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Bock CA, Medford WG, Coughlin E, Mhaskar R, Sunjic KM. Implementing a Stepwise Shivering Protocol During Targeted Temperature Management. J Pharm Pract 2024; 37:871-879. [PMID: 37551844 DOI: 10.1177/08971900231193533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
Background: Shivering is often encountered in patients undergoing targeted temperature management (TTM) after cardiac arrest. The most efficient, safe way to prevent shivering during TTM is not clearly defined. Objective: The purpose of this study was to evaluate the impact of shivering management using a stepwise shivering protocol on time to target temperature (TT), medication utilization and nursing confidence. Methods: Single-center, retrospective chart review of all post-cardiac arrest patients who underwent TTM between 2016 and 2021. The primary outcome is a comparison of time to TT pre- and post-protocol implementation. Secondary objectives compared nursing confidence and medication utilization pre- and post-shivering protocol implementation. Results: Fifty-seven patients were included in the pre-protocol group and thirty-seven were in the post-protocol group. The median (IQR) time to TT was 195 (250) minutes and 165 (170), respectively (p = 0.190). The average doses of acetaminophen was 285 mg pre- vs 1994 mg post- (p <0.001, buspirone 47 mg pre- vs 127 mg post- (p < 0.001), magnesium 0.9 g pre-vs 2.8 g post- (p < 0.001), and fentanyl 1564 mcg pre- vs 2286 mcg post- (p=0.023). No difference was seen for midazolam and cisatracurium. Nurses reported feeling confident with his/her ability to manage shivering during TTM 38.5% of the time pre-protocol compared to 60% post-protocol (p = 0.306). Conclusion: Implementation of a stepwise approach to prevent and treat shivering improved time to TT in our institution, although this finding was not statistically significant. The stepwise protocol supported a reduced amount of high-risk medication use and increased nursing confidence in shivering management.
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Affiliation(s)
- Czarina A Bock
- Pharmacy Department, Tampa General Hospital, Tampa, FL, USA
| | - Whitney G Medford
- Pharmacy Department, Tampa General Hospital, Tampa, FL, USA
- Virtual Intensive Care Unit, BayCare Healthcare System, St Petersburg, FL, USA
| | - Emily Coughlin
- Department of Medical Education, University of South Florida, Tampa, FL, USA
| | - Rahul Mhaskar
- Department of Internal Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Katlynd M Sunjic
- Pharmacy Department, Tampa General Hospital, Tampa, FL, USA
- Department of Pharmacotherapeutics and Clinical Research, University of South Florida, Taneja College of Pharmacy, Tampa, FL, USA
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2
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Memenga F, Sinning C. Emerging Evidence in Out-of-Hospital Cardiac Arrest-A Critical Appraisal of the Cardiac Arrest Center. J Clin Med 2024; 13:3973. [PMID: 38999537 PMCID: PMC11242151 DOI: 10.3390/jcm13133973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2024] [Revised: 06/27/2024] [Accepted: 07/05/2024] [Indexed: 07/14/2024] Open
Abstract
The morbidity and mortality of out-of-hospital cardiac arrest (OHCA) due to presumed cardiac causes have remained unwaveringly high over the last few decades. Less than 10% of patients survive until hospital discharge. Treatment of OHCA patients has traditionally relied on expert opinions. However, there is growing evidence on managing OHCA patients favorably during the prehospital phase, coronary and intensive care, and even beyond hospital discharge. To improve outcomes in OHCA, experts have proposed the establishment of cardiac arrest centers (CACs) as pivotal elements. CACs are expert facilities that pool resources and staff, provide infrastructure, treatment pathways, and networks to deliver comprehensive and guideline-recommended post-cardiac arrest care, as well as promote research. This review aims to address knowledge gaps in the 2020 consensus on CACs of major European medical associations, considering novel evidence on critical issues in both pre- and in-hospital OHCA management, such as the timing of coronary angiography and the use of extracorporeal cardiopulmonary resuscitation (eCPR). The goal is to harmonize new evidence with the concept of CACs.
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Affiliation(s)
- Felix Memenga
- Department of Cardiology, University Heart & Vascular Center Hamburg, 20246 Hamburg, Germany
| | - Christoph Sinning
- Department of Cardiology, University Heart & Vascular Center Hamburg, 20246 Hamburg, Germany
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3
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auf dem Brinke K, Kück F, Jamous A, Ernst M, Kunze-Szikszay N, Psychogios MN, Maier IL. The effect of inadvertent systemic hypothermia after mechanical thrombectomy in patients with large-vessel occlusion stroke. Front Neurol 2024; 15:1381872. [PMID: 38903162 PMCID: PMC11188377 DOI: 10.3389/fneur.2024.1381872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 05/08/2024] [Indexed: 06/22/2024] Open
Abstract
Background and aims Postinterventional hypothermia is a frequent complication in patients with large-vessel occlusion strokes (LVOS) after mechanical thrombectomy (MT). This inadvertent hypothermia might potentially have neuroprotective but also adverse effects on patients' outcomes. The aim of the study was to determine the rate of hypothermia in patients with LVOS receiving MT and its influence on functional outcome. Methods We performed a monocentric, retrospective study using a prospectively derived databank, including all LVOS patients receiving MT between 2015 and 2021. Predictive values of postinterventional body temperature and body temperature categories (hyperthermia (≥38°C), normothermia (35°C-37.9°C), and hypothermia (<35°C)) on functional outcome were analyzed using multivariable Bayesian logistic regression models. Favorable outcome was defined as modified Rankin Scale (mRS) ≤3. Results Of the 480 included LVOS patients with MT (46.0% men; mean ± SD age 73 ± 12.9 years), 5 (1.0%) were hyperthermic, 382 (79.6%) normothermic, and 93 (19.4%) hypothermic. Postinterventional hypothermia was significantly associated with unfavorable functional outcome (mRS > 3) after 90 days (OR 2.06, 95% CI 1.01-4.18, p = 0.045). For short-term functional outcome, patients with hypothermia had a higher discharge NIHSS (OR 1.38, 95% CI 1.06 to 1.79, p = 0.015) and a higher change of NIHSS from admission to discharge (OR 1.35, 95% CI 1.03 to 1.76, p = 0.029). Conclusion Approximately a fifth of LVOS patients in this cohort were hypothermic after MT. Hypothermia was an independent predictor of unfavorable functional outcomes. Our findings warrant a prospective trial investigating active warming during MT.
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Affiliation(s)
| | - Fabian Kück
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Ala Jamous
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - Marielle Ernst
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - Nils Kunze-Szikszay
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | | | - Ilko L. Maier
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
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4
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Miao B, Skaar JR, O'Hara M, Post A, Kelly T, Abella BS. A Systematic Literature Review to Assess Fever Management and the Quality of Targeted Temperature Management in Critically Ill Patients. Ther Hypothermia Temp Manag 2024; 14:68-79. [PMID: 37219898 DOI: 10.1089/ther.2023.0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023] Open
Abstract
Targeted temperature management (TTM) has been proposed to reduce mortality and improve neurological outcomes in postcardiac arrest and other critically ill patients. TTM implementation may vary considerably among hospitals, and "high-quality TTM" definitions are inconsistent. This systematic literature review in relevant critical care conditions evaluated the approaches to and definitions of TTM quality with respect to fever prevention and the maintenance of precise temperature control. Current evidence on the quality of fever management associated with TTM in cardiac arrest, traumatic brain injury, stroke, sepsis, and critical care more generally was examined. Searches were conducted in Embase and PubMed (2016 to 2021) following PRISMA guidelines. In total, 37 studies were identified and included, with 35 focusing on postarrest care. Frequently-reported TTM quality outcomes included the number of patients with rebound hyperthermia, deviation from target temperature, post-TTM body temperatures, and number of patients achieving target temperature. Surface and intravascular cooling were used in 13 studies, while one study used surface and extracorporeal cooling and one study used surface cooling and antipyretics. Surface and intravascular methods had comparable rates of achieving target temperature and maintaining temperature. A single study showed that patients with surface cooling had a lower incidence of rebound hyperthermia. This systematic literature review largely identified cardiac arrest literature demonstrating fever prevention with multiple TTM approaches. There was substantial heterogeneity in the definitions and delivery of quality TTM. Further research is required to define quality TTM across multiple elements, including achieving target temperature, maintaining target temperature, and preventing rebound hyperthermia.
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Affiliation(s)
| | | | | | - Andrew Post
- Trinity Life Sciences, Waltham, Massachusetts, USA
| | - Tim Kelly
- Becton Dickinson, Franklin Lakes, New Jersey, USA
| | - Benjamin S Abella
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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5
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Kalkim A, Karaman E, Birdal O, Tosun Taşar P. Validity and reliability of the heart failure-specific health literacy scale in Turkish. Sci Rep 2024; 14:10338. [PMID: 38710870 DOI: 10.1038/s41598-024-61154-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 05/02/2024] [Indexed: 05/08/2024] Open
Abstract
Inadequate health literacy is common among adults with HF. The disease management process in HF closely depends on health literacy. No questionnaire is used to assess health literacy among Turkish patients with heart failure. This study aimed to determine the validity and reliability of the Turkish form of the 'Heart Failure-Specific Health Literacy Scale'. The research is a methodological study design. The study was conducted at the cardiology clinic between May and July 2021, located in the eastern part of Türkiye. The study sample consisted of 121 patients with HF. Data were collected using the Personal Information Form and the Heart Failure-Specific Health Literacy Scale. The patients' mean age was 62.88 ± 12.55 and 66.9% were men. Based on the factor analysis, three factors with eigenvalue above 1 have been identified. These model has been determined as x2 = 80.209, sd = 49 and p = 0.003. The fit indices were as follows: x2/SD = 1.637; RMSEA = 0.073, GFI = 0.90, CFI = 0.94, IFI = 0.95, TLI = 0.92 and NFI = 0.87. The scale has a total Cronbach's alpha of 0.66. With test-retest analysis, it was determined that it had a good, positive and significant correlation in terms of both the scale and its sub-dimensions. The Turkish form of the form is a valid and reliable tool.
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Affiliation(s)
- Asli Kalkim
- Department of Public Health Nursing, Ege University Faculty of Nursing, İzmir, Turkey
| | - Emine Karaman
- Department of Internal Medicine Nursing, Ege University Faculty of Nursing, İzmir, Turkey.
| | - Oğuzhan Birdal
- Department of Cardiology, Erzurum Atatürk University Faculty of Medicine, Erzurum, Turkey
| | - Pinar Tosun Taşar
- Division of Geriatrics, Department of Internal Medicine, Erzurum Atatürk University Faculty of Medicine, Erzurum, Turkey
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6
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Li A, Hegazy AF, Vasquez LEM, Liu L, Durocher AM, Vucetic A, Patel A, Fleming C, Chui J. Characterizing the impact of thermoregulation in patients after cardiac arrest: a retrospective cohort study. Can J Anaesth 2024; 71:629-639. [PMID: 38514524 DOI: 10.1007/s12630-024-02737-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 08/30/2023] [Accepted: 11/11/2023] [Indexed: 03/23/2024] Open
Abstract
PURPOSE Core body temperature has been extensively investigated as a thereuptic target in care after cardiac arrest. Nevertheless, the integrity of thermoregulation in patients after cardiac arrest has not been well studied. We sought to evaluate whether low spontaneous body temperature after cardiac arrest is associated with increased death and a worse neurologic outcome, and whether patients with low spontaneous body temperature exhibit features suggestive of impaired thermoregulation. METHODS We conducted a single-centre retrospective cohort study. We included all adult patients who underwent temperature control with hypothermia after cardiac arrest between 1 January 2014 and 30 June 2020. The primary exposure was low spontaneous core body temperature (< 35 °C) at initiation of hypothermia therapy. The primary outcome was in-hospital death and the secondary outcome was poor neurologic outcomes at discharge. RESULTS Five hundred and ninety-seven adult patients, comprising both in- and out-of-hospital cardiac arrests, were included. Patients with low spontaneous body temperature also had slightly lower average temperature, and more frequent transient but controlled breakthrough fever episodes in the first 24 hr. In the multivariable logistic regression analysis, low spontaneous body temperature was associated with higher odds of in-hospital death (odds ratio, 2.9; 95% confidence interval, 1.9 to 4.2; P < 0.001). CONCLUSION In this single-centre retrospective cohort study, low spontaneous core body temperature was associated with poor outcomes in patients after cardiac arrest. Patients with low spontaneous body temperature also exhibited features suggestive of impaired thermoregulation. Further research is needed to determine whether body temperature upon presentation reflects the robustness of the patient's underlying physiology and severity of brain insult after a cardiac arrest.
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Affiliation(s)
- Annie Li
- Department of Anesthesia & Perioperative Medicine, Schulich School Medicine & Dentistry, Western University, London, ON, Canada
| | - Ahmed F Hegazy
- Department of Anesthesia & Perioperative Medicine, Schulich School Medicine & Dentistry, Western University, London, ON, Canada
- Department of Critical Care, Schulich School Medicine & Dentistry, Western University, London, ON, Canada
| | - Luis E Mendoza Vasquez
- Department of Anesthesia & Perioperative Medicine, Schulich School Medicine & Dentistry, Western University, London, ON, Canada
| | - Lisa Liu
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Alexandra M Durocher
- Department of Anesthesia & Perioperative Medicine, Schulich School Medicine & Dentistry, Western University, London, ON, Canada
| | - Andrea Vucetic
- Department of Anesthesia & Perioperative Medicine, Schulich School Medicine & Dentistry, Western University, London, ON, Canada
| | - Arjun Patel
- Department of Anesthesia & Perioperative Medicine, Schulich School Medicine & Dentistry, Western University, London, ON, Canada
| | - Courtney Fleming
- Department of Anesthesia & Perioperative Medicine, Schulich School Medicine & Dentistry, Western University, London, ON, Canada
| | - Jason Chui
- Department of Anesthesia & Perioperative Medicine, Schulich School Medicine & Dentistry, Western University, London, ON, Canada.
- Department of Anesthesia & Perioperative Medicine, University of Western Ontario, C3-106, University Hospital, 339 Windermere Rd., London, ON, N6A 5A5, Canada.
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Kawakita K, Shishido H, Kuroda Y. Review of Temperature Management in Traumatic Brain Injuries. J Clin Med 2024; 13:2144. [PMID: 38610909 PMCID: PMC11012999 DOI: 10.3390/jcm13072144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/06/2024] [Accepted: 04/07/2024] [Indexed: 04/14/2024] Open
Abstract
Therapeutic hypothermia (TH) for severe traumatic brain injury has seen restricted application due to the outcomes of randomized controlled trials (RCTs) conducted since 2000. In contrast with earlier RCTs, recent trials have implemented active normothermia management in control groups, ensuring comparable intensities of non-temperature-related therapeutic interventions, such as neurointensive care. This change in approach may be a contributing factor to the inability to establish the efficacy of TH. Currently, an active temperature management method using temperature control devices is termed "targeted temperature management (TTM)". One of the goals of TTM for severe traumatic brain injury is the regulation of increased intracranial pressure, employing TTM as a methodology for intracranial pressure management. Additionally, fever in traumatic brain injury has been acknowledged as contributing to poor prognosis, underscoring the importance of proactively preventing fever. TTM is also employed for the preemptive prevention of fever in severe traumatic brain injury. As an integral component of current neurointensive care, it is crucial to precisely delineate the targets of TTM and to potentially apply them in the treatment of severe traumatic brain injury.
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Affiliation(s)
- Kenya Kawakita
- Emergency Medical Center, Kagawa University Hospital, Miki 761-0793, Japan;
| | - Hajime Shishido
- Emergency Medical Center, Kagawa University Hospital, Miki 761-0793, Japan;
| | - Yasuhiro Kuroda
- Department of Emergency, Disaster, and Critical Care Medicine, Faculty of Medicine, Kagawa University, Miki 760-0793, Japan;
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El-Menyar A, Wahlen BM. Cardiac arrest, stony heart, and cardiopulmonary resuscitation: An updated revisit. World J Cardiol 2024; 16:126-136. [PMID: 38576519 PMCID: PMC10989225 DOI: 10.4330/wjc.v16.i3.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/17/2024] [Accepted: 02/26/2024] [Indexed: 03/21/2024] Open
Abstract
The post-resuscitation period is recognized as the main predictor of cardiopulmonary resuscitation (CPR) outcomes. The first description of post-resuscitation syndrome and stony heart was published over 50 years ago. Major manifestations may include but are not limited to, persistent precipitating pathology, systemic ischemia/reperfusion response, post-cardiac arrest brain injury, and finally, post-cardiac arrest myocardial dysfunction (PAMD) after successful resuscitation. Why do some patients initially survive successful resuscitation, and others do not? Also, why does the myocardium response vary after resuscitation? These questions have kept scientists busy for several decades since the first successful resuscitation was described. By modifying the conventional modalities of resuscitation together with new promising agents, rescuers will be able to salvage the jeopardized post-resuscitation myocardium and prevent its progression to a dismal, stony heart. Community awareness and staff education are crucial for shortening the resuscitation time and improving short- and long-term outcomes. Awareness of these components before and early after the restoration of circulation will enhance the resuscitation outcomes. This review extensively addresses the underlying pathophysiology, management, and outcomes of post-resuscitation syndrome. The pattern, management, and outcome of PAMD and post-cardiac arrest shock are different based on many factors, including in-hospital cardiac arrest vs out-of-hospital cardiac arrest (OHCA), witnessed vs unwitnessed cardiac arrest, the underlying cause of arrest, the duration, and protocol used for CPR. Although restoring spontaneous circulation is a vital sign, it should not be the end of the game or lone primary outcome; it calls for better understanding and aggressive multi-disciplinary interventions and care. The development of stony heart post-CPR and OHCA remain the main challenges in emergency and critical care medicine.
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Affiliation(s)
- Ayman El-Menyar
- Department of Trauma and Vascular Surgery, Clinical Research, Hamad Medical Corporation, Doha 3050, Qatar
- Department of Clinical Medicine, Weill Cornell Medical College, Doha 24144, Qatar.
| | - Bianca M Wahlen
- Department of Anesthesiology, Hamad Medical Corporation, Doha 3050, Qatar
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9
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Lee S, Hwang Y, Park KE, Bae S, Ok SH, Ahn SH, Sim G, Bae M, Sohn JT. Hypothermia Inhibits Dexmedetomidine-Induced Contractions in Isolated Rat Aortae. Int J Mol Sci 2024; 25:3017. [PMID: 38474263 DOI: 10.3390/ijms25053017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 03/04/2024] [Accepted: 03/04/2024] [Indexed: 03/14/2024] Open
Abstract
Dexmedetomidine is widely used to induce sedation in the perioperative period. This study examined the effect of hypothermia (33 and 25 °C) on dexmedetomidine-induced contraction in an endothelium-intact aorta with or without the nitric oxide synthase inhibitor NW-nitro-L-arginine methyl ester (L-NAME). In addition, the effect of hypothermia on the contraction induced by dexmedetomidine in an endothelium-denuded aorta with or without a calcium-free Krebs solution was examined. The effects of hypothermia on the protein kinase C (PKC), myosin light chain (MLC20) phosphorylation, and Rho-kinase membrane translocation induced by dexmedetomidine were examined. Hypothermia inhibited dexmedetomidine-induced contraction in the endothelium-intact aorta with L-NAME or endothelium-denuded aorta. Hypothermia had almost no effect on the dexmedetomidine-induced contraction in the endothelium-denuded aorta with the calcium-free Krebs solution; however, the subsequent contraction induced by the addition of calcium was inhibited by hypothermia. Conversely, the transition from profound hypothermia back to normothermia reversed the hypothermia-induced inhibition of subsequent calcium-induced contractions. Hypothermia inhibited any contraction induced by KCl, PDBu, and NaF, as well as PKC and MLC20 phosphorylation and Rho-kinase membrane translocation induced by dexmedetomidine. These results suggest that hypothermia inhibits dexmedetomidine-induced contraction, which is mediated mainly by the impediment of calcium influx and partially by the attenuation of pathways involving PKC and Rho-kinase activation.
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Affiliation(s)
- Soohee Lee
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Changwon Hospital, Changwon-si 51472, Gyeongsangnam-do, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Jinju-si 52727, Gyeongsangnam-do, Republic of Korea
- Institute of Medical Science, Gyeongsang National University, Jinju-si 52727, Gyeongsangnam-do, Republic of Korea
| | - Yeran Hwang
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, 15 Jinju-daero 816 Beon-gil, Jinju-si 52727, Gyeongsangnam-do, Republic of Korea
| | - Kyeong-Eon Park
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, 15 Jinju-daero 816 Beon-gil, Jinju-si 52727, Gyeongsangnam-do, Republic of Korea
| | - Sungil Bae
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, 15 Jinju-daero 816 Beon-gil, Jinju-si 52727, Gyeongsangnam-do, Republic of Korea
| | - Seong-Ho Ok
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Changwon Hospital, Changwon-si 51472, Gyeongsangnam-do, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Jinju-si 52727, Gyeongsangnam-do, Republic of Korea
- Institute of Medical Science, Gyeongsang National University, Jinju-si 52727, Gyeongsangnam-do, Republic of Korea
| | - Seung-Hyun Ahn
- Institute of Medical Science, Gyeongsang National University, Jinju-si 52727, Gyeongsangnam-do, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, 15 Jinju-daero 816 Beon-gil, Jinju-si 52727, Gyeongsangnam-do, Republic of Korea
| | - Gyujin Sim
- Institute of Medical Science, Gyeongsang National University, Jinju-si 52727, Gyeongsangnam-do, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, 15 Jinju-daero 816 Beon-gil, Jinju-si 52727, Gyeongsangnam-do, Republic of Korea
| | - Moonju Bae
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, 15 Jinju-daero 816 Beon-gil, Jinju-si 52727, Gyeongsangnam-do, Republic of Korea
| | - Ju-Tae Sohn
- Institute of Medical Science, Gyeongsang National University, Jinju-si 52727, Gyeongsangnam-do, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, 15 Jinju-daero 816 Beon-gil, Jinju-si 52727, Gyeongsangnam-do, Republic of Korea
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10
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Kang JK, Darby Z, Bleck TP, Whitman GJR, Kim BS, Cho SM. Post-Cardiac Arrest Care in Adult Patients After Extracorporeal Cardiopulmonary Resuscitation. Crit Care Med 2024; 52:483-494. [PMID: 37921532 PMCID: PMC10922987 DOI: 10.1097/ccm.0000000000006102] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
OBJECTIVES Extracorporeal cardiopulmonary resuscitation (ECPR) serves as a lifesaving intervention for patients experiencing refractory cardiac arrest. With its expanding usage, there is a burgeoning focus on improving patient outcomes through optimal management in the acute phase after cannulation. This review explores systematic post-cardiac arrest management strategies, associated complications, and prognostication in ECPR patients. DATA SOURCES A PubMed search from inception to 2023 using search terms such as post-cardiac arrest care, ICU management, prognostication, and outcomes in adult ECPR patients was conducted. STUDY SELECTION Selection includes original research, review articles, and guidelines. DATA EXTRACTION Information from relevant publications was reviewed, consolidated, and formulated into a narrative review. DATA SYNTHESIS We found limited data and no established clinical guidelines for post-cardiac arrest care after ECPR. In contrast to non-ECPR patients where systematic post-cardiac arrest care is shown to improve the outcomes, there is no high-quality data on this topic after ECPR. This review outlines a systematic approach, albeit limited, for ECPR care, focusing on airway/breathing and circulation as well as critical aspects of ICU care, including analgesia/sedation, mechanical ventilation, early oxygen/C o2 , and temperature goals, nutrition, fluid, imaging, and neuromonitoring strategy. We summarize common on-extracorporeal membrane oxygenation complications and the complex nature of prognostication and withdrawal of life-sustaining therapy in ECPR. Given conflicting outcomes in ECPR randomized controlled trials focused on pre-cannulation care, a better understanding of hemodynamic, neurologic, and metabolic abnormalities and early management goals may be necessary to improve their outcomes. CONCLUSIONS Effective post-cardiac arrest care during the acute phase of ECPR is paramount in optimizing patient outcomes. However, a dearth of evidence to guide specific management strategies remains, indicating the necessity for future research in this field.
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Affiliation(s)
- Jin Kook Kang
- Division of Cardiac Surgery, Department of Surgery, Johns
Hopkins Hospital, Baltimore, MD
| | - Zachary Darby
- Division of Cardiac Surgery, Department of Surgery, Johns
Hopkins Hospital, Baltimore, MD
| | - Thomas P. Bleck
- Davee Department of Neurology, Northwestern University
Feinberg School of Medicine, Chicago IL 60611
| | - Glenn J. R. Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns
Hopkins Hospital, Baltimore, MD
| | - Bo Soo Kim
- Division of Cardiac Surgery, Department of Surgery, Johns
Hopkins Hospital, Baltimore, MD
- Division of Pulmonary and Critical Care Medicine, Johns
Hopkins Hospital, Baltimore, MD
| | - Sung-Min Cho
- Division of Cardiac Surgery, Department of Surgery, Johns
Hopkins Hospital, Baltimore, MD
- Division of Neurosciences Critical Care, Departments of
Neurology, Surgery, Anesthesiology and Critical Care Medicine, Johns Hopkins
Hospital, Baltimore, MD
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11
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Park MJ, Choi YJ, Shim M, Cho Y, Park J, Choi J, Kim J, Lee E, Kim SY. Performance of ECG-Derived Digital Biomarker for Screening Coronary Occlusion in Resuscitated Out-of-Hospital Cardiac Arrest Patients: A Comparative Study between Artificial Intelligence and a Group of Experts. J Clin Med 2024; 13:1354. [PMID: 38592195 PMCID: PMC10932362 DOI: 10.3390/jcm13051354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 02/16/2024] [Accepted: 02/26/2024] [Indexed: 04/10/2024] Open
Abstract
Acute coronary syndrome is a significant part of cardiac etiology contributing to out-of-hospital cardiac arrest (OHCA), and immediate coronary angiography has been proposed to improve survival. This study evaluated the effectiveness of an AI algorithm in diagnosing near-total or total occlusion of coronary arteries in OHCA patients who regained spontaneous circulation. Conducted from 1 July 2019 to 30 June 2022 at a tertiary university hospital emergency department, it involved 82 OHCA patients, with 58 qualifying after exclusions. The AI used was the Quantitative ECG (QCG™) system, which provides a STEMI diagnostic score ranging from 0 to 100. The QCG score's diagnostic performance was compared to assessments by two emergency physicians and three cardiologists. Among the patients, coronary occlusion was identified in 24. The QCG score showed a significant difference between occlusion and non-occlusion groups, with the former scoring higher. The QCG biomarker had an area under the curve (AUC) of 0.770, outperforming the expert group's AUC of 0.676. It demonstrated 70.8% sensitivity and 79.4% specificity. These findings suggest that the AI-based ECG biomarker could predict coronary occlusion in resuscitated OHCA patients, and it was non-inferior to the consensus of the expert group.
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Affiliation(s)
- Min Ji Park
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon-si 16499, Republic of Korea; (M.J.P.); (M.S.); (S.-Y.K.)
| | - Yoo Jin Choi
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon-si 16499, Republic of Korea; (M.J.P.); (M.S.); (S.-Y.K.)
| | - Moonki Shim
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon-si 16499, Republic of Korea; (M.J.P.); (M.S.); (S.-Y.K.)
| | - Youngjin Cho
- Department of Cardiology, Seoul National University Bundang Hospital, Seongnam-si 13620, Republic of Korea; (Y.C.); (J.P.); (J.C.)
| | - Jiesuck Park
- Department of Cardiology, Seoul National University Bundang Hospital, Seongnam-si 13620, Republic of Korea; (Y.C.); (J.P.); (J.C.)
| | - Jina Choi
- Department of Cardiology, Seoul National University Bundang Hospital, Seongnam-si 13620, Republic of Korea; (Y.C.); (J.P.); (J.C.)
| | - Joonghee Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si 13620, Republic of Korea; (J.K.); (E.L.)
- Big Data Center, Seoul National University Bundang Hospital, Seongnam-si 13620, Republic of Korea
| | - Eunkyoung Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si 13620, Republic of Korea; (J.K.); (E.L.)
- Big Data Center, Seoul National University Bundang Hospital, Seongnam-si 13620, Republic of Korea
| | - Seo-Yoon Kim
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon-si 16499, Republic of Korea; (M.J.P.); (M.S.); (S.-Y.K.)
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12
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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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13
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Nakayama R, Bunya N, Uemura S, Sawamoto K, Narimatsu E. Prehospital Advanced Airway Management and Ventilation for Out-of-Hospital Cardiac Arrest with Prehospital Return of Spontaneous Circulation: A Prospective Observational Cohort Study in Japan. PREHOSP EMERG CARE 2023; 28:470-477. [PMID: 37748189 DOI: 10.1080/10903127.2023.2260479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 09/12/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND The relationship among advanced airway management (AAM), ventilation, and oxygenation in patients with out-of-hospital cardiac arrest (OHCA) who achieve prehospital return of spontaneous circulation (ROSC) has not been validated. This study was designed to evaluate ventilation and oxygenation for each AAM technique (supraglottic devices [SGA] or endotracheal intubation [ETI]) using arterial blood gas (ABG) results immediately after hospital arrival. METHODS This observational cohort study, using data from the Japanese Association for Acute Medicine OHCA Registry, included patients with OHCA with prehospital and hospital arrival ROSC between July 1, 2014, and December 31, 2019. The primary outcomes were the partial pressure of carbon dioxide in the arterial blood (PaCO2) and partial pressure of oxygen in the arterial blood (PaO2) in the initial ABG at the hospital for each AAM technique (SGA or ETI) performed by paramedics. The secondary outcome was favorable neurological outcome (cerebral performance category [CPC] 1 or 2) for specific PaCO2 levels, which were defined as good ventilation (PaCO2 ≤45 mmHg) and insufficient ventilation (PaCO2 >45 mmHg). RESULTS This study included 1,527 patients. Regarding AAM, 1,114 and 413 patients were ventilated using SGA and ETI, respectively. The median PaCO2 and PaO2 levels were 74.50 mmHg and 151.35 mmHg in the SGA group, while 66.30 mmHg and 173.50 mmHg in the ETI group. PaCO2 was significantly lower in the ETI group than in the SGA group (12.55 mmHg; 95% CI 15.27 to 8.20, P-value < 0.001), while no significant difference was found in PaO2 by multivariate linear regression analysis. After stabilizing inverse probability of weighting (IPW), the adjusted odds ratio for favorable neurological outcome at 1 month was significant in the good ventilation group compared to the insufficient ventilation cohort (adjusted odds ratio = 2.12, 95%CI: 1.40 to 3.19, P value < 0.001). CONCLUSION The study showed that in OHCA patients with prehospital ROSC, the PaCO2 levels in the initial ABG were lower in the group with AAM by ETI than in the SGA group. Furthermore, patients with prehospital ROSC and PaCO2 ≤45 mmHg on arrival had an increased odds of favorable neurological outcome after stabilized IPW adjustment.
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Affiliation(s)
- Ryuichi Nakayama
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Naofumi Bunya
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Shuji Uemura
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Keigo Sawamoto
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Eichi Narimatsu
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
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14
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Mir A, Rahman MF, Ragab KM, Fathallah AH, Daloub S, Alwifati N, Hagrass AI, Nourelden AZ, Elsayed SM, Kamal I, Elhady MM, Khan R. Efficacy and Safety of Therapeutic Hypothermia as an Adjuvant Therapy for Percutaneous Coronary Intervention in Acute Myocardial Infarction: A Systematic Review and Meta-Analysis. Ther Hypothermia Temp Manag 2023. [PMID: 37792341 DOI: 10.1089/ther.2023.0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023] Open
Abstract
The study aims to compare the use of hypothermia in patients with myocardial infarction (MI) undergoing percutaneous coronary intervention (PCI) with control. We systematically searched four electronic databases until March 2022. The inclusion criteria were any study design that compared hypothermia in patients with MI undergoing PCI with control. The risk of bias assessment of the included randomized controlled trials was conducted through Cochrane Tool, while the quality of the included cohort studies was assessed by the NIH tool. The meta-analysis was performed on RevMan. A total of 19 studies were entered. Regarding the mortality, there were nonsignificant differences between hypothermia and control (odds ratio [OR] = 1.06, 95% confidence interval [CI] 0.75 to 1.50, p = 0.73). There was also no significant difference between the control and hypothermia in recurrent MI (OR = 1.21, 95% CI 0.64 to 2.30, p = 0.56). On the other hand, the analysis showed a significant favor for hypothermia over the control infarct size (mean difference = -1.76, 95% CI -3.04 to -0.47, p = 0.007), but a significant favor for the control over hypothermia in the overall bleeding complications (OR = 1.88, 95% CI 1.11 to 3.18, p = 0.02). Compared with the control, hypothermia reduced the infarct size of the heart, but this finding was not consistent across studies. However, the control had lower rates of bleeding problems. The other outcomes, such as death and the incidence of recurrent MI, were similar between the two groups.
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Affiliation(s)
- Ali Mir
- Department of Internal Medicine, University at Buffalo, Buffalo, New York, USA
| | | | | | | | - Shaden Daloub
- Department of Internal Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, West Virginia, USA
| | - Nader Alwifati
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, USA
| | | | | | | | - Ibrahim Kamal
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | | | - Raheel Khan
- Department of Internal Medicine, University at Buffalo, Buffalo, New York, USA
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15
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Wolfe JD, Waken RJ, Fanous E, Fox DK, May AM, Maddox KEJ. Variation in the Use of Targeted Temperature Management for Cardiac Arrest. Am J Cardiol 2023; 201:25-33. [PMID: 37352661 PMCID: PMC10960656 DOI: 10.1016/j.amjcard.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 05/27/2023] [Accepted: 06/01/2023] [Indexed: 06/25/2023]
Abstract
Targeted temperature management (TTM) is recommended for patients who do not respond after return of spontaneous circulation after cardiac arrest. However, the degree to which patients with cardiac arrest have access to this therapy on a national level is not known. Understanding hospital- and patient-level factors associated with receipt of TTM could inform interventions to improve access to this treatment among appropriate patients. Therefore, we performed a retrospective analysis using National Inpatient Sample data from 2016 to 2019. We used International Classification of Diseases, Tenth Edition diagnosis and procedure codes to identify adult patients with in-hospital and out-of-hospital cardiac arrest and receipt of TTM. We evaluated patient and hospital factors associated with receiving TTM. We identified 478,419 patients with cardiac arrest. Of those, 4,088 (0.85%) received TTM. Hospital use of TTM was driven by large, nonprofit, urban, teaching hospitals, with less use at other hospital types. There was significant regional variation in TTM capabilities, with the proportion of hospitals providing TTM ranging from >21% in the Mid-Atlantic region to <11% in the East and West South Central and Mountain regions. At the patient level, age >74 years (odds ratio [OR] 0.54, p <0.001), female gender (OR 0.89, p >0.001), and Hispanic ethnicity (OR 0.74, p <0.001) were all associated with decreased odds of receiving TTM. Patients with Medicare (OR 0.75, p <0.001) and Medicaid (OR 0.89, p = 0.027) were less likely than patients with private insurance to receive TTM. Part of these differences was driven by inequitable access to TTM-capable hospitals. In conclusion, TTM is rarely used after cardiac arrest. Hospital use of TTM is predominately limited to a subset of academic hospitals with substantial regional variation. Older age, female gender, Hispanic ethnicity, and Medicare or Medicaid insurance are all associated with a decreased likelihood of receiving TTM.
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Affiliation(s)
| | - R J Waken
- Division of Cardiology, Department of Medicine
| | | | | | - Adam M May
- Division of Cardiology, Department of Medicine
| | - Karen E Joynt Maddox
- Center for Health Economics and Policy, Institute for Public Health, Washington University in St Louis, St. Louis, Missouri.
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16
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Roy R, Kanyal R, Abd Razak M, To-Dang B, Chotai S, Abu-Own H, Cannata A, Dworakowski R, Webb I, Pareek M, Shah AM, MacCarthy P, Byrne J, Melikian N, Pareek N. The effect of ethnicity and socioeconomic status on outcomes after resuscitated out-of-hospital cardiac arrest - Findings from a tertiary centre in South London. Resusc Plus 2023; 14:100388. [PMID: 37125005 PMCID: PMC10130337 DOI: 10.1016/j.resplu.2023.100388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 03/23/2023] [Accepted: 03/27/2023] [Indexed: 05/02/2023] Open
Abstract
Background Out-of-hospital cardiac arrest is a common cause of morbidity and mortality, and ethnic variation in outcomes is recognised. We investigated ethnic and socioeconomic differences in arrest circumstances, rates of coronary artery disease, treatment, and outcomes in resuscitated OOHCA. Methods Patients with resuscitated OOHCA of suspected cardiac aetiology were included in the King's Out-of-Hospital Cardiac Arrest Registry between 1-May-2012 and 31-December-2020. Results Of 526 patients (median age 62.0 years, IQR 21.1, 74.1% male), 414 patients (78.7%) were White, 35 (6.7%) were Asian, and 77 (14.6%) were Black. Black patients had more co-existent hypertension (p = 0.007) and cardiomyopathy (p = 0.003), but less prior coronary revascularisation (p = 0.026) compared with White/Asian patients. There were no ethnic differences in location, witnesses, or bystander CPR, but Black patients had more non-shockable rhythms (p < 0.001). Black patients received less immediate coronary angiography (p < 0.001) and percutaneous coronary intervention (p < 0.001) but had lower rates of CAD (p = 0.004) than White/Asian patients. All-cause mortality at 12 months was highest amongst Black patients, followed by Asian and then White patients (57.1% vs 48.6% vs 41.3%, p = 0.032). In Black patients, excess mortality was driven by higher rates of multi-organ dysfunction but lower cardiac death than White/Asian patients, with cardiac death highest amongst Asian patients (p = 0.009). Socioeconomic status had no effect on mortality, and in a multivariable logistic regression, age, location, witnesses, and Black compared to White ethnicity were independent predictors of mortality, whilst social deprivation was not. Conclusion In this single-centre study, Black patients had higher mortality after resuscitated OOHCA than White/Asian patients. This may be in part due to differing underlying aetiology rather than differences in arrest circumstances or social deprivation.
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Affiliation(s)
- Roman Roy
- King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King’s College London, UK
| | - Ritesh Kanyal
- King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King’s College London, UK
| | - Muhamad Abd Razak
- King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King’s College London, UK
| | - Brian To-Dang
- King’s College Hospital NHS Foundation Trust, London, UK
| | - Shayna Chotai
- King’s College Hospital NHS Foundation Trust, London, UK
| | - Huda Abu-Own
- King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King’s College London, UK
| | - Antonio Cannata
- King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King’s College London, UK
| | - Rafal Dworakowski
- King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King’s College London, UK
| | - Ian Webb
- King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King’s College London, UK
| | - Manish Pareek
- Department of Respiratory Sciences, University of Leicester, Leicester, UK
- Department of Infection and HIV Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Ajay M Shah
- King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King’s College London, UK
| | - Philip MacCarthy
- King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King’s College London, UK
| | - Jonathan Byrne
- King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King’s College London, UK
| | - Narbeh Melikian
- King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King’s College London, UK
| | - Nilesh Pareek
- King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King’s College London, UK
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17
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Sundrani S, Chen J, Jin BT, Abad ZSH, Rajpurkar P, Kim D. Predicting patient decompensation from continuous physiologic monitoring in the emergency department. NPJ Digit Med 2023; 6:60. [PMID: 37016152 PMCID: PMC10073111 DOI: 10.1038/s41746-023-00803-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 03/10/2023] [Indexed: 04/06/2023] Open
Abstract
Anticipation of clinical decompensation is essential for effective emergency and critical care. In this study, we develop a multimodal machine learning approach to predict the onset of new vital sign abnormalities (tachycardia, hypotension, hypoxia) in ED patients with normal initial vital signs. Our method combines standard triage data (vital signs, demographics, chief complaint) with features derived from a brief period of continuous physiologic monitoring, extracted via both conventional signal processing and transformer-based deep learning on ECG and PPG waveforms. We study 19,847 adult ED visits, divided into training (75%), validation (12.5%), and a chronologically sequential held-out test set (12.5%). The best-performing models use a combination of engineered and transformer-derived features, predicting in a 90-minute window new tachycardia with AUROC of 0.836 (95% CI, 0.800-0.870), new hypotension with AUROC 0.802 (95% CI, 0.747-0.856), and new hypoxia with AUROC 0.713 (95% CI, 0.680-0.745), in all cases significantly outperforming models using only standard triage data. Salient features include vital sign trends, PPG perfusion index, and ECG waveforms. This approach could improve the triage of apparently stable patients and be applied continuously for the prediction of near-term clinical deterioration.
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Affiliation(s)
- Sameer Sundrani
- School of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Julie Chen
- Department of Computer Science, Stanford University, Stanford, CA, USA
| | - Boyang Tom Jin
- Department of Computer Science, Stanford University, Stanford, CA, USA
| | | | - Pranav Rajpurkar
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
| | - David Kim
- Department of Emergency Medicine, Stanford University, Stanford, CA, USA.
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18
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Belur AD, Sedhai YR, Truesdell AG, Khanna AK, Mishkin JD, Belford PM, Zhao DX, Vallabhajosyula S. Targeted Temperature Management in Cardiac Arrest: An Updated Narrative Review. Cardiol Ther 2023; 12:65-84. [PMID: 36527676 PMCID: PMC9986171 DOI: 10.1007/s40119-022-00292-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022] Open
Abstract
The established benefits of cooling along with development of sophisticated methods to safely and precisely induce, maintain, monitor, and reverse hypothermia have led to the development of targeted temperature management (TTM). Early trials in human subjects showed that hypothermia conferred better neurological outcomes when compared to normothermia among survivors of cardiac arrest, leading to guidelines recommending targeted hypothermia in this patient population. Multiple studies have sought to explore and compare the benefit of hypothermia in various subgroups of patients, such as survivors of out-of-hospital cardiac arrest versus in-hospital cardiac arrest, and survivors of an initial shockable versus non-shockable rhythm. Larger and more recent trials have shown no statistically significant difference in neurological outcomes between patients with targeted hypothermia and targeted normothermia; further, aggressive cooling is associated with a higher incidence of multiple systemic complications. Based on this data, temporal trends have leaned towards using a lenient temperature target in more recent times. Current guidelines recommend selecting and maintaining a constant target temperature between 32 and 36 °C for those patients in whom TTM is used (strong recommendation, moderate-quality evidence), as soon as possible after return of spontaneous circulation is achieved and airway, breathing (including mechanical ventilation), and circulation are stabilized. The comparative benefit of lower (32-34 °C) versus higher (36 °C) temperatures remains unknown, and further research may help elucidate this. Any survivor of cardiac arrest who is comatose (defined as unarousable unresponsiveness to external stimuli) should be considered as a candidate for TTM regardless of the initial presenting rhythm, and the decision to opt for targeted hypothermia versus targeted normothermia should be made on a case-by-case basis.
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Affiliation(s)
- Agastya D Belur
- Division of Cardiology, Department of Medicine, University of Louisville, Louisville, KY, USA
| | - Yub Raj Sedhai
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Kentucky College of Medicine, Bowling Green, KY, USA
| | | | - Ashish K Khanna
- Section of Critical Care Medicine, Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, USA.,Outcomes Research Consortium, Cleveland, OH, USA.,Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA
| | - Joseph D Mishkin
- Section of Advanced Heart Failure and Transplant Cardiology, Atrium Health Sanger Heart and Vascular Institute, Charlotte, NC, USA
| | - P Matthew Belford
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest School of Medicine, 306 Westwood Avenue, Suite 401, High Point, Winston-Salem, NC, 27262, USA
| | - David X Zhao
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest School of Medicine, 306 Westwood Avenue, Suite 401, High Point, Winston-Salem, NC, 27262, USA
| | - Saraschandra Vallabhajosyula
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA. .,Section of Cardiovascular Medicine, Department of Medicine, Wake Forest School of Medicine, 306 Westwood Avenue, Suite 401, High Point, Winston-Salem, NC, 27262, USA. .,Department of Implementation Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA.
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19
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Slagle DL, Caplan RJ, Deitchman AR. Outcomes after decrease in hypothermia usage for out of Hospital Cardiac arrest after targeted temperature management study. J Clin Monit Comput 2023; 37:261-266. [PMID: 35802294 DOI: 10.1007/s10877-022-00887-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 06/14/2022] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Evaluate trends in targeted temperature management with regards to temperature selection, its effect on neurologic outcomes at discharge, and compare this with recent large randomized controlled trial outcomes. DESIGN Retrospective cohort study between January 2010 and December 2019. SETTING Single large tertiary academic community hospital. PATIENTS 634 adult non-traumatic patients presenting with out of hospital cardiac arrest with persistent comatose state treated with active targeted temperature management. INTERVENTIONS, MEASUREMENTS, AND MAIN RESULTS 473 patients received hypothermia of 33 °C and were compared to 161 patients who received targeted normothermia of 36.5 °C. The primary outcome was Cerebral Performance Category (CPC) at hospital discharge, with levels 1 or 2 considered good outcomes. Mortality, ICU days, ventilator days, and overall hospital stay length were secondary outcomes. Patients receiving T33 had more favorable CPC outcomes when compared to patients receiving T36.5 (OR = 2.4 [1.3, 4.6], p = 0.006). Subgroup analysis of initial non-shockable rhythms demonstrated improved CPC scores (OR = 2.5, p = 0.04), however this was not maintained in the shockable rhythm group. T33 patients had a shorter length of stay. Mortality, ICU days, and ventilator days did not differ between the groups. CONCLUSIONS Out of hospital cardiac arrest patients with persistent comatose state treated with hypothermia of 33 °C had improved odds of discharge with good neurologic outcomes when compared to those treated with targeted normothermia. This improvement of outcomes appears to have been driven by the improved outcomes in the patients who had presented with non-shockable rhythm.
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Affiliation(s)
- Dustin L Slagle
- Emergency Medicine and Internal Medicine Residency, ChristianaCare, Newark, DE, USA.
- Department of Emergency Medicine, 4755 Ogletown Stanton Rd, 19718, Newark, DE, USA.
| | - Richard J Caplan
- Institute for Research on Equity and Community Health, ChristianaCare, Newark, DE, USA
| | - Andrew R Deitchman
- Division of Pulmonary and Critical Care, ChristianaCare, Newark, DE, USA
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20
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Wang YC, Wu MJ, Zhou SL, Li ZH. Protective effects of combined treatment with ciprofol and mild therapeutic hypothermia during cerebral ischemia-reperfusion injury. World J Clin Cases 2023; 11:487-492. [PMID: 36793629 PMCID: PMC9923870 DOI: 10.12998/wjcc.v11.i3.487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/13/2022] [Accepted: 01/05/2023] [Indexed: 01/23/2023] Open
Abstract
Despite improvement in cardiopulmonary resuscitation (CPR) performance, cardiac arrest (CA) is still associated with poor prognosis. The high mortality rate is due to multi-organ dysfunction caused by cerebral ischemia and reperfusion injury (I/R). The guidelines for CPR suggest the use of therapeutic hypothermia (TH) as an effective treatment to decrease mortality and the only approach confirmed to reduce I/R injury. During TH, sedative agents (propofol) and analgesia agents (fentanyl) are commonly used to prevent shiver and pain. However, propofol has been associated with a number of serious adverse effects such as metabolic acidosis, cardiac asystole, myocardial failure, and death. In addition, mild TH alters the pharmacokinetics of agents (propofol and fentanyl) and reduces their systemic clearance. For CA patients undergoing TH, propofol can be overdosed, leading to delayed awakening, prolonged mechanical ventilation, and other subsequent complications. Ciprofol (HSK3486) is a novel anesthetic agent that is convenient and easy to administer intravenously outside the operating room. Ciprofol is rapidly metabolized and accumulates at low concentrations after continuous infusion in a stable circulatory system compared to propofol. Therefore, we hypothesized that treatment with HSK3486 and mild TH after CA could protect the brain and other organs.
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Affiliation(s)
- Yi-Chao Wang
- Department of Thyroid & Parathyroid Surgery Center, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- Laboratory of Thyroid and Parathyroid Disease, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Meng-Jun Wu
- Department of Anesthesiology, Chengdu Women and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology, Chengdu 610041, Sichuan Province, China
| | - Sheng-Liang Zhou
- Department of Thyroid & Parathyroid Surgery Center, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- Laboratory of Thyroid and Parathyroid Disease, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Zhi-Hui Li
- Department of Thyroid & Parathyroid Surgery Center, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- Laboratory of Thyroid and Parathyroid Disease, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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21
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Impact of Hospital Safety-Net Burden on Outcomes of In-Hospital Cardiac Arrest in the United States. Crit Care Explor 2023; 5:e0838. [PMID: 36699243 PMCID: PMC9831170 DOI: 10.1097/cce.0000000000000838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
High safety-net burden hospitals (HBHs) treating large numbers of uninsured or Medicaid-insured patients have generally been linked to worse clinical outcomes. However, limited data exist on the impact of the hospitals' safety-net burden on in-hospital cardiac arrest (IHCA) outcomes in the United States. OBJECTIVES To compare the differences in survival to discharge, routine discharge home, and healthcare resource utilization between patients at HBH with those treated at low safety-net burden hospital (LBH). DESIGN SETTING AND PARTICIPANTS Retrospective cohort study across hospitals in the United States: Hospitalized patients greater than or equal to 18 years that underwent cardiopulmonary resuscitation (CPR) between 2008 and 2018 identified from the Nationwide Inpatient Database. Data analysis was conducted in January 2022. EXPOSURE IHCA. MAIN OUTCOMES AND MEASURES The primary outcome is survival to hospital discharge. Other outcomes are routine discharge home among survivors, length of hospital stay, and total hospitalization cost. RESULTS From 2008 to 2018, an estimated 555,016 patients were hospitalized with IHCA, of which 19.2% occurred at LBH and 55.2% at HBH. Compared with LBH, patients at HBH were younger (62 ± 20 yr vs 67 ± 17 yr) and predominantly in the lowest median household income (< 25th percentile). In multivariate analysis, HBH was associated with lower chances of survival to hospital discharge (adjusted odds ratio [aOR], 0.88; 95% CI, 0.85-0.96) and lower odds of routine discharge (aOR, 0.6; 95% CI, 0.47-0.75), compared with LBH. In addition, IHCA patients at publicly owned hospitals and those with medium and large hospital bed size were less likely to survive to hospital discharge, while patients with median household income greater than 25th percentile had better odds of hospital survival. CONCLUSIONS AND RELEVANCE Our study suggests that patients who experience IHCA at HBH may have lower rates and odds of in-hospital survival and are less likely to be routinely discharged home after CPR. Median household income and hospital-level characteristics appear to contribute to survival.
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22
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Brennan KA, Bhutiani M, Kingeter MA, McEvoy MD. Updates in the Management of Perioperative Vasoplegic Syndrome. Adv Anesth 2022; 40:71-92. [PMID: 36333053 DOI: 10.1016/j.aan.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Vasoplegic syndrome occurs relatively frequently in cardiac surgery, liver transplant, major noncardiac surgery, in post-return of spontaneous circulation situations, and in pateints with sepsis. It is paramount for the anesthesiologist to understand both the pathophysiology of vasoplegia and the different treatment strategies available for rescuing a patient from life-threatening hypotension.
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Affiliation(s)
- Kaitlyn A Brennan
- Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Avenue South, MAB 422, Nashville, TN 37212, USA
| | - Monica Bhutiani
- Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Avenue South, VUH 4107, Nashville, TN 37212, USA
| | - Meredith A Kingeter
- Anesthesia Residency, Vanderbilt University Medical Center, 1215 21st Avenue South, Suite 5160 MCE NT, Nashville, TN 37212, USA
| | - Matthew D McEvoy
- VUMC Enhanced Recovery Programs, Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN 37232, USA.
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23
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Ikeda T, Amorim E, Miyazaki Y, Kato R, Marutani E, Silverman MG, Malhotra R, Solt K, Ichinose F. Post-cardiac arrest Sedation Promotes Electroencephalographic Slow-wave Activity and Improves Survival in a Mouse Model of Cardiac Arrest. Anesthesiology 2022; 137:716-732. [PMID: 36170545 PMCID: PMC11079777 DOI: 10.1097/aln.0000000000004390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients resuscitated from cardiac arrest are routinely sedated during targeted temperature management, while the effects of sedation on cerebral physiology and outcomes after cardiac arrest remain to be determined. The authors hypothesized that sedation would improve survival and neurologic outcomes in mice after cardiac arrest. METHODS Adult C57BL/6J mice of both sexes were subjected to potassium chloride-induced cardiac arrest and cardiopulmonary resuscitation. Starting at the return of spontaneous circulation or at 60 min after return of spontaneous circulation, mice received intravenous infusion of propofol at 40 mg · kg-1 · h-1, dexmedetomidine at 1 µg · kg-1 · h-1, or normal saline for 2 h. Body temperature was lowered and maintained at 33°C during sedation. Cerebral blood flow was measured for 4 h postresuscitation. Telemetric electroencephalogram (EEG) was recorded in freely moving mice from 3 days before up to 7 days after cardiac arrest. RESULTS Sedation with propofol or dexmedetomidine starting at return of spontaneous circulation improved survival in hypothermia-treated mice (propofol [13 of 16, 81%] vs. no sedation [4 of 16, 25%], P = 0.008; dexmedetomidine [14 of 16, 88%] vs. no sedation [4 of 16, 25%], P = 0.002). Mice receiving no sedation exhibited cerebral hyperemia immediately after resuscitation and EEG power remained less than 30% of the baseline in the first 6 h postresuscitation. Administration of propofol or dexmedetomidine starting at return of spontaneous circulation attenuated cerebral hyperemia and increased EEG slow oscillation power during and early after sedation (40 to 80% of the baseline). In contrast, delayed sedation failed to improve outcomes, without attenuating cerebral hyperemia and inducing slow-wave activity. CONCLUSIONS Early administration of sedation with propofol or dexmedetomidine improved survival and neurologic outcomes in mice resuscitated from cardiac arrest and treated with hypothermia. The beneficial effects of sedation were accompanied by attenuation of the cerebral hyperemic response and enhancement of electroencephalographic slow-wave activity. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Takamitsu Ikeda
- Anesthesia Center for Critical Care Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Edilberto Amorim
- Department of Neurology, University of California San Francisco, San Francisco, California
- Neurology Service, Zuckerberg San Francisco Hospital, San Francisco, California
| | - Yusuke Miyazaki
- Anesthesia Center for Critical Care Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Risako Kato
- Anesthesia Center for Critical Care Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Physiology and Oral Physiology, Graduate School of Biomedical and Health Sciences, Hiroshima University
| | - Eizo Marutani
- Anesthesia Center for Critical Care Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Rajeev Malhotra
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Ken Solt
- Anesthesia Center for Critical Care Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Fumito Ichinose
- Anesthesia Center for Critical Care Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Andrea L, Bangar MD, Moskowitz A. Questions Remain about Targeted Temperature Management in Cardiac Arrest. NEJM EVIDENCE 2022; 1:EVIDe2200247. [PMID: 38319860 DOI: 10.1056/evide2200247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
For decades, targeted temperature management (TTM) has been a promising intervention for mitigating brain damage after cardiac arrest. Early landmark studies of TTM for out-of-hospital cardiac arrests (OHCAs) with shockable rhythms showed benefits in mortality and neurologic outcome.1,2 On the basis of these results, TTM was established as standard practice and was given a class I recommendation in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care for use in OHCA with initial shockable rhythms, as well as a class IIb recommendation in patients with initial nonshockable rhythms and for in-hospital cardiac arrests (IHCAs).3.
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Affiliation(s)
- Luke Andrea
- Division of Critical Care Medicine, Montefiore Medical Center, Bronx, New York
| | - Maneesha D Bangar
- Division of Critical Care Medicine, Montefiore Medical Center, Bronx, New York
| | - Ari Moskowitz
- Division of Critical Care Medicine, Montefiore Medical Center, Bronx, New York
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25
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Repetitive Electroencephalography as Biomarker for the Prediction of Survival in Patients with Post-Hypoxic Encephalopathy. J Clin Med 2022; 11:jcm11216253. [DOI: 10.3390/jcm11216253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 10/19/2022] [Accepted: 10/20/2022] [Indexed: 11/07/2022] Open
Abstract
Predicting survival in patients with post-hypoxic encephalopathy (HE) after cardiopulmonary resuscitation is a challenging aspect of modern neurocritical care. Here, continuous electroencephalography (cEEG) has been established as the gold standard for neurophysiological outcome prediction. Unfortunately, cEEG is not comprehensively available, especially in rural regions and developing countries. The objective of this monocentric study was to investigate the predictive properties of repetitive EEGs (rEEGs) with respect to 12-month survival based on data for 199 adult patients with HE, using log-rank and multivariate Cox regression analysis (MCRA). A total number of 59 patients (29.6%) received more than one EEG during the first 14 days of acute neurocritical care. These patients were analyzed for the presence of and changes in specific EEG patterns that have been shown to be associated with favorable or poor outcomes in HE. Based on MCRA, an initially normal amplitude with secondary low-voltage EEG remained as the only significant predictor for an unfavorable outcome, whereas all other relevant parameters identified by univariate analysis remained non-significant in the model. In conclusion, rEEG during early neurocritical care may help to assess the prognosis of HE patients if cEEG is not available.
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26
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D'Amato SA, Kimberly WT, Mayer SA. Through the Looking Glass: The Paradoxical Evolution of Targeted Temperature Management for Comatose Survivors of Cardiac Arrest. Neurotherapeutics 2022; 19:1869-1877. [PMID: 36253510 PMCID: PMC9723025 DOI: 10.1007/s13311-022-01315-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2022] [Indexed: 12/13/2022] Open
Abstract
For the past two decades, targeted temperature management (TTM) has been a staple in the care of comatose survivors following cardiac arrest. However, recent clinical trials have failed to replicate the benefit seen in earlier studies, bringing into question the very existence of such clinical practice. In this review, we explore clinical scenarios within critical care that appeared to share a similar fate, but in actuality changed the landscape of practice in a modern world. Accordingly, clinicians may apply these lessons to the utilization of TTM among comatose survivors following cardiac arrest, potentially paving way for a re-framing of clinical care amidst an environment where current data appears upside down in comparison to past successes.
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Affiliation(s)
- Salvatore A D'Amato
- Department of Neurosurgery, Neurocritical Care Fellowship Program, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 7.154, Houston, TX, 77030, USA.
| | - W Taylor Kimberly
- Division of Neurocritical Care, Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Stephan A Mayer
- Neurocritical Care and Emergency Neurology Services, Westchester Medical Center Health System, 100 Woods Road, Valhalla, NY, 10595, USA
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27
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Influence of the Level of Emergency Medical Facility on the Short-Term Treatment Results of Cardiac Arrest: Out-of-Hospital Cardiac Arrest and Interhospital Transfer. Emerg Med Int 2022; 2022:2662956. [PMID: 36065222 PMCID: PMC9440813 DOI: 10.1155/2022/2662956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/01/2022] [Indexed: 11/17/2022] Open
Abstract
Objective. This study aimed to elucidate whether direct transport of out-of-hospital cardiac arrest (OHCA) patients to higher-level emergency medical centres (EMCs) would result in better survival compared to resuscitation in smaller local emergency departments (EDs) and subsequent transfer. Methods. This study was a retrospective population-based analysis of cases registered in the national database of 2019. This study investigated the immediate results of cardiopulmonary resuscitation for OHCA compared between EMCs and EDs and the results of therapeutic temperature management (TTM) compared between the patients directly transported from the field and those transferred from other hospitals. In-hospital mortality was compared using multivariate logistic regression. Results. From the population dataset, 11,493 OHCA patients were extracted. (8,912 in the EMC group vs. 2,581 in the ED group). Multivariate logistic regression revealed that the odds for ED mortality were lower with treatment in EDs than with treatment in EMCs. (odds ratio 0.712 (95% confidence interval (CI): 0.638–0.796)). From the study dataset, 1,798 patients who received TTM were extracted. (1,164 in the direct visit group vs. 634 in the transferred group). Multivariate regression analysis showed that the odds ratio for overall mortality was 1.411 (95% CI: 0.809–2.446) in the transferred group. (
). Conclusion. The immediate outcome of OHCA patients who were transported to EDs was not inferior to that of EMCs. Therefore, it would be acceptable to transport OHCA patients to the nearest emergency facilities rather than to the specialized centres in distant areas.
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28
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Liang M, Ahmad F, Dickinson R. Neuroprotection by the noble gases argon and xenon as treatments for acquired brain injury: a preclinical systematic review and meta-analysis. Br J Anaesth 2022; 129:200-218. [PMID: 35688658 PMCID: PMC9428918 DOI: 10.1016/j.bja.2022.04.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/28/2022] [Accepted: 04/12/2022] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND The noble gases argon and xenon are potential novel neuroprotective treatments for acquired brain injuries. Xenon has already undergone early-stage clinical trials in the treatment of ischaemic brain injuries, with mixed results. Argon has yet to progress to clinical trials as a treatment for brain injury. Here, we aim to synthesise the results of preclinical studies evaluating argon and xenon as neuroprotective therapies for brain injuries. METHODS After a systematic review of the MEDLINE and Embase databases, we carried out a pairwise and stratified meta-analysis. Heterogeneity was examined by subgroup analysis, funnel plot asymmetry, and Egger's regression. RESULTS A total of 32 studies were identified, 14 for argon and 18 for xenon, involving measurements from 1384 animals, including murine, rat, and porcine models. Brain injury models included ischaemic brain injury after cardiac arrest (CA), neurological injury after cardiopulmonary bypass (CPB), traumatic brain injury (TBI), and ischaemic stroke. Both argon and xenon had significant (P<0.001), positive neuroprotective effect sizes. The overall effect size for argon (CA, TBI, stroke) was 18.1% (95% confidence interval [CI], 8.1-28.1%), and for xenon (CA, TBI, stroke) was 34.1% (95% CI, 24.7-43.6%). Including the CPB model, only present for xenon, the xenon effect size (CPB, CA, TBI, stroke) was 27.4% (95% CI, 11.5-43.3%). Xenon, both with and without the CPB model, was significantly (P<0.001) more protective than argon. CONCLUSIONS These findings provide evidence to support the use of xenon and argon as neuroprotective treatments for acquired brain injuries. Current evidence suggests that xenon is more efficacious than argon overall.
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Affiliation(s)
- Min Liang
- Anaesthetics, Pain Medicine, and Intensive Care Section, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Fatin Ahmad
- Anaesthetics, Pain Medicine, and Intensive Care Section, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Robert Dickinson
- Anaesthetics, Pain Medicine, and Intensive Care Section, Department of Surgery and Cancer, Imperial College London, London, UK,Royal British Legion Centre for Blast Injury Studies, Imperial College London, London, UK,Corresponding author
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29
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Murphy TW, Cohen SA, Hwang CW, Avery KL, Balakrishnan MP, Balu R, Chowdhury MAB, Crabb DB, Elmelige Y, Maciel CB, Gul SS, Han F, Becker TK. Cardiac arrest: An interdisciplinary scoping review of clinical literature from 2020. J Am Coll Emerg Physicians Open 2022; 3:e12773. [PMID: 35845142 PMCID: PMC9282171 DOI: 10.1002/emp2.12773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 05/15/2022] [Accepted: 06/02/2022] [Indexed: 11/08/2022] Open
Abstract
Objectives The Interdisciplinary Cardiac Arrest Research Review (ICARE) group was formed in 2018 to conduct an annual search of peer-reviewed literature relevant to cardiac arrest. Now in its third year, the goals of the review are to highlight annual updates in the interdisciplinary world of clinical cardiac arrest research with a focus on clinically relevant and impactful clinical and population-level studies from 2020. Methods A search of PubMed using keywords related to clinical research in cardiac arrest was conducted. Titles and abstracts were screened for relevance and sorted into 7 categories: Epidemiology & Public Health Initiatives; Prehospital Resuscitation, Technology & Care; In-Hospital Resuscitation & Post-Arrest Care; Prognostication & Outcomes; Pediatrics; Interdisciplinary Guidelines & Reviews; and a new section dedicated to the coronavirus disease 2019 (COVID-19) pandemic. Screened manuscripts underwent standardized scoring of methodological quality and impact on the respective fields by reviewer teams lead by a subject matter expert editor. Articles scoring higher than 99 percentiles by category were selected for full critique. Systematic differences between editors' and reviewers' scores were assessed using Wilcoxon signed-rank test. Results A total of 3594 articles were identified on initial search; of these, 1026 were scored after screening for relevance and deduplication, and 51 underwent full critique. The leading category was Prehospital Resuscitation, Technology & Care representing 35% (18/51) of fully reviewed articles. Four COVID-19 related articles were included for formal review that was attributed to a relative lack of high-quality data concerning cardiac arrest and COVID-19 specifically by the end of the 2020 calendar year. No significant differences between editor and reviewer scoring were found among review articles (P = 0.697). Among original research articles, section editors scored a median 1 point (interquartile range, 0-3; P < 0.01) less than reviewers. Conclusions Several clinically relevant studies have added to the evidence base for the management of cardiac arrest patients including methods for prognostication of neurologic outcome following arrest, airway management strategy, timing of coronary intervention, and methods to improve expeditious performance of key components of resuscitation such as chest compressions in adults and children.
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Affiliation(s)
- Travis W. Murphy
- Division of Critical Care MedicineDepartment of Emergency MedicineUniversity of FloridaGainesvilleFloridaUSA
- Cardiothoracic Critical CareMiami Transplant InstituteUniversity of MiamiMiamiFloridaUSA
- Department of Emergency MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Scott A. Cohen
- Department of Emergency MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Charles W. Hwang
- Department of Emergency MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - K. Leslie Avery
- Division of Pediatric Critical CareDepartment of PediatricsUniversity of FloridaGainesvilleFloridaUSA
| | | | - Ramani Balu
- Division of Neurocritical CareDepartment of NeurologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | | | - David B. Crabb
- Department of Emergency MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Yasmeen Elmelige
- Department of Emergency MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Carolina B. Maciel
- Division of Neurocritical CareDepartment of NeurologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of NeurologyYale UniversityNew HavenConnecticutUSA
- Division of Neurocritical CareDepartment of NeurologyUniversity of FloridaGainesvilleFloridaUSA
| | - Sarah S. Gul
- Department of SurgeryYale UniversityNew HavenConnecticutUSA
| | - Francis Han
- Department of Emergency MedicineUniversity of FloridaGainesvilleFloridaUSA
- Lake Erie College of Osteopathic MedicineBradentonFloridaUSA
| | - Torben K. Becker
- Division of Critical Care MedicineDepartment of Emergency MedicineUniversity of FloridaGainesvilleFloridaUSA
- Department of Emergency MedicineUniversity of FloridaGainesvilleFloridaUSA
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30
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Natarajan G, Hamrick SE, Zaniletti I, Lee KS, Mietzsch U, DiGeronimo R, Dizon MLV, Peeples ES, Yanowitz TD, Wu TW, Flibotte J, Joe P, Massaro AN, Rao R. Opioid exposure during therapeutic hypothermia and short-term outcomes in neonatal encephalopathy. J Perinatol 2022; 42:1017-1025. [PMID: 35474129 DOI: 10.1038/s41372-022-01400-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 03/21/2022] [Accepted: 04/08/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess the association between opioid exposure during therapeutic hypothermia (TH) for perinatal hypoxic-ischemic encephalopathy (HIE) and in-hospital outcomes. STUDY DESIGN In this retrospective cohort study, linked data were accessed on infants ≥36 weeks gestation, who underwent TH for HIE, born from 2010-2016 in 23 Neonatal Intensive Care Units participating in Children's Hospitals Neonatal Consortium and Pediatric Health Information Systems. We excluded infants who received opioids for >5 days. RESULTS The cohort (n = 1484) was categorized as No opioid [240(16.2%)], Low opioid (1-2 days) [574 (38.7%)] and High opioid group (HOG, 3-5 days) [670 (45.2%)]. After adjusting for HIE severity, opioids were not associated with abnormal MRI, but were associated with decreased likelihood of complete oral feeds at discharge. HOG had increased likelihood of prolonged hospital stay and ventilation. CONCLUSION Opioid exposure during TH was not associated with abnormal MRI; its association with adverse short-term outcomes suggests need for cautious empiric use.
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Affiliation(s)
- Girija Natarajan
- Pediatrics, Central Michigan University, Children's Hospital of Michigan, Detroit, MI, USA.
| | | | | | - Kyong-Soon Lee
- Pediatrics, Hospital for Sick Children, Toronto, ON, Canada
| | - Ulrike Mietzsch
- Pediatrics/Neonatology, Seattle Children's Hospital/University of Washington, Seattle, WA, USA
| | - Robert DiGeronimo
- Pediatrics/Neonatology, Seattle Children's Hospital/University of Washington, Seattle, WA, USA
| | - Maria L V Dizon
- Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Eric S Peeples
- Pediatrics, University of Nebraska Medical Center, Omaha, NE, USA
| | - Toby D Yanowitz
- Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Tai-Wei Wu
- Neonatology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - John Flibotte
- Pediatrics/ Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Priscilla Joe
- Neonatology, UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA
| | - An N Massaro
- Neonatology, Children's National Health Systems, Washington, DC, USA
| | - Rakesh Rao
- Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
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31
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Kim MJ, Kim YJ, Yum MS, Kim WY. Alpha-power in electroencephalography as good outcome predictor for out-of-hospital cardiac arrest survivors. Sci Rep 2022; 12:10907. [PMID: 35764807 PMCID: PMC9240023 DOI: 10.1038/s41598-022-15144-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 06/20/2022] [Indexed: 11/09/2022] Open
Abstract
This study aimed to investigate the utility of quantitative EEG biomarkers for predicting good neurologic outcomes in OHCA survivors treated with targeted temperature management (TTM) using power spectral density (PSD), event-related spectral perturbation (ERSP), and spectral entropy (SE). This observational registry-based study was conducted at a tertiary care hospital in Korea using data of adult nontraumatic comatose OHCA survivors who underwent standard EEG and treated with TTM between 2010 and 2018. Good neurological outcome at 1 month (Cerebral Performance Category scores 1 and 2) was the primary outcome. The linear mixed model analysis was performed for PSD, ESRP, and SE values of all and each frequency band. Thirteen of the 54 comatose OHCA survivors with TTM and EEG were excluded due to poor EEG quality or periodic/rhythmic pattern, and EEG data of 41 patients were used for analysis. The median time to EEG was 21 h, and the rate of the good neurologic outcome at 1 month was 52.5%. The good neurologic outcome group was significantly younger and showed higher PSD and ERSP and lower SE features for each frequency than the poor outcome group. After age adjustment, only the alpha-PSD was significantly higher in the good neurologic outcome group (1.13 ± 1.11 vs. 0.09 ± 0.09, p = 0.031) and had best performance with 0.903 of the area under the curve for predicting good neurologic outcome. Alpha-PSD best predicts good neurologic outcome in OHCA survivors and is an early biomarker for prognostication. Larger studies are needed to conclusively confirm these findings.
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Affiliation(s)
- Min-Jee Kim
- Division of Pediatric Neurology, Department of Pediatrics, Asan Medical Center Children's Hospital, Ulsan University College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Youn-Jung Kim
- Department of Emergency Medicine, Asan Medical Center, Ulsan University College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Mi-Sun Yum
- Division of Pediatric Neurology, Department of Pediatrics, Asan Medical Center Children's Hospital, Ulsan University College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, Ulsan University College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
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Lin T, Yao Y, Xu Y, Huang HB. Neuromuscular Blockade for Cardiac Arrest Patients Treated With Targeted Temperature Management: A Systematic Review and Meta-Analysis. Front Pharmacol 2022; 13:780370. [PMID: 35685629 PMCID: PMC9171045 DOI: 10.3389/fphar.2022.780370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 05/02/2022] [Indexed: 12/29/2022] Open
Abstract
Background: Neuromuscular-blocking agents (NMBA) are often administered to control shivering in comatose cardiac arrest (CA) survivors during targeted temperature management (TTM) management. Thus, we performed a systematic review and meta-analysis to investigate the effectiveness and safety of NMBA in such a patient population. Methods: We searched for relevant studies in PubMed, Embase, and the Cochrane Library until 15 Jul 2021. Studies were included if they reported data on any of the predefined outcomes in adult comatose CA survivors managed with any NMBA regimens. The primary outcomes were mortality and neurological outcome. Results were expressed as odds ratio (OR) or mean difference (MD) with an accompanying 95% confidence interval (CI). Heterogeneity, sensitivity analysis, and publication bias were also investigated to test the robustness of the primary outcome. Data Synthesis: We included 12 studies (3 randomized controlled trials and nine observational studies) enrolling 11,317 patients. These studies used NMBA in three strategies: prophylactic NMBA, bolus NMBA if demanded, or managed without NMBA. Pooled analysis showed that CA survivors with prophylactic NMBA significantly improved both outcomes of mortality (OR 0.74; 95% CI 0.64-0.86; I 2 = 41%; p < 0.0001) and neurological outcome (OR 0.53; 95% CI 0.37-0.78; I 2 = 59%; p = 0.001) than those managed without NMBA. These results were confirmed by the sensitivity analyses and subgroup analyses. Only a few studies compared CA survivors receiving continuous versus bolus NMBA if demanded strategies and the pooled results showed no benefit in the primary outcomes between the two groups. Conclusion: Our results showed that using prophylactic NMBA strategy compared to the absence of NMBA was associated with improved mortality and neurologic outcome in CA patients undergoing TTM. However, more high-quality randomized controlled trials are needed to confirm our results.
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Affiliation(s)
- Tong Lin
- Department of Reproductive Endocrinology, Hospital of Traditional Chinese Medicine, Zhaoqing, China
| | - Yan Yao
- Department of Critical Care Medicine, School of Clinical Medicine, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Yuan Xu
- Department of Critical Care Medicine, School of Clinical Medicine, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Hui-Bin Huang
- Department of Critical Care Medicine, School of Clinical Medicine, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
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Hillerson DB, Laine ME, Bissell BD, Mefford B. Contemporary targeted temperature management: Clinical evidence and controversies. Perfusion 2022; 38:666-680. [PMID: 35531914 DOI: 10.1177/02676591221076286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Advancements in cardiac arrest and post-cardiac arrest care have led to improved survival to hospital discharge. While survival to hospital discharge is an important clinical outcome, neurologic recovery is also a priority. With the advancement of targeted temperature management (TTM), the American Heart Association guidelines for post-cardiac arrest care recommend TTM in patients who remain comatose after return of spontaneous circulation (ROSC). Recently, the TTM2 randomized controlled trial found no significant difference in neurologic function and mortality at 6-months between traditional hypothermia to 33°C versus 37.5°C. While TTM has been evaluated for decades, current literature suggests that the use of TTM to 33° when compared to a protocol of targeted normothermia does not result in improved outcomes. Instead, perhaps active avoidance of fever may be most beneficial. Extracorporeal cardiopulmonary resuscitation and membrane oxygenation can provide a means of both hemodynamic support and TTM after ROSC. This review aims to describe the pathophysiology, physiologic aspects, clinical trial evidence, changes in post-cardiac arrest care, potential risks, as well as controversies of TTM.
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Affiliation(s)
- Dustin B Hillerson
- 5232University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022; 145:e895-e1032. [PMID: 35363499 DOI: 10.1161/cir.0000000000001063] [Citation(s) in RCA: 671] [Impact Index Per Article: 335.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison
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Johnson TW, Dar IA, Donohue KL, Xu YY, Santiago E, Selioutski O, Marinescu MA, Maddox RK, Wu TT, Schifitto G, Gosev I, Choe R, Khan IR. Cerebral Blood Flow Hemispheric Asymmetry in Comatose Adults Receiving Extracorporeal Membrane Oxygenation. Front Neurosci 2022; 16:858404. [PMID: 35478849 PMCID: PMC9036108 DOI: 10.3389/fnins.2022.858404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/09/2022] [Indexed: 12/03/2022] Open
Abstract
Peripheral veno-arterial extracorporeal membrane oxygenation (ECMO) artificially oxygenates and circulates blood retrograde from the femoral artery, potentially exposing the brain to asymmetric perfusion. Though ECMO patients frequently experience brain injury, neurologic exams and imaging are difficult to obtain. Diffuse correlation spectroscopy (DCS) non-invasively measures relative cerebral blood flow (rBF) at the bedside using an optical probe on each side of the forehead. In this study we observed interhemispheric rBF differences in response to mean arterial pressure (MAP) changes in adult ECMO recipients. We recruited 13 subjects aged 21–78 years (7 with cardiac arrest, 4 with acute heart failure, and 2 with acute respiratory distress syndrome). They were dichotomized via Glasgow Coma Scale Motor score (GCS-M) into comatose (GCS-M ≤ 4; n = 4) and non-comatose (GCS-M > 4; n = 9) groups. Comatose patients had greater interhemispheric rBF asymmetry (ASYMrBF) vs. non-comatose patients over a range of MAP values (29 vs. 11%, p = 0.009). ASYMrBF in comatose patients resolved near a MAP range of 70–80 mmHg, while rBF remained symmetric through a wider MAP range in non-comatose patients. Correlations between post-oxygenator pCO2 or pH vs. ASYMrBF were significantly different between comatose and non-comatose groups. Our findings indicate that comatose patients are more likely to have asymmetric cerebral perfusion.
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Affiliation(s)
- Thomas W. Johnson
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, United States
| | - Irfaan A. Dar
- Department of Biomedical Engineering, University of Rochester, Rochester, NY, United States
| | - Kelly L. Donohue
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Yama Y. Xu
- School of Arts and Sciences, University of Rochester, Rochester, NY, United States
| | - Esmeralda Santiago
- School of Arts and Sciences, University of Rochester, Rochester, NY, United States
| | - Olga Selioutski
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, United States
| | - Mark A. Marinescu
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Ross K. Maddox
- Department of Biomedical Engineering, University of Rochester, Rochester, NY, United States
- Department of Neuroscience, University of Rochester Medical Center, Rochester, NY, United States
| | - Tong Tong Wu
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, United States
| | - Giovanni Schifitto
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, United States
| | - Igor Gosev
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Regine Choe
- Department of Biomedical Engineering, University of Rochester, Rochester, NY, United States
- Department of Electrical and Computer Engineering, University of Rochester, Rochester, NY, United States
| | - Imad R. Khan
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, United States
- *Correspondence: Imad R. Khan,
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2022; 79:e263-e421. [PMID: 35379503 DOI: 10.1016/j.jacc.2021.12.012] [Citation(s) in RCA: 775] [Impact Index Per Article: 387.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. STRUCTURE Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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Hasslacher J, Steinkohl F, Ulmer H, Lehner G, Klein S, Mayerhoefer T, Joannidis M. Increased risk of ventilator-associated pneumonia in patients after cardiac arrest treated with mild therapeutic hypothermia. Acta Anaesthesiol Scand 2022; 66:704-712. [PMID: 35338658 PMCID: PMC9321159 DOI: 10.1111/aas.14063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 02/24/2022] [Accepted: 03/10/2022] [Indexed: 12/12/2022]
Abstract
Background We aimed at investigating the incidence, characteristics and outcome of ventilator‐associated pneumonia (VAP) in patients after cardiac arrest (CA) and its potential association with mild therapeutic hypothermia (MTH). We hypothesized, that MTH might increase the risk of VAP. Methods Prospective observational study including comatose adult patients after successful resuscitation from out‐of‐hospital or in‐hospital CA with presumed cardiac cause admitted to ICU and treated with MTH at 33°C for 24 h or normothermia (NT) with treatment of fever ≥38°C by pharmacological means. The primary outcome measure was the development of VAP. VAP diagnosis included mechanical ventilation >48 h combined with clinical and radiologic criteria. For a microbiologically confirmed VAP (mcVAP), a positive respiratory culture was required. Results About 23% of 171 patients developed VAP, 6% presented with mcVAP. VAP was associated with increased ICU‐LOS (9 (IQR 5–14) vs. 6 (IQR 3–9) days; p < .01), ventilator‐dependent days (6 (IQR 4–9) vs. 4 (IQR 2–7) days; p < .01) and duration of antibiotic treatment (9 (IQR 5–13) vs. 5 (IQR 2–9) days; p < .01), but not with mortality (OR 0.88 (95% CI: 0.43–1.81); p = .74). Patients treated with MTH (47%) presented higher VAP (30% vs. 17%; p = .04) and mcVAP rates (11% vs. 2%; p = .03). MTH was associated with VAP in multivariable logistic regression analysis with an OR of 2.67 (95% CI: 1.22–5.86); p = .01. Conclusions VAP appears to be a common complication in patients after CA, accompanied by more ventilator‐dependent days, prolonged antibiotic treatment, and ICU‐LOS. Treatment with MTH is significantly associated with development of VAP.
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Affiliation(s)
- Julia Hasslacher
- Division of Intensive Care and Emergency Medicine Department of Internal Medicine Medical University Innsbruck Innsbruck Austria
| | - Fabian Steinkohl
- Department of Radiology Medical University Innsbruck Innsbruck Austria
| | - Hanno Ulmer
- Department of Medical Statistics, Informatics and Health Economics Medical University Innsbruck Innsbruck Austria
| | - Georg Lehner
- Division of Intensive Care and Emergency Medicine Department of Internal Medicine Medical University Innsbruck Innsbruck Austria
| | - Sebastian Klein
- Division of Intensive Care and Emergency Medicine Department of Internal Medicine Medical University Innsbruck Innsbruck Austria
| | - Timo Mayerhoefer
- Division of Intensive Care and Emergency Medicine Department of Internal Medicine Medical University Innsbruck Innsbruck Austria
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine Department of Internal Medicine Medical University Innsbruck Innsbruck Austria
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Immediate complete revascularization showed better outcome in out-of-hospital cardiac arrest survivors with left main or triple-vessel coronary diseases. Sci Rep 2022; 12:4354. [PMID: 35288637 PMCID: PMC8921273 DOI: 10.1038/s41598-022-08383-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 02/24/2022] [Indexed: 12/14/2022] Open
Abstract
This study aimed to evaluate the prevalence of left main or triple vessel coronary artery disease (CAD) in comatose out-of-hospital cardiac arrest (OHCA) survivors and assessed their outcome based on the revascularization strategy. This multicenter, retrospective, observational registry-based study was conducted at 9 Korean tertiary care hospitals. Adult comatose OHCA survivors with left main or triple vessel CAD documented by immediate (≤ 2 h) coronary angiography after return of spontaneous circulation between 2011 and 2019 were included. The primary outcome was neurologically intact survival at 1-month. Among 727 OHCA patients, 150 (25%) had left main or triple vessel CAD and underwent complete (N = 32), incomplete (N = 78), and no immediate (N = 40) revascularization, respectively. The rate of neurologically intact survival at 1 month was significantly different among the groups (53%, 32%, and 23% for complete, incomplete, and no immediate revascularization groups, respectively; P = 0.02). After adjustment using the inverse probability of treatment weighting, complete revascularization was associated with neurologically intact survival at 1 month (odds ratio, 2.635; P = 0.01). Left main or triple vessel CAD is not uncommon in OHCA patients. The complete revascularization was associated with better outcome. Further clinical trials to confirm the best revascularization strategy are needed.
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Robba C, Nielsen N, Dankiewicz J, Badenes R, Battaglini D, Ball L, Brunetti I, Pedro David WG, Young P, Eastwood G, Chew MS, Jakobsen J, Unden J, Thomas M, Joannidis M, Nichol A, Lundin A, Hollenberg J, Lilja G, Hammond NE, Saxena M, Martin A, Solar M, Taccone FS, Friberg HA, Pelosi P. Ventilation management and outcomes in out-of-hospital cardiac arrest: a protocol for a preplanned secondary analysis of the TTM2 trial. BMJ Open 2022; 12:e058001. [PMID: 35241476 PMCID: PMC8896064 DOI: 10.1136/bmjopen-2021-058001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Mechanical ventilation is a fundamental component in the management of patients post cardiac arrest. However, the ventilator settings and the gas-exchange targets used after cardiac arrest may not be optimal to minimise post-anoxic secondary brain injury. Therefore, questions remain regarding the best ventilator management in such patients. METHODS AND ANALYSIS This is a preplanned analysis of the international randomised controlled trial, targeted hypothermia versus targeted normothermia after out-of-hospital cardiac arrest (OHCA)-target temperature management 2 (TTM2). The primary objective is to describe ventilatory settings and gas exchange in patients who required invasive mechanical ventilation and included in the TTM2 trial. Secondary objectives include evaluating the association of ventilator settings and gas-exchange values with 6 months mortality and neurological outcome. Adult patients after an OHCA who were included in the TTM2 trial and who received invasive mechanical ventilation will be eligible for this analysis. Data collected in the TTM2 trial that will be analysed include patients' prehospital characteristics, clinical examination, ventilator settings and arterial blood gases recorded at hospital and intensive care unit (ICU) admission and daily during ICU stay. ETHICS AND DISSEMINATION The TTM2 study has been approved by the regional ethics committee at Lund University and by all relevant ethics boards in participating countries. No further ethical committee approval is required for this secondary analysis. Data will be disseminated to the scientific community by abstracts and by original articles submitted to peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT02908308.
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Affiliation(s)
- Chiara Robba
- Department of Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Genoa, Italy
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care and Clinical Sciences Helsingborg, Helsingborg Hospital, Lund University, Lund, Sweden
| | - Josef Dankiewicz
- Department of Clinical Sciences Lund, Cardiology, Skåne University Hospital,Lund University, Lund, Lund, UK
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de València, Universitat de València, Valencia, Spain
| | - Denise Battaglini
- Department of Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Genoa, Italy
- Department of Medicine, University of Barcelona, Barcelona, Spain, Genoa, Italy
| | - Lorenzo Ball
- Department of Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Genoa, Italy
| | - Iole Brunetti
- Department of Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Wendel-Garcia Pedro David
- Institute of Intensive Care Medicine, Zurich, Switzerland, University Hospital of Zürich, Zürich, Switzerland
| | - Paul Young
- Department of Intensive Care, Wellington Hospital, Wellington, New Zealand
| | - Glenn Eastwood
- Department of Intensive Care, Faculty of Health, Deakin University, Burwood, Victoria, Australia
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Janus Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Copenhagen, UK
| | - Johan Unden
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Operation and Intensive Care, Hallands Hospital Halmstad, Halland, Sweden
| | - Matthew Thomas
- Department of Anaesthesia, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Deptartment of Medicine, Medizinische Universität Innsbruck, Innsbruck, Austria
| | - Alistair Nichol
- Monash University, Melbourne, Victoria, Australia, Melbourne, Ireland
| | - Andreas Lundin
- Department of Anaesthesiology and Intensive Care Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Jacob Hollenberg
- Department of Medicine, Center for Resuscitation Science, Karolinska Institutet, Solna, Sweden
| | - Gisela Lilja
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Naomi E Hammond
- Department of Critical Care, George Institute for Global Health, Newtown, New South Wales, Australia
| | - Manoj Saxena
- St George Hospital, Sydney, New South Wales, Australia
| | - Annborn Martin
- Department of Clinical Medicine, Anaesthesiology and Intensive Care, Lund University, Lund, Sweden
| | - Miroslav Solar
- Department of Internal Medicine, Faculty of Medicine in Hradec Králové, Charles University, Prague, Czech Republic
| | - Fabio Silvio Taccone
- Department of Intensive Care Medicine, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Hans A Friberg
- Department of of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Paolo Pelosi
- Department of Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche, Università degli Studi di Genova, Genoa, Italy
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Wu SN, Tsai MS, Huang CH, Chen WJ. Omecamtiv mecarbil treatment improves post-resuscitation cardiac function and neurological outcome in a rat model. PLoS One 2022; 17:e0264165. [PMID: 35176110 PMCID: PMC8853579 DOI: 10.1371/journal.pone.0264165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 02/02/2022] [Indexed: 11/29/2022] Open
Abstract
Background Myocardial dysfunction is a major cause of poor outcomes in the post-cardiac arrest period. Omecamtiv mecarbil (OM) is a selective small molecule activator of cardiac myosin that prolongs myocardial systole and increases stroke volume without apparent effects on myocardial oxygen demand. OM administration is safe and improves cardiac function in patients with acute heart failure. Whether OM improves post-resuscitation myocardial dysfunction remains unclear. This study investigated the effect of OM treatment on post-resuscitation myocardial dysfunction and outcomes. Methods and results Adult male rats were resuscitated after 9.5 min of asphyxia-induced cardiac arrest. OM and normal saline was continuously intravenously infused after return of spontaneous circulation (ROSC) at 0.25 mg/kg/h for 4 h in the experimental group and control group, respectively (n = 20 in each group). Hemodynamic parameters were measured hourly and monitored for 4 h after cardiac arrest. Recovery of neurological function was evaluated by neurological functioning scores (0–12; favorable: 11–12) for rats 72 h after cardiac arrest. OM treatment prolonged left ventricular ejection time and improved post-resuscitation cardiac output. Post-resuscitation heart rate and left ventricular systolic function (dp/dt40) were not different between groups. Kaplan-Meier analysis showed non-statistically higher 72-h survival in the OM group (72.2% [13/18] and 58.8% [10/17], p = 0.386). The OM group had a higher chance of having favorable neurological outcomes in surviving rats 72 h after cardiac arrest (84.6% [11/13] vs. 40% [4/10], p = 0.026). The percentage of damaged neurons was lower in the OM group in a histology study at 72 h after cardiac arrest (55.5±2.3% vs. 76.2±10.2%, p = 0.004). Conclusions OM treatment improved post-resuscitation myocardial dysfunction and neurological outcome in an animal model. These findings support further pre-clinical studies to improve outcomes in post-cardiac arrest care.
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Affiliation(s)
- Shih-Ni Wu
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Min-Shan Tsai
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
- * E-mail:
| | - Wen-Jone Chen
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
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Hinkelbein J, Kolaparambil Varghese Johnson L, Kiselev N, Schmitz J, Hellmich M, Drinhaus H, Lichtenstein T, Storm C, Adler C. Proteomics-Based Serum Alterations of the Human Protein Expression after Out-of-Hospital Cardiac Arrest: Pilot Study for Prognostication of Survivors vs. Non-Survivors at Day 1 after Return of Spontaneous Circulation (ROSC). J Clin Med 2022; 11:jcm11040996. [PMID: 35207267 PMCID: PMC8874966 DOI: 10.3390/jcm11040996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/02/2022] [Accepted: 02/10/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Targeted temperature management (TTM) is considered standard therapy for patients after out-of-hospital cardiac arrest (OHCA), cardiopulmonary resuscitation (CPR), and return of spontaneous circulation (ROSC). To date, valid protein markers do not exist to prognosticate survivors and non-survivors before the end of TTM. The aim of this study is to identify specific protein patterns/arrays, which are useful for prediction in the very early phase after ROSC. Material and Methods: A total of 20 adult patients with ROSC (19 male, 1 female; 69.9 ± 9.5 years) were included and dichotomized in two groups (survivors and non-survivors at day 30). Serum samples were drawn at day 1 after ROSC (during TTM). Three panels (organ failure, metabolic, neurology, inflammation; OLINK, Uppsala, Sweden) were utilised. A total of four proteins were found to be differentially regulated (>2- or <−0.5-fold decrease; t-test). Bioinformatic platforms were utilised to analyse pathways and identify signalling cascades and to screen for potential biomarkers. Results: A total of 276 proteins were analysed and revealed only 11 statistically significant protein alterations (Siglec-9, LAYN, SKR3, JAM-B, N2DL-2, TNF-B, BAMBI, NUCB2, STX8, PTK7, and PVLAB). Following the Bonferroni correction, no proteins were found to be regulated as statistically significant. Concerning the protein fold change for clinical significance, four proteins (IL-1 alpha, N-CDase, IL5, CRH) were found to be regulated in a clinically relevant context. Conclusions: Early analysis at 1 day after ROSC was not sufficiently possible during TTM to prognosticate survival or non-survival after OHCA. Future studies should evaluate protein expression later in the course after ROSC to identify promising protein candidates.
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Affiliation(s)
- Jochen Hinkelbein
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Cologne, 50937 Cologne, Germany; (J.S.); (H.D.)
- Correspondence:
| | | | - Nikolai Kiselev
- Clinic for Anesthesiology, Intensive Care Medicine, Preclinical Emergency Medicine and Pain Management, Sankt Katharinen Hospital Frechen, 50226 Frechen, Germany;
| | - Jan Schmitz
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Cologne, 50937 Cologne, Germany; (J.S.); (H.D.)
| | - Martin Hellmich
- Institute of Medical Statistics and Computational Biology (IMSB), Faculty of Medicine, University Hospital Cologne, University of Cologne, 50937 Cologne, Germany;
| | - Hendrik Drinhaus
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Cologne, 50937 Cologne, Germany; (J.S.); (H.D.)
| | - Theresa Lichtenstein
- Department of Psychiatry and Psychotherapy, Faculty of Medicine, University Hospital Cologne, University of Cologne, 50937 Cologne, Germany;
| | - Christian Storm
- Medical Department, Division of Nephrology and Internal Intensive Care Medicine, Charité—Universitaetsmedizin Berlin, 10117 Berlin, Germany;
| | - Christoph Adler
- Heart Centre, University Hospital Cologne, 50937 Cologne, Germany;
- Fire Department City of Cologne, Institute for Security Science and Rescue Technology, 50737 Cologne, Germany
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Blood-brain barrier disruption as a cause of various serum neuron-specific enolase cut-off values for neurological prognosis in cardiac arrest patients. Sci Rep 2022; 12:2186. [PMID: 35140324 PMCID: PMC8828866 DOI: 10.1038/s41598-022-06233-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 01/25/2022] [Indexed: 11/21/2022] Open
Abstract
We compared the cut-off and prognostic value of serum neuron-specific enolase (NSE) between groups with and without severe blood–brain barrier (BBB) disruption to reveal that a cause of various serum NSE cut-off value for neurological prognosis is severe BBB disruption in out-of-hospital cardiac arrest (OHCA) patients underwent target temperature management (TTM). This was a prospective, single-centre study conducted from January 2019 to June 2021. Severe BBB disruption was indicated using cerebrospinal fluid-serum albumin quotient values > 0.02. The area under the receiver operating characteristic curve of serum NSE obtained on day 3 of hospitalisation to predict poor outcomes was used. In patients with poor neurologic outcomes, serum NSE in those with severe BBB disruption was higher than in those without (P = 0.006). A serum NSE cut-off value of 40.4 μg/L for poor outcomes in patients without severe BBB disruption had a sensitivity of 41.7% and a specificity of 96.0%, whereas a cut-off value of 34.6 μg/L in those with severe BBB disruption had a sensitivity of 86.4% and a specificity of 100.0%. We demonstrated that the cut-off and prognostic value of serum NSE were heterogeneous, depending on severe BBB disruption in OHCA patients treated with TTM.
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Kim JG, Choi HY, Kang GH, Jang YS, Kim W, Lee Y. Prognostic value of targeted temperature management on outcomes of hanging-induced out-of-hospital cardiac arrest: A nationwide observational study. Medicine (Baltimore) 2022; 101:e28688. [PMID: 35119012 PMCID: PMC8812659 DOI: 10.1097/md.0000000000028688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 12/17/2021] [Accepted: 01/03/2022] [Indexed: 01/04/2023] Open
Abstract
ABSTRACT This study aimed to evaluate the prognostic significance of targeted temperature management (TTM) on hanging-induced out-of-hospital cardiac arrest (OHCA) patients using nationwide data of South Korea.Adult hanging-induced OHCA patients from 2008 to 2018 were included in this nationwide observational study. Patients who assigned into 2 groups based on whether they did (TTM group) or did not (non-TTM group) receive TTM. Outcome measures included survival to hospital discharge and a good neurological outcome at hospital discharge.Among the 293,852 OHCA patients, 3545 patients (non-TTM, n = 2762; TTM, n = 783) were investigated. After propensity score matching for all patients, 783 matched pairs were available for analysis. We observed no significant inter-group differences in the survival to hospital discharge (non-TTM, n = 27 [3.4%] vs TTM, n = 23 [2.9%], P = .666) or good neurological outcomes (non-TTM, n = 23 [2.9%] vs TTM, n = 14 [1.8%], P = .183). In the multivariate analysis, prehospital return of spontaneous circulation (odds ratio [OR], 22.849; 95% confidence interval [CI], 11.479-45.481, P < .001) was associated with an increase in survival to hospital discharge, and age (OR, 0.971; 95% CI, 0.944-0.998, P = .035), heart disease (OR, 16.875; 95% CI, 3.028-94.036, P = .001), and prehospital return of spontaneous circulation (OR, 133.251; 95% CI, 30.512-581.930, P < .001) were significant prognostic factors of good neurological outcome. However, TTM showed no significant association with either outcome.There were no significant differences in the survival to hospital discharge and good neurological outcomes between non-TTM and TTM groups of hanging-induced OHCA patients.
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Daniş F, Kudu E. The evolution of cardiopulmonary resuscitation: Global productivity and publication trends. Am J Emerg Med 2022; 54:151-164. [DOI: 10.1016/j.ajem.2022.01.071] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/19/2022] [Accepted: 01/30/2022] [Indexed: 01/03/2023] Open
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Duan J, Zhai Q, Shi Y, Ge H, Zheng K, Du L, Duan B, Yu J, Ma Q. Optimal Time of Collapse to Return of Spontaneous Circulation to Apply Targeted Temperature Management for Cardiac Arrest: A Bayesian Network Meta-Analysis. Front Cardiovasc Med 2022; 8:784917. [PMID: 35071355 PMCID: PMC8777010 DOI: 10.3389/fcvm.2021.784917] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/30/2021] [Indexed: 12/14/2022] Open
Abstract
Background: Both the American Heart Association (AHA) and European Resuscitation Council (ERC) have strongly recommended targeted temperature management (TTM) for patients who remain in coma after return of spontaneous circulation (ROSC). However, the role of TTM, especially hypothermia, in cardiac arrest patients after TTM2 trials has become much uncertain. Methods: We searched four online databases (PubMed, Embase, CENTRAL, and Web of Science) and conducted a Bayesian network meta-analysis. Based on the time of collapse to ROSC and whether the patient received TTM or not, we divided this analysis into eight groups (<20 min + TTM, <20 min, 20–39 min + TTM, 20–39 min, 40–59 min + TTM, 40–59 min, ≥60 min + TTM and ≥60 min) to compare their 30-day and at-discharge survival and neurologic outcomes. Results: From an initial search of 3,023 articles, a total of 9,005 patients from 42 trials were eligible and were included in this network meta-analysis. Compared with other groups, patients in the <20 min + TTM group were more likely to have better survival and good neurologic outcomes (probability = 46.1 and 52.5%, respectively). In comparing the same time groups with and without TTM, only the survival and neurologic outcome of the 20–39 min + TTM group was significantly better than that of the 20–39 min group [odds ratio = 1.41, 95% confidence interval (1.04–1.91); OR = 1.46, 95% CI (1.07–2.00) respectively]. Applying TTM with <20 min or more than 40 min of collapse to ROSC did not improve survival or neurologic outcome [ <20 min vs. <20 min + TTM: OR = 1.02, 95% CI (0.61–1.71)/OR = 1.03, 95% CI (0.61–1.75); 40–59 min vs. 40–59 min + TTM: OR = 1.50, 95% CI (0.97–2.32)/OR = 1.40, 95% CI (0.81–2.44); ≧60 min vs. ≧60 min + TTM: OR = 2.09, 95% CI (0.70–6.24)/OR = 4.14, 95% CI (0.91–18.74), respectively]. Both survival and good neurologic outcome were closely related to the time from collapse to ROSC. Conclusion: Survival and good neurologic outcome are closely associated with the time of collapse to ROSC. These findings supported that 20–40 min of collapse to ROSC should be a more suitable indication for TTM for cardiac arrest patients. Moreover, the future trials should pay more attention to these patients who suffer from moderate injury. Systematic Review Registration: [https://inplasy.com/?s=202180027], identifier [INPLASY202180027]
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Affiliation(s)
- Jingwei Duan
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Qiangrong Zhai
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Yuanchao Shi
- First Clinical Medicine School, Lanzhou University, Lanzhou, China
| | - Hongxia Ge
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Kang Zheng
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Lanfang Du
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Baomin Duan
- Emergency Department, Kaifeng Center Hospital, Kaifeng, China
| | - Jie Yu
- The George Institute for Global Health, The University of New South Wales Sydney, Sydney, NSW, Australia
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Department of Cardiology, Peking University Third Hospital, Beijing, China
- Jie Yu
| | - Qingbian Ma
- Emergency Department, Peking University Third Hospital, Beijing, China
- *Correspondence: Qingbian Ma
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Zhou C, Lin Q, Xiang G, Chen M, Cai M, Zhu Q, Zhou R, Huang W, Shan P. Impact of Pre-Revascularization and Post-Revascularization Cardiac Arrest on Survival Prognosis in Patients With Acute Myocardial Infarction and Following Emergency Percutaneous Coronary Intervention. Front Cardiovasc Med 2021; 8:705504. [PMID: 34869623 PMCID: PMC8639596 DOI: 10.3389/fcvm.2021.705504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 10/11/2021] [Indexed: 11/20/2022] Open
Abstract
Objectives: To evaluate the effects of occurrence and timing of sudden cardiac arrest (SCA) on survival in patients with acute myocardial infarction (AMI) who underwent emergency percutaneous coronary intervention (PCI). Methods: We analyzed 1,956 consecutive patients with AMI with emergency PCI from 2014 to 2018. Patients with cardiac arrest events were identified, and their medical records were reviewed. Results: Patients were divided into non-cardiac arrest group (NCA group, n = 1,724), pre-revascularization cardiac arrest (PRCA group, n = 175), and post-revascularization SCA (POCA group, n = 57) according to SCA timing. Compared to NCA group, PRCA group and POCA group presented with higher brain natriuretic polypeptide (BNP), more often Killip class 3/4, atrial fibrillation, and less often completed recovery of coronary artery perfusion (all p < 0.05). Both patients with PRCA and POCA showed increased 30-day all-cause mortality when compared to patients with NCA (8.0 and 70.2% vs. 2.9%, both p < 0.001). However, when compared to patients with NCA, patients with PRCA did not lead to higher mortality during long-term follow-up (median time 917 days) (16.3 vs. 18.6%, p = 0.441), whereas patients with POCA were associated with increased all-cause mortality (36.3 vs. 18.6%, p < 0.001). Multivariate analysis identified Killip class 3/4, atrial fibrillation, high maximum MB isoenzyme of creatine kianse, and high creatinine as predictive factors for POCA. In Cox regression analysis, POCA was found as a strong mortality-increase predictor (HR, 8.87; 95% CI, 2.26–34.72; p = 0.002) for long-term all-cause death. Conclusions: POCA appeared to be a strong life-threatening factor for 30-day and long-term all-cause mortality among patients with AMI who admitted alive and underwent emergency PCI. However, PRCA experience did not lead to a poorer long-term survival in patients with AMI surviving the first 30 days.
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Affiliation(s)
- Changzuan Zhou
- Department of Cardiology, The Key Laboratory of Cardiovascular Disease of Wenzhou, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.,Department of Cardiology, Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine, Wenzhou, China
| | - Qingcheng Lin
- Department of Cardiology, The Key Laboratory of Cardiovascular Disease of Wenzhou, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Guangze Xiang
- Department of Cardiology, The Key Laboratory of Cardiovascular Disease of Wenzhou, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Mengmeng Chen
- Department of Cardiology, The Key Laboratory of Cardiovascular Disease of Wenzhou, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Mengxing Cai
- Department of Cardiology, The Key Laboratory of Cardiovascular Disease of Wenzhou, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Qianli Zhu
- Department of Cardiology, The Key Laboratory of Cardiovascular Disease of Wenzhou, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Rui Zhou
- Department of Cardiology, Wenzhou People's Hospital, Wenzhou, China
| | - Weijian Huang
- Department of Cardiology, The Key Laboratory of Cardiovascular Disease of Wenzhou, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Peiren Shan
- Department of Cardiology, The Key Laboratory of Cardiovascular Disease of Wenzhou, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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MicroRNA Cues from Nature: A Roadmap to Decipher and Combat Challenges in Human Health and Disease? Cells 2021; 10:cells10123374. [PMID: 34943882 PMCID: PMC8699674 DOI: 10.3390/cells10123374] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 11/22/2021] [Accepted: 11/27/2021] [Indexed: 12/15/2022] Open
Abstract
MicroRNAs are small non-coding RNA (18–24 nt long) that fine-tune gene expression at the post-transcriptional level. With the advent of “multi-omics” analysis and sequencing approaches, they have now been implicated in every facet of basic molecular networks, including metabolism, homeostasis, and cell survival to aid cellular machinery in adapting to changing environmental cues. Many animals must endure harsh environmental conditions in nature, including cold/freezing temperatures, oxygen limitation (anoxia/hypoxia), and food or water scarcity, often requiring them to revamp their metabolic organization, frequently on a seasonal or life stage basis. MicroRNAs are important regulatory molecules in such processes, just as they are now well-known to be involved in many human responses to stress or disease. The present review outlines the role of miRNAs in natural animal models of environmental stress and adaptation including torpor/hibernation, anoxia/hypoxia tolerance, and freeze tolerance. We also discuss putative medical applications of advances in miRNA biology including organ preservation for transplant, inflammation, ageing, metabolic disorders (e.g., obesity), mitochondrial dysfunction (mitoMirs) as well as specialized miRNA subgroups respective to low temperature (CryomiRs) and low oxygen (OxymiRs). The review also covers differential regulation of conserved and novel miRNAs involved at cell, tissue, and stress specific levels across multiple species and their roles in survival. Ultimately, the species-specific comparison and conserved miRNA responses seen in evolutionarily disparate animal species can help us to understand the complex miRNA network involved in regulating and reorganizing metabolism to achieve diverse outcomes, not just in nature, but in human health and disease.
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Chung H, Namgung M, Lee DH, Choi YH, Bae SJ. Effect of delayed transport on clinical outcomes among patients with cardiac arrest during the coronavirus disease 2019 pandemic. Australas Emerg Care 2021; 25:241-246. [PMID: 34876368 PMCID: PMC8629739 DOI: 10.1016/j.auec.2021.11.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/23/2021] [Accepted: 11/23/2021] [Indexed: 11/27/2022]
Abstract
Background The coronavirus disease 2019 (COVID-19) pandemic has prompted many changes. Revised cardiopulmonary resuscitation (CPR) recommendations were issued including increased requirement for personal protective equipment (PPE) during CPR and isolation rooms. We hypothesized that these changes might have affected transport times and distance. Accordingly, we investigated any differences in transport time and distance and their effect on patient neurologic outcomes at hospital discharge. Methods This retrospective study was conducted among patients who experienced cardiopulmonary arrest and were admitted to an emergency department during specific periods — pre-COVID-19 (January 1 to December 31, 2019) and COVID-19 (March 1, 2020, to February 28, 2021). Result The mean transport distance was 3.5 ± 2.1 km and 3.7 ± 2.3 km during the pre-COVID-19 and COVID-19 periods, respectively (p = 0.664). The mean total transport time was 30.3 ± 6.9 min and 35.6 ± 9.3 min during the pre-COVID-19 and COVID-19 periods, respectively (p < 0.001). The mean activation time was 1.5 ± 2.2 min and 2.9 ± 4.5 min during the pre-COVID-19 and COVID-19 periods, respectively (p = 0.003). The mean transport time was 9.3 ± 3.5 min and 11.5 ± 6 min during the pre-COVID-19 and COVID-19 periods, respectively (p = 0.001). Conclusion Total transport time, including activation time for out-of-hospital cardiac arrest patients, increased owing to increased PPE requirements. However, there was no significant difference in the neurological outcome at hospital discharge.
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Affiliation(s)
- Hosub Chung
- Department of Emergency Medicine, Ewha Womans University Mokdong Hospital, College of Medicine, Ewha Womans University, 1071, Anyangcheon-ro, Yangcheon-gu, Seoul, Republic of Korea; Department of Emergency Medicine, Graduate school of Medicine, Seoul, Chung-Ang University, 102, Heukseok-ro, Dongjak-gu, Seoul, Republic of Korea.
| | - Myeong Namgung
- Department of emergency medicine, College of Medicine, Seoul, Chung-Ang University, Emergency medicine, Chung-Ang university hospital, 102, Heukseok-ro, Dongjak-gu, Seoul, Republic of Korea.
| | - Dong Hoon Lee
- Department of emergency medicine, College of Medicine, Seoul, Chung-Ang University, Emergency medicine, Chung-Ang university hospital, 102, Heukseok-ro, Dongjak-gu, Seoul, Republic of Korea.
| | - Yoon Hee Choi
- Department of Emergency Medicine, Ewha Womans University Mokdong Hospital, College of Medicine, Ewha Womans University, 1071, Anyangcheon-ro, Yangcheon-gu, Seoul, Republic of Korea.
| | - Sung Jin Bae
- Department of emergency medicine, College of Medicine, Seoul, Chung-Ang University, Emergency medicine, Chung-Ang university hospital, 102, Heukseok-ro, Dongjak-gu, Seoul, Republic of Korea.
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Abusnina W, Al-Abdouh A, Latif A, Alkhouli M, Alraies MC, Daggubati R, Alasnag M, Kerrigan J, Paul TK. Timing of coronary angiography in patients following out-of-hospital cardiac arrest without ST-segment elevation: A systematic review and Meta-analysis of randomized trials. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 40:92-98. [PMID: 34844869 DOI: 10.1016/j.carrev.2021.11.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/20/2021] [Accepted: 11/22/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Out-of-hospital cardiac arrest (OHCA) has a poor prognosis. The timing and role of early coronary angiography (CAG) in OHCA patients without ST elevation remains unclear. OBJECTIVE We performed a meta-analysis of randomized controlled trials (RCTs) that compared early CAG to delayed CAG in OHCA patients without ST elevation. METHODS We searched PubMed, Cochrane, and ClinicalTrials.gov databases (from inception to September 2021) for studies comparing early CAG to delayed CAG in OHCA patients without ST elevation. We used a random-effect model to calculate relative ratio (RR) with 95% confidence interval (CI). The primary outcome was all-cause mortality at 30 days. Secondary outcomes included neurological status with cerebral performance category ≤2 (CPC) and the rate of percutaneous coronary intervention (PCI) following CAG. RESULTS A total of 6 RCTs including 1822 patients, of whom 895 underwent early CAG, and 927 underwent delayed CAG, were included in this meta-analysis. There was no statistically significant difference between the 2 groups in terms of 30-day all-cause mortality (Relative risk [RR] 1.06; 95%CI 0.94-1.20; P = 0.32; I2 = 13%), neurological status (CPC ≤2) (RR 1.01; 95%CI 0.90-1.13; P = 0.85, I2 = 37%), and rates of PCI following CAG (RR 1.08; 95%CI 0.84-1.39; P = 0.56; I2 = 49%). CONCLUSION In patients suffering OHCA without ST-elevation, early CAG is not associated with reduced 30-day mortality when compared to patients who underwent delayed CAG. Given our meta-analysis results including multiple trials that have not shown a benefit, it is likely that updated guidelines will not support early angiography in patients suffering OHCA without ST-elevation.
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Affiliation(s)
- Waiel Abusnina
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE, USA
| | - Ahmad Al-Abdouh
- Division of Hospital Medicine, University of Kentucky, Lexington, KY, USA
| | - Azka Latif
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE, USA
| | | | - M Chadi Alraies
- Wayne State University, Detroit Medical Center, Heart Hospital, Detroit, MI, USA
| | | | | | - Jimmy Kerrigan
- Department of Medical Education, University of Tennessee at Nashville, Nashville, TN, USA
| | - Timir K Paul
- Department of Medical Education, University of Tennessee at Nashville, Nashville, TN, USA.
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Liu N, Roth KR, Nesbit DA, Giordano JR, Stirparo JJ, Miller AH. Hemoperitoneum identified by focused assessment with sonography for trauma following cardiopulmonary resuscitation. Radiol Case Rep 2021; 16:3987-3989. [PMID: 34729130 PMCID: PMC8545660 DOI: 10.1016/j.radcr.2021.09.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 09/16/2021] [Accepted: 09/18/2021] [Indexed: 01/03/2023] Open
Abstract
It is generally recognized that lives are saved by administering high-quality cardiopulmonary resuscitation (CPR) to patients in cardiac arrest. A focused assessment with sonography for trauma (FAST) examination is an effective and non-invasive method for detecting rare complications of CPR, such as hemorrhage from abdominal visceral injury. We report the case of a 56-year-old female suffering from intra-abdominal hemorrhage caused by a liver laceration following CPR. The hemoperitoneum was diagnosed by a FAST examination. Although severe complications of CPR are rare, they can be easily detected with the use of a FAST examination. A FAST examination should be considered as a post-resuscitation approach to assess for life-threatening complications in all patients following cardiopulmonary resuscitation.
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Affiliation(s)
- Nina Liu
- Lehigh Valley Health Network, Department of Emergency and Hospital Medicine/USF Morsani College of Medicine, Cedar Crest Boulevard & I-78, Allentown, PA 18103, USA
| | - Kevin R. Roth
- Lehigh Valley Health Network, Department of Emergency and Hospital Medicine/USF Morsani College of Medicine, Cedar Crest Boulevard & I-78, Allentown, PA 18103, USA
- Corresponding author.
| | - Danielle A. Nesbit
- Lehigh Valley Health Network, Department of Emergency and Hospital Medicine/USF Morsani College of Medicine, Cedar Crest Boulevard & I-78, Allentown, PA 18103, USA
| | - Justin R. Giordano
- Lehigh Valley Health Network, Department of Emergency and Hospital Medicine/USF Morsani College of Medicine, Cedar Crest Boulevard & I-78, Allentown, PA 18103, USA
| | - Joseph J. Stirparo
- Lehigh Valley Health Network, Department of Surgery/USF Morsani College of Medicine, Cedar Crest Boulevard & I-78, Allentown, PA 18103, USA
| | - Andrew H. Miller
- Lehigh Valley Health Network, Department of Emergency and Hospital Medicine/USF Morsani College of Medicine, Cedar Crest Boulevard & I-78, Allentown, PA 18103, USA
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