.14.13551] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Vaity C, Al-Subaie N, Cecconi M. Cooling techniques for targeted temperature management post-cardiac arrest. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:103. [PMID: 25886948 PMCID: PMC4361155 DOI: 10.1186/s13054-015-0804-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2015 and co-published as a series in Critical Care. Other articles in the series can be found online at http://ccforum.com/series/annualupdate2015. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
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Lascarrou JB, Meziani F, Le Gouge A, Boulain T, Bousser J, Belliard G, Asfar P, Frat JP, Dequin PF, Gouello JP, Delahaye A, Hssain AA, Chakarian JC, Pichon N, Desachy A, Bellec F, Thevenin D, Quenot JP, Sirodot M, Labadie F, Plantefeve G, Vivier D, Girardie P, Giraudeau B, Reignier J. Therapeutic hypothermia after nonshockable cardiac arrest: the HYPERION multicenter, randomized, controlled, assessor-blinded, superiority trial. Scand J Trauma Resusc Emerg Med 2015; 23:26. [PMID: 25882712 PMCID: PMC4353458 DOI: 10.1186/s13049-015-0103-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 02/11/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Meta-analyses of nonrandomized studies have provided conflicting data on therapeutic hypothermia, or targeted temperature management (TTM), at 33°C in patients successfully resuscitated after nonshockable cardiac arrest. Nevertheless, the latest recommendations issued by the International Liaison Committee on Resuscitation and by the European Resuscitation Council recommend therapeutic hypothermia. New data are available on the adverse effects of therapeutic hypothermia, notably infectious complications. The risk/benefit ratio of therapeutic hypothermia after nonshockable cardiac arrest is unclear. METHODS HYPERION is a multicenter (22 French ICUs) trial with blinded outcome assessment in which 584 patients with successfully resuscitated nonshockable cardiac arrest are allocated at random to either TTM between 32.5 and 33.5°C (therapeutic hypothermia) or TTM between 36.5 and 37.5°C (therapeutic normothermia) for 24 hours. Both groups are managed with therapeutic normothermia for the next 24 hours. TTM is achieved using locally available equipment. The primary outcome is day-90 neurological status assessed by the Cerebral Performance Categories (CPC) Scale with dichotomization of the results (1 + 2 versus 3 + 4 + 5). The primary outcome is assessed by a blinded psychologist during a semi-structured telephone interview of the patient or next of kin. Secondary outcomes are day-90 mortality, hospital mortality, severe adverse events, infections, and neurocognitive performance. The planned sample size of 584 patients will enable us to detect a 9% absolute difference in day-90 neurological status with 80% power, assuming a 14% event rate in the control group and a two-sided Type 1 error rate of 4.9%. Two interim analyses will be performed, after inclusion of 200 and 400 patients, respectively. DISCUSSION The HYPERION trial is a multicenter, randomized, controlled, assessor-blinded, superiority trial that may provide an answer to an issue of everyday relevance, namely, whether TTM is beneficial in comatose patients resuscitated after nonshockable cardiac arrest. Furthermore, it will provide new data on the tolerance and adverse events (especially infectious complications) of TTM at 32.5-33.5°C. TRIAL REGISTRATION ClinicalTrials.gov: NCT01994772 .
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Affiliation(s)
| | - Ferhat Meziani
- Medical Intensive Care Unit, University Hospital Center, University of Strasbourg, Strasbourg, France.
| | - Amélie Le Gouge
- INSERM CIC1415, CHRU de Tours, Tours, France. .,Université François-Rabelais de Tours, PRES Centre-Val de Loire Université, Tours, France.
| | - Thierry Boulain
- Medical Intensive Care Unit, Regional Hospital Center, Orleans, France.
| | - Jérôme Bousser
- Medical-Surgical intensive Care Unit, General Hospital Center, Saint Brieuc, France.
| | - Guillaume Belliard
- Medical Intensive Care Unit, South Brittany General Hospital Center, Lorient, France.
| | - Pierre Asfar
- Medical Intensive Care Unit, University Hospital Center, Angers, France.
| | - Jean Pierre Frat
- Medical Intensive Care Unit, University Hospital Center, Poitiers, France.
| | | | - Jean Paul Gouello
- Medical-Surgical Intensive Care Unit, General Hospital Center, Saint Malo, France.
| | - Arnaud Delahaye
- Medical-Surgical Intensive Care Unit, General Hospital Center, Rodez, France.
| | - Ali Ait Hssain
- Medical Intensive Care Unit, University Hospital Center, Clermond-Ferrand, France.
| | | | - Nicolas Pichon
- Medical-Surgical Intensive Care Unit, University Hospital Center, Limoges, France.
| | - Arnaud Desachy
- Medical-Surgical Intensive Care Unit, General Hospital Center, Angouleme, France.
| | - Fréderic Bellec
- Medical-Surgical Intensive Care Unit, General Hospital Center, Montauban, France.
| | - Didier Thevenin
- Medical-Surgical Intensive Care Unit, General Hospital Center, Lens, France.
| | | | - Michel Sirodot
- Medical-Surgical Intensive Care Unit, General Hospital Center, Annecy, France.
| | - François Labadie
- Medical-Surgical Intensive Care Unit, General Hospital Center, Saint Nazaire, France.
| | - Gaétan Plantefeve
- Medical-Surgical Intensive Care Unit, General Hospital Center, Argenteuil, France.
| | - Dominique Vivier
- Medical-Surgical Intensive Care Unit, General Hospital Center, Le Mans, France.
| | - Patrick Girardie
- Medical Intensive Care Unit, University Hospital Center, Lille, France.
| | - Bruno Giraudeau
- INSERM CIC1415, CHRU de Tours, Tours, France. .,Université François-Rabelais de Tours, PRES Centre-Val de Loire Université, Tours, France.
| | - Jean Reignier
- Medical-Surgical Intensive Care Unit, District Hospital Center, La Roche-sur-Yon, France.
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Uray T, Mayr FB, Stratil P, Aschauer S, Testori C, Sterz F, Haugk M. Prehospital surface cooling is safe and can reduce time to target temperature after cardiac arrest. Resuscitation 2014; 87:51-6. [PMID: 25447355 DOI: 10.1016/j.resuscitation.2014.10.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 10/25/2014] [Accepted: 10/30/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE Mild therapeutic hypothermia proved to be beneficial when induced after cardiac arrest in humans. Prehospital cooling with i.v. fluids was associated with adverse side effects. Our primary objective was to compare time to target temperature of out-of hospital cardiac arrest patients cooled non-invasively either in the prehospital setting vs. the in-hospital (IH) setting, to assess surface-cooling safety profile and long term outcome. METHODS In this retrospective, single center cohort study, a group of adult patients with restoration of spontaneous circulation (ROSC) after out-of hospital cardiac arrest were cooled with a surface cooling pad beginning either in the prehospital or IH setting for 24h. Time to target temperature (33.9°C), temperature on admission, time to admission after ROSC and outcome were compared. Also, rearrests and pulmonary edema were assessed. Neurologic outcome at 12 months was evaluated (Cerebral Performance Category, CPC 1-2, favorable outcome). RESULTS Between September 2005 and February 2010, 56 prehospital cooled patients and 54 IH-cooled patients were treated. Target temperature was reached in 85 (66-117)min (prehospital) and in 135 (102-192)min (IH) after ROSC (p<0.001). After prehospital cooling, hospital admission temperature was 35.2 (34.2-35.8)°C, and in the IH-cooling patients initial temperature was 35.8 (35.2-36.3)°C (p=0.001). No difference in numbers of rearrests and pulmonary edema between groups was observed. In both groups, no skin lesions were observed. Favorable outcome was reached in 26.8% (prehospital) and in 37.0% (IH) of the patients (p=0.17). CONCLUSIONS Using a non-invasive prehospital surface cooling method after cardiac arrest, target temperature can be reached faster without any major complications than starting cooling IH. The effect of early non-invasive cooling on long-term outcome remains to be determined in larger studies.
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Affiliation(s)
- Thomas Uray
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Florian B Mayr
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, PA, USA
| | - Peter Stratil
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Stefan Aschauer
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Christoph Testori
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Fritz Sterz
- Department of Emergency Medicine, Medical University of Vienna, Austria.
| | - Moritz Haugk
- Department of Emergency Medicine, Medical University of Vienna, Austria
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Esposito E, Ebner M, Ziemann U, Poli S. In cold blood: intraarteral cold infusions for selective brain cooling in stroke. J Cereb Blood Flow Metab 2014; 34:743-52. [PMID: 24517972 PMCID: PMC4013766 DOI: 10.1038/jcbfm.2014.29] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Revised: 12/19/2013] [Accepted: 01/19/2014] [Indexed: 12/29/2022]
Abstract
Hypothermia is a promising therapeutic option for stroke patients and an established neuroprotective treatment for global cerebral ischemia after cardiac arrest. While whole body cooling is a feasible approach in intubated and sedated patients, its application in awake stroke patients is limited by severe side effects: Strong shivering rewarms the body and potentially worsens ischemic conditions because of increased O2 consumption. Drugs used for shivering control frequently cause sedation that increases the risk of aspiration and pneumonia. Selective brain cooling by intraarterial cold infusions (IACIs) has been proposed as an alternative strategy for patients suffering from acute ischemic stroke. Preclinical studies and early clinical experience indicate that IACI induce a highly selective brain temperature decrease within minutes and reach targeted hypothermia 10 to 30 times faster than conventional cooling methods. At the same time, body core temperature remains largely unaffected, thus systemic side effects are potentially diminished. This review critically discusses the limitations and side effects of current cooling techniques for neuroprotection from ischemic brain damage and summarizes the available evidence regarding advantages and potential risks of IACI.
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Affiliation(s)
- Elga Esposito
- Department Neurology & Stroke, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Matthias Ebner
- Department Neurology & Stroke, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Ulf Ziemann
- Department Neurology & Stroke, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Sven Poli
- Department Neurology & Stroke, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
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Seif D, Henderson SO. Use of therapeutic hypothermia in postcardiac arrest patients by emergency departments. Ther Hypothermia Temp Manag 2014; 1:23-7. [PMID: 24716884 DOI: 10.1089/ther.2010.0004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Since 2003, resuscitation guidelines have recommended the use of induced hypothermia as a therapy for patients who achieve return of spontaneous circulation after cardiac arrest from ventricular fibrillation. The aim of this study was to survey emergency physicians across the United States on their use of therapeutic hypothermia (TH) after cardiac arrest. An 18-question survey was e-mailed to a sample of emergency physicians. Fifty-eight respondents completed the survey. Most (71%) were associated with an emergency medicine residency training program. Annual census ranged from 12,000 to >170,000 visits. TH is used by the majority (69%) of respondents, 79% of which report the presence of a formal institutional protocol. The majority of respondents use TH in arrest rhythms including but not limited to ventricular fibrillation, and 21% begin the process in the prehospital setting. To induce hypothermia, a majority of respondents use commercial cooling products. The average time to target temperature was 95 minutes. The majority of respondents report a goal temperature between 32°C and 34°C. A shivering protocol is used by 76% of respondents, and as a first line medication, 46% use benzodiazepines. For those who do not use TH or do not have a protocol in place, the reasons cited include "too expensive," "too difficult to implement," and "not enough science to warrant it." In this sample of practicing emergency physicians, TH after cardiac arrest is not being used as described in the original literature. Although awareness and implementation of TH have increased, there appears to be a wide variation in the application of this therapy.
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Affiliation(s)
- Dina Seif
- 1 Department of Emergency Medicine, Keck School of Medicine of the University of Southern California , Los Angeles, California
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37
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Jin SW, Choi YH, Lee DH. Utilization of rapid infusion system with cold saline in the induction of therapeutic hypothermia. J Int Med Res 2014; 42:744-9. [PMID: 24670537 DOI: 10.1177/0300060514525760] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2013] [Accepted: 02/05/2014] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To examine the cooling effectiveness of a rapid infusion system (RIS) during induction of therapeutic hypothermia. METHODS This laboratory study simulated the effect of three fluid delivery methods: rapid dripping without any other equipment (control); RIS; pressure bag. Cold energy loss (℃ × min) was calculated as: (temperature of the proximal thermoprobe--temperature of the distal thermoprobe) × (total infusion time). RESULTS Infusion time was significantly shorter and cold energy loss significantly lower in the RIS group than in the two other groups. CONCLUSIONS RIS preserves the cold energy of fluid more effectively than pressure bag or control. RIS allows for rapid infusion at a constant pressure and can be easily applied in an emergency setting.
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Affiliation(s)
- Sung Woong Jin
- Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Yoon Hee Choi
- Department of Emergency Medicine, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Dong Hoon Lee
- Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
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Biazar E. Use of umbilical cord and cord blood-derived stem cells for tissue repair and regeneration. Expert Opin Biol Ther 2014; 14:301-10. [PMID: 24456082 DOI: 10.1517/14712598.2014.867943] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Potential use of umbilical cord (UC) is one of the most exciting frontiers in medicine for repairing damaged tissues. UC and cord blood-derived stem cells are the world's largest potential sources of stem cells. UC contains a mixture of stem and progenitor cells at different lineage commitment stages and UC has been verified as a candidate for cell-based therapies and tissue engineering applications due to the capability of these cells for extensive self-renewal and multi-lineage character in differentiation potential. AREAS COVERED UC-based repair or regeneration of organs (i.e., heart, nerve, skin, etc.) is a high-priority research worldwide. EXPERT OPINION The aim of this review is to summarize the knowledge about UC with main focus on its applications for tissue repair and regeneration.
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Affiliation(s)
- Esmaeil Biazar
- Islamic Azad University, Department of Biomedical Engineering, Tonekabon Branch , Tonekabon , Iran +00981924271105 ;
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Skulec R, Truhlar A, Turek Z, Parizkova R, Dostal P, Hicks S, Lehmann C, Cerny V. Comparison of cold crystalloid and colloid infusions for induction of therapeutic hypothermia in a porcine model of cardiac arrest. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R242. [PMID: 24131867 PMCID: PMC4057502 DOI: 10.1186/cc13068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Accepted: 09/17/2013] [Indexed: 11/13/2022]
Abstract
Introduction Large-volume cold intravenous infusion of crystalloids has been used for induction of therapeutic hypothermia after cardiac arrest. However, the effectiveness of cold colloids has not been evaluated. Therefore, we performed an experimental study to investigate the cooling effect of cold normal saline compared to colloid solution in a porcine model of ventricular fibrillation. Methods Ventricular fibrillation was induced for 15 minutes in 22 anesthetized domestic pigs. After spontaneous circulation was restored, the animals were randomized to receive either 45 ml/kg of 1°C cold normal saline (Group A, 9 animals); or 45 ml/kg of 1°C cold colloid solution (Voluven®, 6% hydroxyethyl starch 130/0.4 in 0.9% NaCl) during 20 minutes (Group B, 9 animals); or to undergo no cooling intervention (Group C, 4 animals). Then, the animals were observed for 90 minutes. Cerebral, rectal, intramuscular, pulmonary artery, and subcutaneous fat body temperatures (BT) were recorded. In the mechanical ex-vivo sub study we added a same amount of cold normal saline or colloid into the bath of normal saline and calculated the area under the curve (AUC) for induced temperature changes. Results Animals treated with cold fluids achieved a significant decrease of BT at all measurement sites, whereas there was a consistent significant spontaneous increase in group C. At the time of completion of infusion, greater decrease in pulmonary artery BT and cerebral BT in group A compared to group B was detected (−2.1 ± 0.3 vs. -1.6 ± 0.2°C, and −1.7 ± 0.4 vs. -1.1 ± 0.3°C, p < 0.05, respectively). AUC analysis of the decrease of cerebral BT revealed a more vigorous cooling effect in group A compared to group B (−91 ± 22 vs. -68 ± 23°C/min, p = 0.046). In the mechanical sub study, AUC analysis of the induced temperature decrease of cooled solution revealed that addition of normal saline led to more intense cooling than colloid solution (−7155 ± 647 vs. -5733 ± 636°C/min, p = 0.008). Conclusions Intravenous infusion of cold normal saline resulted in more intense decrease of cerebral and pulmonary artery BT than colloid infusion in this porcine model of cardiac arrest. This difference is at least partially related to the various specific heat capacities of the coolants.
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Zimmermann S, Flachskampf FA, Schneider R, Dechant K, Alff A, Klinghammer L, Rittger H, Achenbach S. Mild therapeutic hypothermia after out-of-hospital cardiac arrest complicating ST-elevation myocardial infarction: long-term results in clinical practice. Clin Cardiol 2013; 36:414-21. [PMID: 23649889 DOI: 10.1002/clc.22131] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 03/24/2013] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Recently, mild therapeutic hypothermia (MTH) has been integrated into the European resuscitation guidelines to improve outcomes after out-of-hospital cardiac arrest (OHCA). Data on long-term results are limited, especially in patients with acute ST-elevation myocardial infarction (STEMI). HYPOTHESIS Invasive MTH influences long-term prognosis after OHCA due to STEMI. METHODS We analyzed 48 patients who underwent emergency coronary angiography for STEMI after witnessed OHCA. In 24 consecutive patients, MTH was performed via intravascular cooling (CoolGard System, 34°C maintained for 24 hours) after initialization by rapid infusion of cold saline. Clinical, procedural, and mortality data were compared to 24 historical controls. Neurological recovery was assessed using the Cerebral Performance Category score (CPC) at 30-day and 1-year follow-up. RESULTS Median time delay until arrival of emergency medical service was 6 minutes (MTH group) vs 6.5 minutes (controls) (P = 0.16). Initial rhythm was ventricular fibrillation in 75% vs 66.7% (P = 0.75). There were no differences regarding baseline characteristics, angiographic findings, and success of cardiac catheterization procedures. MTH was not associated with a higher frequency of bleeding complications or of pneumonia. Thirty-day mortality was 33.3% in both groups. One-year mortality was 37.5% (MTH group) vs 50% (controls) (P = 0.56). At 1 year, favorable neurological outcome (CPC ≤2) was significantly more frequent in the MTH group (58.3% vs 20.8%, P = 0.017). Multivariate analysis identified MTH as independent predictor of favorable neurological outcome (P < 0.02, odds ratio: 12.73). CONCLUSIONS MTH via intravascular cooling improves neurological long-term prognosis after OHCA due to STEMI and is safe in clinical practice.
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Affiliation(s)
- Stefan Zimmermann
- Department of Cardiology, University Hospital Erlangen-Nuremberg, Nuremberg, Germany.
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Nichol G, Huszti E, Kim F, Fly D, Parnia S, Donnino M, Sorenson T, Callaway CW. Does induction of hypothermia improve outcomes after in-hospital cardiac arrest? Resuscitation 2013; 84:620-5. [PMID: 23246514 DOI: 10.1016/j.resuscitation.2012.12.009] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Revised: 11/28/2012] [Accepted: 12/10/2012] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Hypothermia improves neurologic recovery compared to normothermia after resuscitation from out-of-hospital ventricular fibrillation, but may or may not be beneficial for patients resuscitated from in-hospital cardiac arrest. Therefore, we evaluated the effect of induced hypothermia in a large cohort of patients with in-hospital cardiac arrest. METHODS Retrospective analysis of multi-center prospective cohort of patients with in-hospital cardiac arrest enrolled in an ongoing quality improvement project. Included were adults with a pulseless event in an in-patient hospital ward of a participating institution who achieved restoration of spontaneous circulation between 2000 and 2009. The exposure of interest was induced hypothermia. The primary outcome was survival to discharge. The secondary outcome was neurological status at discharge. Analyses evaluated all eligible patients; those with a shockable rhythm; or those with endotracheal tube inserted after resuscitation; and the effect of no hypothermia versus hypothermia (lowest temperature>32 °C but ≤34 °C) versus overcooled (≤32 °C). Associations were assessed using propensity score methods. RESULTS Included were 8316 patients with complete data, of whom 214 (2.6%) had hypothermia induced and 2521 (30%) survived to discharge. Of patients reported to receive hypothermia, only 40% were documented as achieving a temperature between 32 °C and 34 °C. Adjusted for known potential confounders using propensity score methods, induced hypothermia was associated with an odds ratio of survival of 0.90 (95% confidence interval: 0.65, 1.23; p-value=0.49) compared to no hypothermia. Induced hypothermia was associated with an odds ratio of neurologically-favorable survival of 0.93 (95% confidence interval: 0.65, 1.32; p-value=0.68) compared to no hypothermia. For patients with shockable first-recorded rhythm, induced hypothermia was associated with an odds ratio of survival of 1.43 (95% confidence interval: 0.68, 3.01; p-value=0.35) compared to no hypothermia. CONCLUSION Hypothermia is induced infrequently in patients resuscitated from in-hospital cardiac arrest with only 40% achieving target temperatures. Induced hypothermia was not associated with improved or worsened survival or neurologically-favorable survival. The lack of benefit in this population may reflect lack of effect, inefficient application of the intervention, or residual confounding. High-quality controlled studies are required to better characterize the effect of induced hypothermia in this population.
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Affiliation(s)
- Graham Nichol
- University of Washington-Harborview Center for Prehospital Emergency Care, USA.
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Alkadri ME, Peters MN, Katz MJ, White CJ. State-of-the-art paper: Therapeutic hypothermia in out of hospital cardiac arrest survivors. Catheter Cardiovasc Interv 2013; 82:E482-90. [PMID: 23475635 DOI: 10.1002/ccd.24914] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2012] [Revised: 01/12/2013] [Accepted: 03/03/2013] [Indexed: 11/09/2022]
Abstract
Out of hospital cardiac arrest (OHCA) is associated with an extremely poor survival rate, with mortality in most cases being related to neurological injury. Among patients who experience return of spontaneous circulation (ROSC), therapeutic hypothermia (TH) is the only proven intervention shown to reduce mortality and improve neurological outcome. First described in 1958, the field of TH has rapidly evolved in recent years. While recent technological advances in TH will likely improve outcomes in OHCA survivors, several fundamental questions remain to be answered including the optimal speed of cooling, which patients benefit from an early invasive strategy, and whether technological advances will facilitate application of TH in the field. An increased awareness and understanding of TH strategies, devices, monitoring, techniques, and complications will allow for a more widespread adoption of this important treatment modality.
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Affiliation(s)
- Mohi E Alkadri
- Department of Cardiology, Ochsner Medical Center, New Orleans, Louisiana
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Ratajczak MZ, Mierzejewska K, Ratajczak J, Kucia M. CD133 Expression Strongly Correlates with the Phenotype of Very Small Embryonic-/Epiblast-Like Stem Cells. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2013; 777:125-41. [PMID: 23161080 DOI: 10.1007/978-1-4614-5894-4_9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
CD133 antigen (prominin-1) is a useful cell surface marker of very small embryonic-like stem cells (VSELs). Antibodies against it, conjugated to paramagnetic beads or fluorochromes, are thus powerful biological tools for their isolation from human umbilical cord blood, mobilized peripheral blood, and bone marrow. VSELs are described with the following characteristics: (1) are slightly smaller than red blood cells; (2) display a distinct morphology, typified by a high nuclear/cytoplasmic ratio and an unorganized euchromatin; (3) become mobilized during stress situations into peripheral blood; (4) are enriched in the CD133(+)Lin(-)CD45(-) cell fraction in humans; and (5) express markers of pluripotent stem cells (e.g., Oct-4, Nanog, and stage-specific embryonic antigen-4). The most recent in vivo data from our and other laboratories demonstrated that human VSELs exhibit some characteristics of long-term repopulating hematopoietic stem cells and are at the top of the hierarchy in the mesenchymal lineage. However, still more labor is needed to characterize better at a molecular level these rare cells.
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Affiliation(s)
- Mariusz Z Ratajczak
- Stem Cell Institute at James Graham Brown Cancer Center, University of Louisville, 500 S. Floyd Street, 40202 Rm. 107, Louisville, KY, USA,
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Effects of hypothermia on brain injury assessed by magnetic resonance imaging after cardiopulmonary resuscitation in a porcine model of cardiac arrest. Am J Emerg Med 2013; 31:86-93. [DOI: 10.1016/j.ajem.2012.06.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 06/17/2012] [Accepted: 06/19/2012] [Indexed: 11/19/2022] Open
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Chelly J, Mongardon N, Dumas F, Varenne O, Spaulding C, Vignaux O, Carli P, Charpentier J, Pène F, Chiche JD, Mira JP, Cariou A. Benefit of an early and systematic imaging procedure after cardiac arrest: Insights from the PROCAT (Parisian Region Out of Hospital Cardiac Arrest) registry. Resuscitation 2012; 83:1444-50. [DOI: 10.1016/j.resuscitation.2012.08.321] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Revised: 08/16/2012] [Accepted: 08/19/2012] [Indexed: 10/28/2022]
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Wang CJ, Yang SH, Lee CH, Lin RL, Peng MJ, Wu CL. Therapeutic hypothermia application vs standard support care in post resuscitated out-of-hospital cardiac arrest patients. Am J Emerg Med 2012; 31:319-25. [PMID: 23158613 DOI: 10.1016/j.ajem.2012.08.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Revised: 08/08/2012] [Accepted: 08/17/2012] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Survival after cardiac arrest remains poor, especially when it occurs outside of hospital. In recent years, therapeutic hypothermia has been used to improve outcomes in patients who have experienced cardiac arrest, however, application to out-of-hospital cardiac arrest (OHCA) patients remains controversial. METHODS A total of 175 OHCA patients underwent therapeutic hypothermia (TH), which was performed using large volume ice crystalloid fluid (LVICF) infusions after ICU admission. Ice packs and conventional cooling blankets were used to maintain a core body temperature of 33°C, according to standard protocol for 36 hours. Patients in the control group received standard supportive care without TH. Hospital survival and neurologic outcomes were compared. RESULTS There was no significant difference between the groups with regards to patient characteristics, underlying etiologies, and length of hospital stays. The duration of cardiac pulmonary resuscitation (CPR) was also similar. In the 51 patients that received TH, 14 were alive at hospital discharge. In the 124 patients belonging to the supportive care group, only 15 were alive at hospital discharge (27.5% vs. 12.1%, p = 0.013). Approximately 7.9% of patients in the TH group had good neurologic outcomes (4 of 51) compared with the 1.7% (2 of 124) of patients in the supportive group (p = 0.04). There were no specific treatment-related complications. CONCLUSION Therapeutic hypothermia can be safely applied to OHCA patients and can improve their outcome. Further large scale studies are needed to verify our results.
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Affiliation(s)
- Chieh-Jen Wang
- Division of Pulmonary and Critical Care Medicine, Mackay Memorial Hospital, Taipei, Taiwan
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Isenberg DL, Pasirstein MJ. A simple method of maintaining chilled saline in the prehospital setting. Am J Emerg Med 2012; 30:1385-8. [DOI: 10.1016/j.ajem.2011.10.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Revised: 10/01/2011] [Accepted: 10/10/2011] [Indexed: 11/16/2022] Open
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Gaieski DF, Fuchs B, Carr BG, Merchant R, Kolansky DM, Abella BS, Becker LB, Maguire C, Whitehawk M, Levine J, Goyal M. Practical implementation of therapeutic hypothermia after cardiac arrest. Hosp Pract (1995) 2012; 37:71-83. [PMID: 20877174 DOI: 10.3810/hp.2009.12.257] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Survival after out-of-hospital cardiac arrest (OHCA) remains unacceptably low. Therapeutic hypothermia (TH) is the most efficacious treatment option available for comatose survivors of cardiac arrest. However, clearly delineated instructions for how to induce, maintain, and conclude TH have not been published in a codified format. OBJECTIVE We assembled 11 clinicians from the University of Pennsylvania Schools of Medicine and Nursing for a day-long moderated discussion to review our institution's TH protocol and reach consensus on a step-by-step management plan of the comatose survivor of OHCA. We attempted to systematically work our way through the existing University of Pennsylvania TH protocol. The goal was to address critical decisions at each stage of care of the post-arrest patient, including whom to cool, how to cool, how long to cool, how to rewarm, neuroprognostication, and other fundamental aspects of patient management. We made every effort to include relevant scientific evidence with appropriate citations. However, given the paucity of data in certain areas, we have relied heavily on expert opinion. SUMMARY We present a step-by-step management plan for incorporation of TH in the care of the comatose survivor of OHCA, which can be adapted to a variety of clinical settings with diverse resources. This article is intended to supplement current care provided by health care providers and should be adopted in concert with current standards of post-arrest and intensive care unit care.
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Affiliation(s)
- David F Gaieski
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Ground Ravdin, Philadelphia, PA19104, USA.
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