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Lemée P, Chapalain X, Bailly P, Sparrow RL, Jean-Michel V, Prat G, Renault A, Tonnelier JM, Aubron C. PROACTIVE SCREENING ALGORITHM FOR EARLY-ONSET PNEUMONIA IN PATIENTS WITH OUT-OF-HOSPITAL CARDIAC ARREST: A BEFORE-AFTER IMPLEMENTATION STUDY. Shock 2024; 62:13-19. [PMID: 38661180 DOI: 10.1097/shk.0000000000002347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
ABSTRACT Introduction : Early-onset pneumonia (EOP) occurs in around 50% of critically ill patients with out-of-hospital cardiac arrest (OHCA) and is associated with increased morbidity. Prompt diagnosis of EOP in these patients is difficult because of targeted temperature management and the postcardiac arrest syndrome. We hypothesized that an algorithm for proactive screening of EOP would improve patient outcomes. Methods : We conducted a single-center observational study comparing the outcomes of mechanically ventilated adult patients with OHCA, before (study period 1) and after (study period 2) implementation of an algorithm for proactive diagnosis of EOP, including an early distal pulmonary specimen. An inverse probability treatment weighted multivariable regression was performed to identify independent parameters associated with duration of mechanical ventilation. A subgroup analysis was conducted in patients alive on day 5 after intensive care unit admission. Results : Over the 4-year study period, 190 patients (99 and 91 for study periods 1 and 2, respectively) were enrolled. The overall incidence of EOP was 57.4% and was similar between both study periods. Although there was no difference in the time interval to antibiotic initiation, study period 2 was independently associated with higher SpO 2 /FiO 2 ratios on days 3 and 4. We also observed a decrease in mechanical ventilation time in study period 2 (4.5 [1-11.3] vs. 3 [2-5.8] days; P = 0.07), and this reached statistical significance in the subgroup analysis of patients alive at day 5 (10 [5-17] vs. 5 [3-9] days, P = 0.01). Conclusion: In critically ill patients with OHCA, proactive diagnosis of EOP was not associated with a significant change in the time to antibiotic initiation. Further research is warranted to better define optimal diagnosis and management of EOP in this setting.
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Affiliation(s)
- Pauline Lemée
- Departement de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
| | - Xavier Chapalain
- Departement d'anesthésie-Réanimation, Centre Hospitalier Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
| | - Pierre Bailly
- Departement de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
| | - Rosemary L Sparrow
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Vanessa Jean-Michel
- Departement de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
| | - Gwenael Prat
- Departement de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
| | - Anne Renault
- Departement de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
| | - Jean-Marie Tonnelier
- Departement de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
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García-Delgado M, Rodríguez-García R, Ochagavía A, Rodríguez-Esteban MDLÁ. The medical treatment of cardiogenic shock. Med Intensiva 2024:S2173-5727(24)00135-8. [PMID: 38834498 DOI: 10.1016/j.medine.2024.05.012] [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: 05/10/2024] [Accepted: 05/18/2024] [Indexed: 06/06/2024]
Abstract
Cardiogenic shock is characterized by tissue hypoperfusion due to the inadequate cardiac output to maintain the tissue oxygen demand. Despite some advances in cardiogenic shock management, extremely high mortality is still associated with this clinical syndrome. Its management is based on the immediate stabilization of hemodynamic parameters through medical care and the use of mechanical circulatory supports in specialized centers. This review aims to understand the cardiogenic shock current medical treatment, consisting mainly of inotropic drugs, vasopressors and coronary revascularization. In addition, we highlight the relevance of applying measures to other organ levels based on the optimization of mechanical ventilation and the appropriate initiation of renal replacement therapy.
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Affiliation(s)
- Manuel García-Delgado
- Servicio de Medicina Intensiva, Hospital Universitario Virgen de las Nieves, Granada, Spain; Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, Spain
| | - Raquel Rodríguez-García
- Servicio de Medicina Intensiva, Hospital Universitario Central de Asturias, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Spain; CIBER-Enfermedades Respiratorias, Instituto de Salud Carlos III, Spain.
| | - Ana Ochagavía
- Servicio de Medicina Intensiva, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
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Marchese G, Bungaro E, Magliocca A, Fumagalli F, Merigo G, Semeraro F, Mereto E, Babini G, Roman-Pognuz E, Stirparo G, Cucino A, Ristagno G. Acute Lung Injury after Cardiopulmonary Resuscitation: A Narrative Review. J Clin Med 2024; 13:2498. [PMID: 38731027 PMCID: PMC11084269 DOI: 10.3390/jcm13092498] [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: 03/06/2024] [Revised: 04/15/2024] [Accepted: 04/21/2024] [Indexed: 05/13/2024] Open
Abstract
Although cardiopulmonary resuscitation (CPR) includes lifesaving maneuvers, it might be associated with a wide spectrum of iatrogenic injuries. Among these, acute lung injury (ALI) is frequent and yields significant challenges to post-cardiac arrest recovery. Understanding the relationship between CPR and ALI is determinant for refining resuscitation techniques and improving patient outcomes. This review aims to analyze the existing literature on ALI following CPR, emphasizing prevalence, clinical implications, and contributing factors. The review seeks to elucidate the pathogenesis of ALI in the context of CPR, assess the efficacy of CPR techniques and ventilation strategies, and explore their impact on post-cardiac arrest outcomes. CPR-related injuries, ranging from skeletal fractures to severe internal organ damage, underscore the complexity of managing post-cardiac arrest patients. Chest compression, particularly when prolonged and vigorous, i.e., mechanical compression, appears to be a crucial factor contributing to ALI, with the concept of cardiopulmonary resuscitation-associated lung edema (CRALE) gaining prominence. Ventilation strategies during CPR and post-cardiac arrest syndrome also play pivotal roles in ALI development. The recognition of CPR-related lung injuries, especially CRALE and ALI, highlights the need for research on optimizing CPR techniques and tailoring ventilation strategies during and after resuscitation.
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Affiliation(s)
- Giuseppe Marchese
- UOC Anestesia e Rianimazione, Ospedale Nuovo di Legnano, ASST Ovest Milanese, 20025 Legnano, Italy
| | - Elisabetta Bungaro
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy (A.M.); (E.M.)
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.M.)
| | - Aurora Magliocca
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy (A.M.); (E.M.)
| | - Francesca Fumagalli
- Department of Acute Brain and Cardiovascular Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20122 Milan, Italy
| | - Giulia Merigo
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.M.)
- Department of Biomedical Sciences for Health, University of Milan, 20122 Milan, Italy
| | - Federico Semeraro
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, 40133 Bologna, Italy
| | - Elisa Mereto
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy (A.M.); (E.M.)
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.M.)
| | - Giovanni Babini
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.M.)
| | - Erik Roman-Pognuz
- Department of Anesthesia and Intensive Care, University of Trieste, 34127 Trieste, Italy
| | | | - Alberto Cucino
- Department of Anaesthesia and Intensive Care Medicine, APSS, Provincia Autonoma di Trento, 38121 Trento, Italy;
| | - Giuseppe Ristagno
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy (A.M.); (E.M.)
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.M.)
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4
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Nikolovski SS, Lazic AD, Fiser ZZ, Obradovic IA, Tijanic JZ, Raffay V. Recovery and Survival of Patients After Out-of-Hospital Cardiac Arrest: A Literature Review Showcasing the Big Picture of Intensive Care Unit-Related Factors. Cureus 2024; 16:e54827. [PMID: 38529434 PMCID: PMC10962929 DOI: 10.7759/cureus.54827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2024] [Indexed: 03/27/2024] Open
Abstract
As an important public health issue, out-of-hospital cardiac arrest (OHCA) requires several stages of high quality medical care, both on-field and after hospital admission. Post-cardiac arrest shock can lead to severe neurological injury, resulting in poor recovery outcome and increased risk of death. These characteristics make this condition one of the most important issues to deal with in post-OHCA patients hospitalized in intensive care units (ICUs). Also, the majority of initial post-resuscitation survivors have underlying coronary diseases making revascularization procedure another crucial step in early management of these patients. Besides keeping myocardial blood flow at a satisfactory level, other tissues must not be neglected as well, and maintaining mean arterial pressure within optimal range is also preferable. All these procedures can be simplified to a certain level along with using targeted temperature management methods in order to decrease metabolic demands in ICU-hospitalized post-OHCA patients. Additionally, withdrawal of life-sustaining therapy as a controversial ethical topic is under constant re-evaluation due to its possible influence on overall mortality rates in patients initially surviving OHCA. Focusing on all of these important points in process of managing ICU patients is an imperative towards better survival and complete recovery rates.
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Affiliation(s)
- Srdjan S Nikolovski
- Pathology and Laboratory Medicine, Cardiovascular Research Institute, Loyola University Chicago Health Science Campus, Maywood, USA
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Aleksandra D Lazic
- Emergency Center, Clinical Center of Vojvodina, Novi Sad, SRB
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Zoran Z Fiser
- Emergency Medicine, Department of Emergency Medicine, Novi Sad, SRB
| | - Ivana A Obradovic
- Anesthesiology, Resuscitation, and Intensive Care, Sveti Vračevi Hospital, Bijeljina, BIH
| | - Jelena Z Tijanic
- Emergency Medicine, Municipal Institute of Emergency Medicine, Kragujevac, SRB
| | - Violetta Raffay
- School of Medicine, European University Cyprus, Nicosia, CYP
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
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5
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Gonzalez D, Dahiya G, Mutirangura P, Ergando T, Mello G, Singh R, Bentho O, Elliott AM. Post Cardiac Arrest Care in the Cardiac Intensive Care Unit. Curr Cardiol Rep 2024; 26:35-49. [PMID: 38214836 DOI: 10.1007/s11886-023-02015-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2023] [Indexed: 01/13/2024]
Abstract
PURPOSE OF REVIEW Cardiac arrests constitute a leading cause of mortality in the adult population and cardiologists are often tasked with the management of patients following cardiac arrest either as a consultant or primary provider in the cardiac intensive care unit. Familiarity with evidence-based practice for post-cardiac arrest care is a requisite for optimizing outcomes in this highly morbid group. This review will highlight important concepts necessary to managing these patients. RECENT FINDINGS Emerging evidence has further elucidated optimal care of post-arrest patients including timing for routine coronary angiography, utility of therapeutic hypothermia, permissive hypercapnia, and empiric aspiration pneumonia treatment. The complicated state of multi-organ failure following cardiac arrest needs to be carefully optimized by the clinician to prevent further neurologic injury and promote systemic recovery. Future studies should be aimed at understanding if these findings extend to specific patient populations, especially those at the highest risk for poor outcomes.
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Affiliation(s)
- Daniel Gonzalez
- Department of Medicine, Division of Cardiology, University of Minnesota, 420 Delaware St SE, MMC 508, Minneapolis, MN, 55455, USA
| | - Garima Dahiya
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University, Durham, USA
| | | | | | - Gregory Mello
- University of Minnesota Medical School, Minneapolis, USA
| | - Rahul Singh
- Department of Medicine, Division of Cardiology, University of Minnesota, 420 Delaware St SE, MMC 508, Minneapolis, MN, 55455, USA
| | - Oladi Bentho
- Department of Neurology, University of Minnesota, Minneapolis, USA
| | - Andrea M Elliott
- Department of Medicine, Division of Cardiology, University of Minnesota, 420 Delaware St SE, MMC 508, Minneapolis, MN, 55455, USA.
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Naito H, Hanafusa H, Hongo T, Yumoto T, Yorifuji T, Weissman A, Rittenberger JC, Guyette FX, Fujishima M, Maeyama H, Nakao A. Effect of stomach inflation during cardiopulmonary resuscitation on return of spontaneous circulation in out-of-hospital cardiac arrest patients: A retrospective observational study. Resuscitation 2023; 193:109994. [PMID: 37813147 DOI: 10.1016/j.resuscitation.2023.109994] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 09/28/2023] [Accepted: 10/02/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND Gastric inflation caused by excessive ventilation is a common complication of cardiopulmonary resuscitation. Gastric inflation may further compromise ventilation via increases in intrathoracic pressure, leading to decreased venous return and cardiac output, which may impair out-of-hospital cardiac arrest (OHCA) outcomes. The purpose of this study was to measure the gastric volume of OHCA patients using computed tomography (CT) scan images and evaluate the effect of gastric inflation on return of spontaneous circulation (ROSC). METHODS In this single-center, retrospective, observational study, CT scan was conducted after ROSC or immediately after death. Total gastric volume was measured. Primary outcome was ROSC. Achievement of ROSC was compared in the gastric distention group and the no gastric distention group; gastric distension was defined as total gastric volume in the ≥75th percentile. Additionally, factors associated with gastric distention were examined. RESULTS A total of 446 cases were enrolled in the study; 120 cases (27%) achieved ROSC. The median gastric volume was 400 ml for all OHCA subjects; 1068 ml in gastric distention group vs. 287 ml in no gastric distention group. There was no difference in ROSC between the groups (27/112 [24.1%] vs. 93/334 [27.8%], p = 0.440). Gastric distention did not have a significant impact, even after adjustments (adjusted odds ratio 0.73, 95% confidence interval [0.42-1.29]). Increased gastric volume was associated with longer emergency medical service activity time. CONCLUSIONS We observed a median gastric volume of 400 ml in patients after OHCA resuscitation. In our setting, gastric distention did not prevent ROSC.
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Affiliation(s)
- Hiromichi Naito
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan; Emergency and Critical Care Center, Tsuyama Chuo Hospital, Tsuyama, Japan.
| | - Hiroaki Hanafusa
- Emergency and Critical Care Center, Tsuyama Chuo Hospital, Tsuyama, Japan; Department of Emergency Medicine and Critical Care Medicine, Tochigi Prefectural Emergency and Critical Care Center, Imperial Gift Foundation SAISEIKAI, Utsunomiya Hospital, Tochigi, Japan
| | - Takashi Hongo
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Tetsuya Yumoto
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takashi Yorifuji
- Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Alexandra Weissman
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Jon C Rittenberger
- Department of Emergency Medicine, Guthrie Robert Packer Hospital, Sayre, USA
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | | | - Hiroki Maeyama
- Emergency and Critical Care Center, Tsuyama Chuo Hospital, Tsuyama, Japan
| | - Astunori Nakao
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Iida E, Ichihara N, Hifumi T, Shirasaki K, Horie K, Isokawa S, Inoue A, Sakamoto T, Kuroda Y, Otani N. Frequency, clinical characteristics, and outcomes of pneumonia in patients with out-of-hospital cardiac arrest undergoing extracorporeal cardiopulmonary resuscitation. Resusc Plus 2023; 16:100474. [PMID: 37766913 PMCID: PMC10519840 DOI: 10.1016/j.resplu.2023.100474] [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: 08/31/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
Aim This study aimed to describe the frequency, clinical characteristics, and outcomes of pneumonia in OHCA patients treated with ECPR in a multicenter setting. Methods This is a secondary analysis of the SAVE-J II study, which was a multicenter, retrospective cohort of OHCA patients treated with ECPR. Age, sex, comorbidities, presence of witnessed CA, presence of bystander CPR, initial rhythm, cause of CA, low-flow time, initiation of targeted temperature management, details of sputum culture, pneumonia, and prophylactic antibiotic use were recorded. Pneumonia was diagnosed when the patients met all the clinical, radiologic, and microbiologic criteria acquired after hospitalization. Results In total, 1,986 patients were included in the analysis, and 947 (48%) died during the first 2 days of admission. A prophylactic antibiotic was used in 712 (35.9%) patients. Overall, the hazard of death was high on days 1 and 2 of admission, exceeding 20% on both days; 251 (12.6%) patients developed pneumonia during hospitalization, and the hazard of pneumonia development remained high (>2%) in the first 7 days of admission.Staphylococcus aureus and Klebsiella species were commonly identified in the sputum culture. Among patients who survived the first 7 days, the odds ratio (OR) of those with pneumonia and unfavorable neurological outcomes defined by cerebral performance category 3-5 was approximately 1. In those who survived the first 10 days, the OR was greater than 1 with a wide confidence interval. Conclusions This is the first study describing details of pneumonia in OHCA patients treated with ECPR using a large dataset.
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Affiliation(s)
- Eiki Iida
- Department of Emergency and Critical Care Medicine, St. Luke’s International Hospital, Tokyo, Japan
| | - Nao Ichihara
- Department of Cardiovascular Surgery, The Jikei University School of Medicine, Tokyo, Japan
- Department of Healthcare Quality Assessment, The University of Tokyo, Tokyo, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke’s International Hospital, Tokyo, Japan
| | - Kasumi Shirasaki
- Department of Emergency and Critical Care Medicine, St. Luke’s International Hospital, Tokyo, Japan
| | - Katsuhiro Horie
- Department of Emergency and Critical Care Medicine, St. Luke’s International Hospital, Tokyo, Japan
| | - Shutaro Isokawa
- Department of Emergency and Critical Care Medicine, St. Luke’s International Hospital, Tokyo, Japan
| | - Akihiko Inoue
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Japan
| | - Tetsuya Sakamoto
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Yasuhiro Kuroda
- Department of Emergency Medicine, Kagawa University School of Medicine, Kagawa, Japan
| | - Norio Otani
- Department of Emergency and Critical Care Medicine, St. Luke’s International Hospital, Tokyo, Japan
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Trieu C, Rajagopalan S, Kofke WA, Cruz Navarro J. Overview of Hypothermia, Its Role in Neuroprotection, and the Application of Prophylactic Hypothermia in Traumatic Brain Injury. Anesth Analg 2023; 137:953-962. [PMID: 37115720 DOI: 10.1213/ane.0000000000006503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
The current standard of practice is to maintain normothermia in traumatic brain injury (TBI) patients despite the theoretical benefits of hypothermia and numerous animal studies with promising results. While targeted temperature management or induced hypothermia to support neurological function is recommended for a select patient population postcardiac arrest, similar guidelines have not been instituted for TBI. In this review, we will examine the pathophysiology of TBI and discuss the benefits and risks of induced hypothermia in this patient population. In addition, we provide an overview of the largest randomized controlled trials testing-induced hypothermia. Our literature review on hypothermia returned a myriad of studies and trials, many of which have inconclusive results. The aim of this review was to recognize the effects of hypothermia, summarize the latest trials, address the inconsistencies, and discuss future directions for the study of hypothermia in TBI.
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Affiliation(s)
- Christine Trieu
- From the Department of Anesthesiology, Baylor College of Medicine, Houston, Texas; Departments of
| | - Suman Rajagopalan
- From the Department of Anesthesiology, Baylor College of Medicine, Houston, Texas; Departments of
| | - W Andrew Kofke
- Anesthesiology and Critical Care
- Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania; and Departments of
| | - Jovany Cruz Navarro
- Anesthesiology and Critical Care
- Neurosurgery, Baylor College of Medicine, Houston, Texas
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9
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Cotter EKH, Jacobs M, Jain N, Chow J, Estimé SR. Post-cardiac arrest care in the intensive care unit. Int Anesthesiol Clin 2023; 61:71-78. [PMID: 37678200 DOI: 10.1097/aia.0000000000000418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Affiliation(s)
- Elizabeth K H Cotter
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas
| | - Matthew Jacobs
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, Illinois
| | - Nisha Jain
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, Illinois
| | - Jarva Chow
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, Illinois
| | - Stephen R Estimé
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, Illinois
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10
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Introducing novel insights into the postresuscitation clinical course and care of cardiac arrest. Resuscitation 2023; 183:109691. [PMID: 36646372 DOI: 10.1016/j.resuscitation.2023.109691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 01/05/2023] [Indexed: 01/15/2023]
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11
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Gutierrez A, Kalra R, Elliott AM, Marquez A, Yannopoulos D, Bartos JA. Acute lung injury and recovery in patients with refractory VT/VF cardiac arrest treated with prolonged CPR and veno-arterial extracorporeal membrane oxygenation. Resuscitation 2023; 182:109651. [PMID: 36442595 DOI: 10.1016/j.resuscitation.2022.11.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 11/19/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022]
Abstract
AIM Describe the lung injury patterns among patients presenting with refractory ventricular tachycardia/ventricular fibrillation out-of-hospital cardiac arrest (VT/VF OHCA) supported with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) facilitated resuscitation. METHODS In this retrospective single-center cohort study including VT/VF OHCA patients supported with VA ECMO, we compared OHCA characteristics, post-arrest computed tomography (CT) scans, ventilator parameters, and other lung-related pathology between survivors, patients who developed brain death, and those with other causes of death. RESULTS Among 138 patients, 48/138 (34.8%) survived, 31/138 (22.4%) developed brain death, and 59/138 (42.7%) died of other causes. Successful extubation was achieved in 39/138 (28%) with a median time to extubation of 8.0 days (6.0, 11.0) in those who survived. Tracheostomy was required in 15/48 (31.3%) survivors. Chest CT obtained on all patients showed lung injury in at least one lung area in 124/135 (91.8%) patients, predominantly in the dependent posterior areas. There was no association between the number of affected areas and survival. Lung compliance was low on admission [26 (19,33) ml/cmH20], improved throughout hospitalization (p = 0.03), and recovered faster in survivors compared to those who died (p < 0.001). VA-ECMO allowed the use of lung-protective ventilation while maintaining normalized PaO2 and PaCO2. Patients treated with V-A ECMO and either IABP or Impella had lower pulmonary compliance and more affected areas on their CT compared to those treated with V-A ECMO alone. CONCLUSIONS Lung injury is common among patients with refractory VT/VF OHCA requiring V-A ECMO, but imaging severity is not associated with survival. Reductions in lung compliance accompany post-arrest lung injury while compliance recovery is associated with survival.
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Affiliation(s)
- Alejandra Gutierrez
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States; Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States.
| | - Rajat Kalra
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States; Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Andrea M Elliott
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States; Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Alexandra Marquez
- Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States; Pediatric Cardiology Critical Care, Children's Hospital, University of Minnesota, United States
| | - Demetris Yannopoulos
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States; Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Jason A Bartos
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States; Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
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12
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Nasuno M, Yokoyama Y, Motobayashi M, Kobayashi K, Omori N, Murai T, Kubota N, Kitamura M, Minami K, Inaba Y. Targeted temperature management at 36°C is a risk factor for ventilator-associated pneumonia. Pediatr Int 2023; 65:e15556. [PMID: 37368497 DOI: 10.1111/ped.15556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 04/16/2023] [Accepted: 04/27/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND In contrast to the adult population, limited information is currently available on risk factors for ventilator-associated pneumonia (VAP) in children. Therapeutic hypothermia has been identified as a risk factor for the early onset of VAP in adults; however, the relationship between VAP and normothermia remains unclear. The present study investigated risk factors for VAP in children, with a focus on the deleterious effects of therapeutic normothermia on VAP. METHODS We retrospectively investigated the clinical characteristics of children treated with mechanical ventilation for more than 48 h and analyzed risk factors for VAP. The endpoint was the onset of VAP by the seventh day after the initiation of mechanical ventilation. RESULTS Among the 288 patients enrolled, seven (2.4%) developed VAP. No significant differences were observed in clinical backgrounds between the VAP and non-VAP groups. A univariate analysis identified target temperature management (TTM) at 36°C (p < 0.0001) and methylprednisolone (mPSL) pulse therapy (p = 0.02) as risk factors for VAP. An analysis of the time to the onset of VAP by the Kaplan-Meier plot and log-rank test revealed a significantly higher incidence of VAP in the TTM group (p < 0.0001) and mPSL pulse group (p = 0.001). CONCLUSION TTM at 36°C and mPSL pulse therapy may be risk factors for VAP in the pediatric population.
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Affiliation(s)
- Masaru Nasuno
- Department of Medical Genetics, Shinshu University School of Medicine, Matsumoto, Japan
- Division of Neuropediatrics, Nagano Children's Hospital, Azumino, Japan
| | - Yukari Yokoyama
- Department of Nursing, Nagano Children's Hospital, Azumino, Japan
| | - Mitsuo Motobayashi
- Division of Neuropediatrics, Nagano Children's Hospital, Azumino, Japan
- Life Science Research Center, Nagano Children's Hospital, Azumino, Japan
- Neuro-Care Center, Nagano Children's Hospital, Azumino, Japan
- Department of Pediatrics, Shinshu University School of Medicine, Nagano, Japan
| | - Keiko Kobayashi
- Department of Pharmacy, Nagano Children's Hospital, Azumino, Japan
| | - Norio Omori
- Pediatric Intensive Care Unit, Nagano Children's Hospital, Azumino, Japan
| | - Takemi Murai
- Department of Infectious Diseases, Nagano Children's Hospital, Azumino, Japan
| | - Noriko Kubota
- Clinical Laboratory, Nagano Children's Hospital, Azumino, Japan
| | - Masatomo Kitamura
- Pediatric Intensive Care Unit, Nagano Children's Hospital, Azumino, Japan
| | - Kisei Minami
- Department of Infectious Diseases, Nagano Children's Hospital, Azumino, Japan
| | - Yuji Inaba
- Division of Neuropediatrics, Nagano Children's Hospital, Azumino, Japan
- Life Science Research Center, Nagano Children's Hospital, Azumino, Japan
- Neuro-Care Center, Nagano Children's Hospital, Azumino, Japan
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13
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Lazzarin T, Tonon CR, Martins D, Fávero EL, Baumgratz TD, Pereira FWL, Pinheiro VR, Ballarin RS, Queiroz DAR, Azevedo PS, Polegato BF, Okoshi MP, Zornoff L, Rupp de Paiva SA, Minicucci MF. Post-Cardiac Arrest: Mechanisms, Management, and Future Perspectives. J Clin Med 2022; 12:jcm12010259. [PMID: 36615059 PMCID: PMC9820907 DOI: 10.3390/jcm12010259] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 12/22/2022] [Accepted: 12/23/2022] [Indexed: 12/31/2022] Open
Abstract
Cardiac arrest is an important public health issue, with a survival rate of approximately 15 to 22%. A great proportion of these deaths occur after resuscitation due to post-cardiac arrest syndrome, which is characterized by the ischemia-reperfusion injury that affects the role body. Understanding physiopathology is mandatory to discover new treatment strategies and obtain better results. Besides improvements in cardiopulmonary resuscitation maneuvers, the great increase in survival rates observed in recent decades is due to new approaches to post-cardiac arrest care. In this review, we will discuss physiopathology, etiologies, and post-resuscitation care, emphasizing targeted temperature management, early coronary angiography, and rehabilitation.
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Cassara CM, Long MT, Dollerschell JT, Chae F, Hall DJ, Demiralp G, Stampfl MJ, Bernardoni B, McCarthy DP, Glazer JM. Extracorporeal Cardiopulmonary Resuscitation: A Narrative Review and Establishment of a Sustainable Program. Medicina (B Aires) 2022; 58:medicina58121815. [PMID: 36557017 PMCID: PMC9781756 DOI: 10.3390/medicina58121815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 11/15/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022] Open
Abstract
The rates of survival with functional recovery for out of hospital cardiac arrest remain unacceptably low. Extracorporeal cardiopulmonary resuscitation (ECPR) quickly resolves the low-flow state of conventional cardiopulmonary resuscitation (CCPR) providing valuable perfusion to end organs. Observational studies have shown an association with the use of ECPR and improved survivability. Two recent randomized controlled studies have demonstrated improved survival with functional neurologic recovery when compared to CCPR. Substantial resources and coordination amongst different specialties and departments are crucial for the successful implementation of ECPR. Standardized protocols, simulation based training, and constant communication are invaluable to the sustainability of a program. Currently there is no standardized protocol for the post-cannulation management of these ECPR patients and, ideally, upcoming studies should aim to evaluate these protocols.
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Affiliation(s)
- Chris M. Cassara
- Department of Anesthesiology, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
- Correspondence: ; Tel.: +1-608-263-8100
| | - Micah T. Long
- Department of Anesthesiology, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - John T. Dollerschell
- Department of Anesthesiology, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - Floria Chae
- Department of Anesthesiology, Ohio State University Wexner Medical Center, 370 W. 9th Ave., Columbus, OH 43210, USA
| | - David J. Hall
- Department of Surgery, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - Gozde Demiralp
- Department of Anesthesiology, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - Matthew J. Stampfl
- Department of Emergency Medicine, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - Brittney Bernardoni
- Department of Emergency Medicine, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - Daniel P. McCarthy
- Department of Surgery, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - Joshua M. Glazer
- Department of Emergency Medicine, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
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15
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Oestreich MA, Seidel K, Bertrams W, Müller HH, Sassen M, Steinfeldt T, Wulf H, Schmeck B. Pulmonary inflammatory response and immunomodulation to multiple trauma and hemorrhagic shock in pigs. PLoS One 2022; 17:e0278766. [PMID: 36476845 PMCID: PMC9728855 DOI: 10.1371/journal.pone.0278766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 10/31/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Patients suffering from severe trauma experience substantial immunological stress. Lung injury is a known risk factor for the development of posttraumatic complications, but information on the long-term course of the pulmonary inflammatory response and treatment with mild hypothermia are scarce. AIM To investigate the pulmonary inflammatory response to multiple trauma and hemorrhagic shock in a porcine model of combined trauma and to assess the immunomodulatory properties of mild hypothermia. METHODS Following induction of trauma (blunt chest trauma, liver laceration, tibia fracture), two degrees of hemorrhagic shock (45 and 50%) over 90 (n = 30) and 120 min. (n = 20) were induced. Animals were randomized to hypothermia (33°C) or normothermia (38°C). We evaluated bronchoalveolar lavage (BAL) fluid and tissue levels of cytokines and investigated changes in microRNA- and gene-expression as well as tissue apoptosis. RESULTS We observed a significant induction of Interleukin (IL) 1β, IL-6, IL-8, and Cyclooxygenase-2 mRNA in lung tissue. Likewise, an increased IL-6 protein concentration could be detected in BAL-fluid, with a slight decrease of IL-6 protein in animals treated with hypothermia. Lower IL-10 protein levels in normothermia and higher IL-10 protein concentrations in hypothermia accompanied this trend. Tissue apoptosis increased after trauma. However, intervention with hypothermia did not result in a meaningful reduction of pro-inflammatory biomarkers or tissue apoptosis. CONCLUSION We observed signs of a time-dependent pulmonary inflammation and apoptosis at the site of severe trauma, and to a lower extent in the trauma-distant lung. Intervention with mild hypothermia had no considerable effect during 48 hours following trauma.
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Affiliation(s)
- Marc-Alexander Oestreich
- Institute for Lung Research, Universities of Giessen and Marburg Lung Center, German Center for Lung Research (DZL), Philipps University Marburg, Marburg, Germany
| | - Kerstin Seidel
- Vascular Biology Section, Evans Department of Medicine, Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, United States of America
| | - Wilhelm Bertrams
- Institute for Lung Research, Universities of Giessen and Marburg Lung Center, German Center for Lung Research (DZL), Philipps University Marburg, Marburg, Germany
| | - Hans-Helge Müller
- Institute for Medical Bioinformatics and Biostatistics, Philipps-Universität Marburg, Marburg, Germany
| | - Martin Sassen
- Department of Anesthesia and Intensive Care Medicine, University Medical Center Gießen and Marburg, Philipps University Marburg, Marburg, Germany
- Center for Emergency Medicine, University Medical Center Gießen and Marburg, Philipps University Marburg, Marburg, Germany
| | - Thorsten Steinfeldt
- BG Unfallklinik Frankfurt am Main gGmbH, Department for Anesthesia, Intensive Care Medicine and Pain Therapy, Frankfurt am Main, Germany
| | - Hinnerk Wulf
- Department of Anesthesia and Intensive Care Medicine, University Medical Center Gießen and Marburg, Philipps University Marburg, Marburg, Germany
| | - Bernd Schmeck
- Institute for Lung Research, Universities of Giessen and Marburg Lung Center, German Center for Lung Research (DZL), Philipps University Marburg, Marburg, Germany
- Department of Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, German Center for Lung Research (DZL), Philipps University Marburg, Marburg, Germany
- Center for Synthetic Microbiology (SYNMIKRO), Philipps-University of Marburg, Marburg, Germany
- German Center for Infection Research (DZIF), Partner Site Giessen-Marburg-Langen, Marburg, Germany
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Keller K, Sagoschen I, Schmitt VH, Münzel T, Gori T, Hobohm L. Hypothermia and its role in patients with ST-segment-elevation myocardial infarction and cardiac arrest. Front Cardiovasc Med 2022; 9:1051978. [DOI: 10.3389/fcvm.2022.1051978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 11/07/2022] [Indexed: 11/30/2022] Open
Abstract
BackgroundPatients suffering cardiac arrest resulting from ST-segment-elevation myocardial infarction (STEMI) are at very high risk of death. In addition to reperfusion strategies, therapeutic hypothermia is recommended for cardiac arrest patients who remain unconscious after resuscitation. However, data analysis of the impact of therapeutic hypothermia on survival showed inconsistent results. We aimed to investigate the benefits of therapeutic hypothermia in STEMI patients after cardiopulmonary resuscitation (CPR).MethodsPatients with STEMI who received CPR were identified after nationwide German inpatient data (2005–2019) were screened. These patients were stratified for therapeutic hypothermia. The impact of hypothermia on mortality and adverse in-hospital outcomes was analyzed.ResultsOverall, 133,070 inpatients with STEMI and CPR (53.3% aged ≥70 years; 34% females) were recorded in Germany between 2005 and 2019, of which 12.3% (16,386 patients) underwent therapeutic hypothermia. Females (23.8 vs. 35.4%, p < 0.001) and patients aged ≥70 years (34.9 vs. 55.9%, p < 0.001) were less frequently treated with therapeutic hypothermia. The in-hospital case fatality rate was lower for STEMI with CPR and subsequent therapeutic hypothermia than for treatment without therapeutic hypothermia (53.5 vs. 66.7%, p < 0.001). Therapeutic hypothermia was independently associated with a reduced in-hospital case fatality rate {OR 0.83 [95% confidence interval (CI) 0.80–0.86], p < 0.001}. In addition, therapeutic hypothermia was associated with an increased risk for stroke (OR 1.37 [95% CI 1.25–1.49], p < 0.001), pneumonia (OR 1.75 [95% CI 1.68–1.82], p < 0.001), and acute kidney injury (OR 2.21 [95% CI 2.07–2.35], p < 0.001).ConclusionTherapeutic hypothermia is associated with a survival benefit for STEMI patients after cardiac arrest.
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17
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Mueller M, Jankow E, Grafeneder J, Schoergenhofer C, Poppe M, Schriefl C, Clodi C, Koch M, Ettl F, Holzer M, Losert H. The difference between arterial pCO 2 and etCO 2 after cardiac arrest - Outcome predictor or marker of unfavorable resuscitation circumstances? Am J Emerg Med 2022; 61:120-126. [PMID: 36096013 DOI: 10.1016/j.ajem.2022.08.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 08/13/2022] [Accepted: 08/28/2022] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION In former studies, the arterio-alveolar carbon dioxide gradient (ΔCO2) predicted in-hospital mortality after initially survived cardiac arrest. As early outcome predictors are urgently needed, we evaluated ΔCO2 as predictor for good neurological outcome in our cohort. METHODS We retrospectively analyzed all patients ≥18 years of age after non-traumatic in- and out of hospital cardiac arrest in the year 2018 from our resuscitation database. Patients without advanced airway management, incomplete datasets or without return of spontaneous circulation were excluded. The first arterial pCO2 after admission and the etCO2 in mmHg at the time of blood sampling were recorded from patient's charts. We then calculated ΔCO2 (pCO2 - etCO2). For baseline analyses, ΔCO2 was dichotomized into a low and high group with separation at the median. Good neurological outcome on day 30, expressed as Cerebral Performance Category 1-2, defined our primary endpoint. Survival to 30 days was used as secondary endpoint. RESULTS Out of 302 screened patients, 128 remained eligible for analyses. ΔCO2 was lower in 30-day survivors with good neurological outcome (12.2 mmHg vs. 18.8 mmHg, p = 0.009) and in 30-day survivors (12.5 mmHg vs. 20.0 mmHg, p = 0.001). In patients with high ΔCO2, a cardiac etiology of arrest was found less often. They had a higher body mass index, longer duration of resuscitation, higher amounts of epinephrine, lower pO2 levels but both higher pCO2 and blood lactate levels, resulting in lower blood pH and HCO3- levels at admission. In a crude binary logistic regression analysis, ΔCO2 was associated with 30-day neurological outcome (OR = 1.041 per mmHg of ΔCO2, 95% CI 1.008-1.074, p = 0.014). This association persisted after the adjustment for age, sex, witnessed arrest and shockable first rhythm. However, after addition of the duration of resuscitation or the cumulative epinephrine dosage to the model, ΔCO2 lost its association. CONCLUSION ΔCO2 at admission after a successfully resuscitated cardiac arrest is associated with 30 days survival with good neurological outcome. However, a higher ΔCO2 may rather be a surrogate for unfavorable resuscitation circumstances than an independent outcome predictor.
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Affiliation(s)
- Matthias Mueller
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Emmely Jankow
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Juergen Grafeneder
- Department of Emergency Medicine, Medical University of Vienna, Austria.
| | | | - Michael Poppe
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | | | - Christian Clodi
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Moritz Koch
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Florian Ettl
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Michael Holzer
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Heidrun Losert
- Department of Emergency Medicine, Medical University of Vienna, Austria
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Kawai Y, Takano K, Miyazaki K, Yamamoto K, Tada Y, Asai H, Maegawa N, Urisono Y, Saeki K, Fukushima H. Association of multiple rib fractures with the frequency of pneumonia in the post-resuscitation period. Resusc Plus 2022; 11:100267. [PMID: 35812719 PMCID: PMC9256829 DOI: 10.1016/j.resplu.2022.100267] [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: 11/29/2021] [Revised: 06/11/2022] [Accepted: 06/20/2022] [Indexed: 11/18/2022] Open
Abstract
Purpose Successful cardiopulmonary resuscitation is associated with a high incidence of chest wall injuries. However, few studies have examined chest wall injury as a risk factor for respiratory complications after cardiopulmonary resuscitation. Therefore, herein, we investigated the association of multiple rib fractures on the incidence of post-resuscitation pneumonia. Methods This single-centre retrospective cohort study enrolled adult, nontraumatic, out-of-hospital cardiac arrest patients who maintained circulation for more than 48 h between June 2015 and May 2019. Rib fractures were evaluated by computed tomography on the day of hospital admission. The association with newly developed pneumonia within 7 days of hospitalisation was analysed using a Fine-Gray proportional hazards regression model adjusted for the propensity score of multiple rib fractures estimated from age, sex, presence of witnessed status, bystander CPR, initial rhythm, and total CPR time and for previously reported risk factors for pneumonia (therapeutic hypothermia and prophylactic antibiotics). Results Overall, 683 patients with out-of-hospital cardiac arrest were treated; 87 eligible cases were enrolled for analysis. Thirty-two (36.8%) patients had multiple rib fractures identified on computed tomography, and 35 (40.2%) patients developed pneumonia. The presence of multiple rib fractures was significantly associated with a higher incidence of pneumonia, consistently both with and without adjustment for background factors (unadjusted hazard ratio 4.63, 95% confidence interval: 2.35–9.13, p < 0.001; adjusted hazard ratio 4.03, 95% confidence interval: 2.08–7.82, p < 0.001). Conclusions Multiple rib fractures are independently associated with the development of pneumonia after successful resuscitation.
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Baker TS, Kellner CP, Colbourne F, Rincon F, Kollmar R, Badjatia N, Dangayach N, Mocco J, Selim MH, Lyden P, Polderman K, Mayer S. Consensus recommendations on therapeutic hypothermia after minimally invasive intracerebral hemorrhage evacuation from the hypothermia for intracerebral hemorrhage (HICH) working group. Front Neurol 2022; 13:859894. [PMID: 36062017 PMCID: PMC9428129 DOI: 10.3389/fneur.2022.859894] [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: 01/21/2022] [Accepted: 06/30/2022] [Indexed: 12/03/2022] Open
Abstract
Background and purpose Therapeutic hypothermia (TH), or targeted temperature management (TTM), is a classic treatment option for reducing inflammation and potentially other destructive processes across a wide range of pathologies, and has been successfully used in numerous disease states. The ability for TH to improve neurological outcomes seems promising for inflammatory injuries but has yet to demonstrate clinical benefit in the intracerebral hemorrhage (ICH) patient population. Minimally invasive ICH evacuation also presents a promising option for ICH treatment with strong preclinical data but has yet to demonstrate functional improvement in large randomized trials. The biochemical mechanisms of action of ICH evacuation and TH appear to be synergistic, and thus combining hematoma evacuation with cooling therapy could provide synergistic benefits. The purpose of this working group was to develop consensus recommendations on optimal clinical trial design and outcomes for the use of therapeutic hypothermia in ICH in conjunction with minimally invasive ICH evacuation. Methods An international panel of experts on the intersection of critical-care TH and ICH was convened to analyze available evidence and form a consensus on critical elements of a focal cooling protocol and clinical trial design. Three focused sessions and three full-group meetings were held virtually from December 2020 to February 2021. Each meeting focused on a specific subtopic, allowing for guided, open discussion. Results These recommendations detail key elements of a clinical cooling protocol and an outline for the roll-out of clinical trials to test and validate the use of TH in conjunction with hematoma evacuation as well as late-stage protocols to improve the cooling approach. The combined use of systemic normothermia and localized moderate (33.5°C) hypothermia was identified as the most promising treatment strategy. Conclusions These recommendations provide a general outline for the use of TH after minimally invasive ICH evacuation. More research is needed to further refine the use and combination of these promising treatment paradigms for this patient population.
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Affiliation(s)
- Turner S. Baker
- Icahn School of Medicine at Mount Sinai, Sinai BioDesign, New York, NY, United States
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- *Correspondence: Turner S. Baker
| | - Christopher P. Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | | | - Fred Rincon
- Department of Neurology, Thomas Jefferson University Hospital, Thomas Jefferson University, Philadelphia, PA, United States
| | - Rainer Kollmar
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
- Department of Neurology and Neurological Intensive Care, Darmstadt Academic Teaching Hospital, Darmstadt, Germany
| | - Neeraj Badjatia
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Neha Dangayach
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - J. Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Magdy H. Selim
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA, United States
| | - Patrick Lyden
- Department of Physiology and Neuroscience, Keck School of Medicine, Zilkha Neurogenetic Institute, University of Southern California, CA, United States
| | - Kees Polderman
- United Memorial Medical Center, Houston, TX, United States
| | - Stephan Mayer
- Westchester Medical Center Health Network, Valhalla, NY, United States
- Department of Neurology, New York Medical College, Valhalla, NY, United States
- Department of Neurosurgery, New York Medical College, Valhalla, NY, United States
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Moussali A, Cauchois E, Carvelli J, Hraeich S, Bouzana F, Lesaux A, Boucekine M, Bichon A, Gainnier M, Fromonot J, Bourenne J. Salivary Alpha Amylase Bronchial Measure for Early Aspiration Pneumonia Diagnosis in Patients Treated With Therapeutic Hypothermia After Out-of-hospital Cardiac Arrest. Front Med (Lausanne) 2022; 9:880803. [PMID: 35646993 PMCID: PMC9137879 DOI: 10.3389/fmed.2022.880803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 04/19/2022] [Indexed: 11/15/2022] Open
Abstract
Background Aspiration pneumonia is the most common respiratory complication following out-of-hospital cardiac arrests (OHCA). Alpha-amylase (α-amylase) in pulmonary secretions is a biomarker of interest in detecting inhalation. The main goal of this study is to evaluate the performance of bronchoalveolar levels of α-amylase in early diagnosis of aspiration pneumonia, in patients admitted to intensive care unit (ICU) after OHCA. Methods This is a prospective single-center trial, led during 5 years (July 2015 to September 2020). We included patients admitted to ICU after OHCA. A protected specimen bronchial brushing and a mini-bronchoalveolar lavage (mini-BAL) were collected during the first 6 h after admission. Dosage of bronchial α-amylase and standard bacterial analysis were performed. Investigators confirmed pneumonia diagnosis using clinical, radiological, and microbiological criteria. Every patient underwent targeted temperature management. Results 88 patients were included. The 34% (30 patients) developed aspiration pneumonia within 5 days following admission. The 55% (17) of pneumonias occurred during the first 48 h. The 57% of the patients received a prophylactic antibiotic treatment on their admission day. ICU mortality was 50%. Median value of bronchial α-amylase did not differ whether patients had aspiration pneumonia (15 [0–94]) or not (3 [0–61], p = 0,157). Values were significantly different concerning early-onset pneumonia (within 48 h) [19 (7–297) vs. 3 (0–82), p = 0,047]. If one or more microorganisms were detected in the initial mini-BAL, median value of α-amylase was significantly higher [25 (2–230)] than in sterile cultures (2 [0–43], p = 0,007). With an 8.5 IU/L cut-point, sensitivity and specificity of α-amylase value for predicting aspiration pneumonia during the first 2 days were respectively 74 and 62%. True positive and negative rates were respectively 44 and 86%. The area under the ROC curve was 0,654 (CI 95%; 0,524–0,785). Mechanical ventilation duration, length of ICU stay, and mortality were similar in both groups. Conclusion In our study, dosage of bronchial α-amylase was not useful in predicting aspiration pneumonia within the first 5 days after ICU admission for OHCA. Performance in predicting early-onset pneumonia was moderate.
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Affiliation(s)
- Anis Moussali
- Réanimation des Urgences, Timone University Hospital APHM, Marseille, France
| | - Emi Cauchois
- Réanimation des Urgences, Timone University Hospital APHM, Marseille, France
| | - Julien Carvelli
- Réanimation des Urgences, Timone University Hospital APHM, Marseille, France
| | - Sami Hraeich
- Réanimation des Détresses Respiratoires et Infections Sévères, North University Hospital APHM, Marseille, France
- Aix-Marseille University, School of Medicine—La Timone, EA 3279: CEReSS—Health Service Research and Quality of Life Center, Marseille, France
| | - Fouad Bouzana
- Réanimation des Urgences, Timone University Hospital APHM, Marseille, France
| | - Audrey Lesaux
- Réanimation des Urgences, Timone University Hospital APHM, Marseille, France
| | - Mohamed Boucekine
- Aix-Marseille University, School of Medicine—La Timone, EA 3279: CEReSS—Health Service Research and Quality of Life Center, Marseille, France
- Department of Clinical Research and Innovation, Support Unit for Clinical Research and Economic Evaluation, Assistance Publique—Hôpitaux de Marseille, Marseille, France
| | - Amandine Bichon
- Réanimation des Urgences, Timone University Hospital APHM, Marseille, France
| | - Marc Gainnier
- Réanimation des Urgences, Timone University Hospital APHM, Marseille, France
- Aix Marseille University, INSERM, INRAE, C2VN, Marseille, France
| | - Julien Fromonot
- Aix Marseille University, INSERM, INRAE, C2VN, Marseille, France
- Laboratory of Biochemistry, Timone University Hospital APHM, Marseille, France
| | - Jeremy Bourenne
- Réanimation des Urgences, Timone University Hospital APHM, Marseille, France
- Aix Marseille University, INSERM, INRAE, C2VN, Marseille, France
- *Correspondence: Jeremy Bourenne
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Segond N, Bellier A, Duhem H, Sanchez C, Busi O, Deutsch S, Aguilera L, Truan D, Koch FX, Viglino D, Debaty G. Supraglottic airway device to improve ventilation success and reduce pulmonary aspiration during cardio-pulmonary resuscitation by basic life support rescuers: a randomised cross-over human cadaver study. PREHOSP EMERG CARE 2022:1-9. [PMID: 35543652 DOI: 10.1080/10903127.2022.2075994] [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: 10/18/2022]
Abstract
Objectives: Early airway management during cardiopulmonary resuscitation (CPR) prevents aspiration of gastric contents. Endotracheal intubation is the gold standard to protect airways, but supraglottic airway devices (SGA) may provide some protection with less training. Bag-mask ventilation (BMV) is the most common method used by rescuers. We hypothesized that SGA use by first rescuers during CPR could increase ventilation success rate and also decrease intragastric pressure and pulmonary aspiration.Methods: We performed a randomized cross-over experimental trial on human cadavers. Protocol A: we assessed the rate of successful ventilation (chest rise), intragastric pressure, and CPR key time metrics. Protocol B: cadaver stomachs were randomized to be filled with 300 mL of either blue or green serum saline solution through a Foley catheter. Each rescuer was randomly assigned to use SGA or BMV during a 5-minute standard CPR period. Then, in a crossover design, the stomach was filled with the second colour solution and another 5-minute CPR period was performed using the other airway method. Pulmonary aspiration, defined as the presence of coloured solution below the vocal cords, was assessed by a blinded operator using bronchoscopy. A generalized linear mixed model was used for statistical analysis.Results: Protocol A: Forty-eight rescuers performed CPR on 11 cadavers. Median ventilation success was higher with SGA than BMV: 75.0% (IQR: 59.8-87.3) vs. 34.7% (IQR: 25.0-50.0), (p = 0.003). Gastric pressure and differential (maximum minus minimum) gastric pressure were lower in the SGA group: 2.21 mmHg (IQR: 1.66; 2.68) vs. 3.02 mmHg (IQR: 2.02; 4.22) (p = 0.02) and 5.70 mmHg (IQR: 4.10; 7.60) vs. 8.05 mmHg (IQR: 5.40; 11.60) (p = 0.05). CPR key times were not different between groups. Protocol B: Ten cadavers were included with 20 CPR periods. Aspiration occurred in 2 (20%) SGA procedures and 5 (50%) BMV procedures (p = 0.44).Conclusion: Use of SGA by rescuers improved the ventilation success rate, decreased intragastric pressure, and did not affect key CPR metrics. SGA use by basic life support rescuers appears feasible and efficient.
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Affiliation(s)
- N Segond
- Emergency Department and Mobile Intensive Care Unit, University Hospital of Grenoble Alpes, Grenoble, France.,CNRS TIMC Laboratory, UMR 5525, Univ. Grenoble Alpes, Grenoble, France
| | - A Bellier
- CNRS TIMC Laboratory, UMR 5525, Univ. Grenoble Alpes, Grenoble, France.,LADAF-Laboratoire d'Anatomie Des Alpes Françaises, Univ. Grenoble Alpes, Grenoble, France
| | - H Duhem
- Emergency Department and Mobile Intensive Care Unit, University Hospital of Grenoble Alpes, Grenoble, France.,CNRS TIMC Laboratory, UMR 5525, Univ. Grenoble Alpes, Grenoble, France
| | - C Sanchez
- Emergency Department and Mobile Intensive Care Unit, University Hospital of Grenoble Alpes, Grenoble, France
| | - O Busi
- Emergency Department and Mobile Intensive Care Unit, University Hospital of Grenoble Alpes, Grenoble, France
| | - S Deutsch
- Emergency Department and Mobile Intensive Care Unit, University Hospital of Grenoble Alpes, Grenoble, France
| | - L Aguilera
- Emergency Department and Mobile Intensive Care Unit, University Hospital of Grenoble Alpes, Grenoble, France
| | - D Truan
- Emergency Department and Mobile Intensive Care Unit, University Hospital of Grenoble Alpes, Grenoble, France
| | - F X Koch
- Emergency Department and Mobile Intensive Care Unit, University Hospital of Grenoble Alpes, Grenoble, France
| | - D Viglino
- Emergency Department and Mobile Intensive Care Unit, University Hospital of Grenoble Alpes, Grenoble, France.,INSERM U1300, HP2 Laboratory, Univ. Grenoble Alpes, Grenoble, France
| | - G Debaty
- Emergency Department and Mobile Intensive Care Unit, University Hospital of Grenoble Alpes, Grenoble, France.,CNRS TIMC Laboratory, UMR 5525, Univ. Grenoble Alpes, Grenoble, France
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22
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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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23
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Gagnon DJ, Ryzhov SV, May MA, Riker RR, Geller B, May TL, Bockian S, deKay JT, Eldridge A, Van der Kloot T, Lerwick P, Lord C, Lucas FL, Mailloux P, McCrum B, Searight M, Wirth J, Zuckerman J, Sawyer D, Seder DB. Ceftriaxone to PRevent pneumOnia and inflammaTion aftEr Cardiac arresT (PROTECT): study protocol for a randomized, placebo-controlled trial. Trials 2022; 23:197. [PMID: 35246202 PMCID: PMC8895836 DOI: 10.1186/s13063-022-06127-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 02/23/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Pneumonia is the most common infection after out-of-hospital cardiac arrest (OHCA) occurring in up to 65% of patients who remain comatose after return of spontaneous circulation. Preventing infection after OHCA may (1) reduce exposure to broad-spectrum antibiotics, (2) prevent hemodynamic derangements due to local and systemic inflammation, and (3) prevent infection-associated morbidity and mortality. METHODS The ceftriaxone to PRevent pneumOnia and inflammaTion aftEr Cardiac arrest (PROTECT) trial is a randomized, placebo-controlled, single-center, quadruple-blind (patient, treatment team, research team, outcome assessors), non-commercial, superiority trial to be conducted at Maine Medical Center in Portland, Maine, USA. Ceftriaxone 2 g intravenously every 12 h for 3 days will be compared with matching placebo. The primary efficacy outcome is incidence of early-onset pneumonia occurring < 4 days after mechanical ventilation initiation. Concurrently, T cell-mediated inflammation bacterial resistomes will be examined. Safety outcomes include incidence of type-one immediate-type hypersensitivity reactions, gallbladder injury, and Clostridioides difficile-associated diarrhea. The trial will enroll 120 subjects over approximately 3 to 4 years. DISCUSSION The PROTECT trial is novel in its (1) inclusion of OHCA survivors regardless of initial heart rhythm, (2) use of a low-risk antibiotic available in the USA that has not previously been tested after OHCA, (3) inclusion of anti-inflammatory effects of ceftriaxone as a novel mechanism for improved clinical outcomes, and (4) complete metagenomic assessment of bacterial resistomes pre- and post-ceftriaxone prophylaxis. The long-term goal is to develop a definitive phase III trial powered for mortality or functional outcome. TRIAL REGISTRATION ClinicalTrials.gov NCT04999592 . Registered on August 10, 2021.
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Affiliation(s)
- David J Gagnon
- Department of Pharmacy, Maine Medical Center, Portland, ME, USA.
- Maine Medical Center Research Institute, Scarborough, ME, USA.
- Tufts University School of Medicine, Boston, MA, USA.
| | - Sergey V Ryzhov
- Maine Medical Center Research Institute, Scarborough, ME, USA
| | - Meghan A May
- University of New England College of Osteopathic Medicine, Biddeford, ME, USA
| | - Richard R Riker
- Tufts University School of Medicine, Boston, MA, USA
- Department of Critical Care Services, Maine Medical Center, Portland, ME, USA
| | - Bram Geller
- Tufts University School of Medicine, Boston, MA, USA
- Maine Medical Partners, MaineHealth Cardiology, Scarborough, ME, USA
| | - Teresa L May
- Maine Medical Center Research Institute, Scarborough, ME, USA
- Tufts University School of Medicine, Boston, MA, USA
- Department of Critical Care Services, Maine Medical Center, Portland, ME, USA
| | - Sarah Bockian
- Maine Medical Center Neuroscience Institute, Maine Medical Center, Portland, ME, USA
| | - Joanne T deKay
- Maine Medical Center Research Institute, Scarborough, ME, USA
| | - Ashley Eldridge
- Maine Medical Center Neuroscience Institute, Maine Medical Center, Portland, ME, USA
| | | | - Patricia Lerwick
- Department of Critical Care Services, Maine Medical Center, Portland, ME, USA
| | - Christine Lord
- Maine Medical Center Neuroscience Institute, Maine Medical Center, Portland, ME, USA
| | - F Lee Lucas
- Maine Medical Center Research Institute, Scarborough, ME, USA
| | - Patrick Mailloux
- Department of Critical Care Services, Maine Medical Center, Portland, ME, USA
| | - Barbara McCrum
- Maine Medical Center Neuroscience Institute, Maine Medical Center, Portland, ME, USA
| | - Meghan Searight
- Maine Medical Center Neuroscience Institute, Maine Medical Center, Portland, ME, USA
| | - Joel Wirth
- Department of Critical Care Services, Maine Medical Center, Portland, ME, USA
| | | | - Douglas Sawyer
- Maine Medical Center Research Institute, Scarborough, ME, USA
- Maine Medical Partners, MaineHealth Cardiology, Scarborough, ME, USA
| | - David B Seder
- Maine Medical Center Research Institute, Scarborough, ME, USA
- Tufts University School of Medicine, Boston, MA, USA
- Department of Critical Care Services, Maine Medical Center, Portland, ME, USA
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24
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Teng G, Wang N, Nie X, Zhang L, Liu H. Analysis of risk factors for early-onset ventilator-associated pneumonia in a neurosurgical intensive care unit. BMC Infect Dis 2022; 22:66. [PMID: 35057762 PMCID: PMC8772091 DOI: 10.1186/s12879-022-07053-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 01/11/2022] [Indexed: 12/21/2022] Open
Abstract
Abstract
Background
Ventilator-associated pneumonia (VAP) is a severe infection among patients in the neurosurgery intensive care unit (NICU).
Methods
We retrospectively evaluated risk factors for early-onset ventilator-associated pneumonia (EOVAP) from January 2019 to December 2019 at a NICU. A total of 89 NICU patients who were intubated within 48 h of onset and whose mechanical ventilation time was at least 7 days were enrolled. We evaluated EOVAP that occurred within the first 7 days after the onset of mechanical ventilation. The enrolled patients had no history of chronic lung disease and no clinical manifestations of infection before intubation. Clinical data of patients were recorded, and the incidence of and risk factors for EOVAP were analyzed. Patients were also grouped by age (≥ 65 vs. < 65 years) and whether they had received hypothermia treatment or not.
Results
Among 89 mechanically ventilated patients (49 men and 40 women; the mean age ± SD was 60.1 ± 14.3 years), 40 patients (44.9%) developed EOVAP within 7 days and 14 patients (15.7%) had a multidrug resistant bacterial infection. Binary logistic regression analysis indicated that older age (≥ 65 years) (odds ratio [OR]:3.53, 95% confidence interval [CI]:1.27–9.79, P = 0.015) and therapeutic hypothermia (OR:3.68, CI:1.10–12.31, p = 0.034) were independent predictors of EOVAP. Levels of peripheral blood leukocytes, neutrophils and platelets were lower in the therapeutic hypothermia group than those who did not receive hypothermia treatment.
Conclusions
This study found that older age (≥ 65 years) and therapeutic hypothermia were independently associated with the risk of EOVAP in NICU patients.
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25
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Navarro JC, Kofke WA. Perioperative Management of Acute Central Nervous System Injury. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00024-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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26
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Kosutova P, Mikolka P. Aspiration syndromes and associated lung injury: incidence, pathophysiology and management. Physiol Res 2021. [DOI: 10.33549//physiolres.934767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Aspiration is a common condition affecting healthy or sick patients which could create an acute or chronic inflammatory reaction in the lungs. Aspiration syndromes could be categorized according to a content entering the respiratory system into bacterial aspiration pneumonia with the gastric or oropharyngeal bacteria entering, aspiration chemical pneumonitis with bacteria-freegastric acid aspiration, or aspiration of a foreign body which causes an acute pulmonary emergency. There are differences in the clinical presentation of volume-dependent aspirations (microaspiration and macroaspiration): the higher is the volume of aspiration, the greater is the injury to the patient and more serious are the health consequences (with 70 % mortality rate for hospitalized patients). Aspiration syndromes can affect both the airways and pulmonary parenchyma, leading to acute lung injury, increased hospitalization rate and worse outcomes in critically ill patients. Impaired alveolar-capillary permeability, oedema formation, neutrophilic inflammatory response and pulmonary surfactant inactivation lead to reduced lung compliance and loss of aerated lung tissue and give rise to hypoxemia and respiratory failure. This review discusses the effect of aspiration events on the pulmonary tissue. The main focus is to distinguish the differences between bacterial and chemical pneumonia, their clinical presentation and symptoms, risk factors of developing the changes, possibilities of diagnostics and management as well as prevention of aspirations. Because of a risk of serious lung damage after the aspiration, pathophysiology and processes leading to lung tissue injury are discussed in detail. Data sources represent a systematic literature search using relevant medical subject headings.
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27
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Han Chin Y, Yu Leon Yaow C, En Teoh S, Zhi Qi Foo M, Luo N, Graves N, Eng Hock Ong M, Fu Wah Ho A. Long-term outcomes after out-of-hospital cardiac arrest: a systematic review and meta-analysis. Resuscitation 2021; 171:15-29. [PMID: 34971720 DOI: 10.1016/j.resuscitation.2021.12.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/21/2021] [Accepted: 12/21/2021] [Indexed: 12/21/2022]
Abstract
AIMS Long term outcomes after out-of-hospital cardiac arrest (OHCA) are not well understood. This study aimed to evaluate the long-term (1-year and beyond) survival outcomes, including overall survival and survival with favorable neurological status and the quality-of-life (QOL) outcomes, among patients who survived the initial OHCA event (30 days or till hospital discharge). METHODS Embase, Medline and PubMed were searched for primary studies (randomized controlled trials, cohort and cross-sectional studies) which reported the long-term survival outcomes of OHCA patients. Data abstraction and quality assessment was conducted, and survival at predetermined timepoints were assessed via single-arm meta-analyses of proportions, using generalized linear mixed models. Comparative meta-analyses were conducted using the Mantel-Haenszel Risk Ratio (RR) estimates, using the DerSimonian and Laird model. RESULTS 67 studies were included, and among patients that survived to hospital discharge or 30-days, 77.3% (CI=71.2-82.4), 69.6% (CI=54.5-70.3), 62.7% (CI=54.5-70.3), 46.5% (CI=32.0-61.6), and 20.8% (CI=7.8-44.9) survived to 1-, 3-, 5-, 10- and 15-years respectively. Compared to Asia, the probability of 1-year survival was greater in Europe (RR=2.1, CI=1.8-2.3), North America (RR=2.0, CI=1.7-2.2) and Oceania (RR=1.9,CI=1.6-2.1). Males had a higher 1-year survival (RR:1.41, CI=1.25-1.59), and patients with initial shockable rhythm had improved 1-year (RR=3.07, CI=1.78-5.30) and 3-year survival (RR=1.45, CI=1.19-1.77). OHCA occurring in residential locations had worse 1-year survival (RR=0.42, CI=0.25-0.73). CONCLUSION Our study found that up to 20.8% of OHCA patients survived to 15-years, and survival was lower in Asia compared to the other regions. Further analysis on the differences in survival between the regions are needed to direct future long-term treatment of OHCA patients.
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Affiliation(s)
- Yip Han Chin
- School of Medicine, National University Singapore, Singapore, Singapore
| | | | - Seth En Teoh
- School of Medicine, National University Singapore, Singapore, Singapore
| | - Mabel Zhi Qi Foo
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - Nan Luo
- Saw Swee Hock School of Public Health, National University Singapore, Singapore
| | - Nicholas Graves
- Pre-hospital and Emergency Research Centre, Duke-NUS Medical School, Singapore
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore; Pre-hospital and Emergency Research Centre, Duke-NUS Medical School, Singapore
| | - Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore; Saw Swee Hock School of Public Health, National University Singapore, Singapore; Pre-hospital and Emergency Research Centre, Duke-NUS Medical School, Singapore.
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28
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Poppe M, Clodi C, Schriefl C, Mueller M, Sunder-Plaßmann R, Reiter B, Rechenmacher M, van Os W, van Hasselt JGC, Holzer M, Herkner H, Schwameis M, Jilma B, Schoergenhofer C, Weiser C. Targeted temperature management after cardiac arrest is associated with reduced metabolism of pantoprazole - A probe drug of CYP2C19 metabolism. Biomed Pharmacother 2021; 146:112573. [PMID: 34959115 DOI: 10.1016/j.biopha.2021.112573] [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: 10/21/2021] [Revised: 12/16/2021] [Accepted: 12/19/2021] [Indexed: 11/02/2022] Open
Abstract
OBJECTIVE Targeted temperature management (TTM) is part of standard post-resuscitation care. TTM may downregulate cytochrome enzyme activity and thus impact drug metabolism. This study compared the pharmacokinetics (PK) of pantoprazole, a probe drug of CYP2C19-dependent metabolism, at different stages of TTM following cardiac arrest. METHODS This prospective controlled study was performed at the Medical University of Vienna and enrolled 16 patients following cardiac arrest. The patients completed up to three study periods (each lasting 24 h) in which plasma concentrations of pantoprazole were quantified: (P1) hypothermia (33 °C) after admission, (P2) normothermia after rewarming (36 °C, intensive care), and (P3) normothermia during recovery (normal ward, control group). PK was analysed using non-compartmental analysis and nonlinear mixed-effects modelling. RESULTS 16 patients completed periods P1 and P2; ten completed P3. The median half-life of pantoprazole was 2.4 h (quartiles: 1.8-4.8 h) in P1, 2.8 h (2.1-6.8 h, p = 0.046 vs. P1, p = 0.005 vs. P3) in P2 and 1.2 h (0.9 - 2.3 h, p = 0.007 vs. P1) in P3. A two-compartment model described the PK data best. Typical values for clearance were estimated separately for each study period, indicating 40% and 29% reductions during P1 and P2, respectively, compared to P3. The central volume of distribution was estimated separately for P2, indicating a 64% increase compared to P1 and P3. CONCLUSION CYP2C19-dependent drug metabolism is downregulated during TTM following cardiac arrest. These results may influence drug choice and dosing of similarly metabolized drugs and may be helpful for designing studies in similar clinical situations.
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Affiliation(s)
- Michael Poppe
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Christian Clodi
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | | | - Matthias Mueller
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Raute Sunder-Plaßmann
- Clinical Institute of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Birgit Reiter
- Clinical Institute of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Wisse van Os
- Department of Clinical Pharmacology, Medical University of Vienna, Austria
| | | | - Michael Holzer
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Michael Schwameis
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Austria
| | | | - Christoph Weiser
- Department of Emergency Medicine, Medical University of Vienna, Austria
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29
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Radu RI, Ben Gal T, Abdelhamid M, Antohi E, Adamo M, Ambrosy AP, Geavlete O, Lopatin Y, Lyon A, Miro O, Metra M, Parissis J, Collins SP, Anker SD, Chioncel O. Antithrombotic and anticoagulation therapies in cardiogenic shock: a critical review of the published literature. ESC Heart Fail 2021; 8:4717-4736. [PMID: 34664409 PMCID: PMC8712803 DOI: 10.1002/ehf2.13643] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/08/2021] [Accepted: 09/19/2021] [Indexed: 01/09/2023] Open
Abstract
Cardiogenic shock (CS) is a complex multifactorial clinical syndrome, developing as a continuum, and progressing from the initial insult (underlying cause) to the subsequent occurrence of organ failure and death. There is a large phenotypic variability in CS, as a result of the diverse aetiologies, pathogenetic mechanisms, haemodynamics, and stages of severity. Although early revascularization remains the most important intervention for CS in settings of acute myocardial infarction, the administration of timely and effective antithrombotic therapy is critical to improving outcomes in these patients. In addition, other clinical settings or non-acute myocardial infarction aetiologies, associated with high thrombotic risk, may require specific regimens of short-term or long-term antithrombotic therapy. In CS, altered tissue perfusion, inflammation, and multi-organ dysfunction induce unpredictable alterations to antithrombotic drugs' pharmacokinetics and pharmacodynamics. Other interventions used in the management of CS, such as mechanical circulatory support, renal replacement therapies, or targeted temperature management, influence both thrombotic and bleeding risks and may require specific antithrombotic strategies. In order to optimize safety and efficacy of these therapies in CS, antithrombotic management should be more adapted to CS clinical scenario or specific device, with individualized antithrombotic regimens in terms of type of treatment, dose, and duration. In addition, patients with CS require a close and appropriate monitoring of antithrombotic therapies to safely balance the increased risk of bleeding and thrombosis.
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Affiliation(s)
- Razvan I. Radu
- ICCU DepartmentEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C.C. Iliescu’BucharestRomania
| | - Tuvia Ben Gal
- Department of Cardiology, Rabin Medical Center (Beilinson Campus), Sackler Faculty of MedicineTel Aviv UniversityTel AvivIsrael
| | - Magdy Abdelhamid
- Cardiology Department, Kasr Alainy School of MedicineCairo UniversityCairoEgypt
| | - Elena‐Laura Antohi
- ICCU DepartmentEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C.C. Iliescu’BucharestRomania
- University for Medicine and Pharmacy ‘Carol Davila’ BucharestBucharestRomania
| | - Marianna Adamo
- Cardiothoracic Department, Civil Hospitals and Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - Andrew P. Ambrosy
- Department of CardiologyKaiser Permanente San Francisco Medical CenterSan FranciscoCAUSA
- Division of Research, Kaiser Permanente Northern CaliforniaOaklandCAUSA
| | - Oliviana Geavlete
- ICCU DepartmentEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C.C. Iliescu’BucharestRomania
- University for Medicine and Pharmacy ‘Carol Davila’ BucharestBucharestRomania
| | - Yuri Lopatin
- Cardiology CentreVolgograd Medical UniversityVolgogradRussian Federation
| | - Alexander Lyon
- Cardio‐Oncology ServiceRoyal Brompton Hospital and Imperial College LondonLondonUK
| | - Oscar Miro
- Emergency Department, Hospital Clínic de BarcelonaUniversity of BarcelonaBarcelonaSpain
| | - Marco Metra
- Cardiology, Cardiothoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - John Parissis
- Second Department of Cardiology, Attikon University HospitalNational and Kapodistrian University of AthensAthensGreece
| | - Sean P. Collins
- Department of Emergency Medicine; Vanderbilt University Medical CentreNashvilleTNUSA
| | - Stefan D. Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site BerlinCharité—Universitätsmedizin BerlinBerlinGermany
| | - Ovidiu Chioncel
- ICCU DepartmentEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C.C. Iliescu’BucharestRomania
- University for Medicine and Pharmacy ‘Carol Davila’ BucharestBucharestRomania
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30
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Patlolla SH, Sundaragiri PR, Cheungpasitporn W, Doshi R, Vallabhajosyula S. Impact of concomitant respiratory infections in the management and outcomes acute myocardial infarction-cardiogenic shock. Indian Heart J 2021; 73:565-571. [PMID: 34627570 PMCID: PMC8514410 DOI: 10.1016/j.ihj.2021.07.004] [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: 02/24/2021] [Revised: 06/26/2021] [Accepted: 07/13/2021] [Indexed: 11/02/2022] Open
Abstract
OBJECTIVE To evaluate the prevalence and impact of respiratory infections in cardiogenic shock complicating acute myocardial infarction (AMI-CS). METHODS Using the National Inpatient Sample (2000-2017), this study identified adult (≥18 years) admitted with AMI-CS complicated by respiratory infections. Outcomes of interest included in-hospital mortality of AMI-CS admissions with and without respiratory infections, hospitalization costs, hospital length of stay, and discharge disposition. Temporal trends of prevalence, in-hospital mortality and cardiac procedures were evaluated. RESULTS Among 557,974 AMI-CS admissions, concomitant respiratory infections were identified in 84,684 (15.2%). Temporal trends revealed a relatively stable trend in prevalence of respiratory infections over the 18-year period. Admissions with respiratory infections were on average older, less likely to be female, with greater comorbidity, had significantly higher rates of NSTEMI presentation, and acute non-cardiac organ failure compared to those without respiratory infections (all p < 0.001). These admissions received lower rates of coronary angiography (66.8% vs 69.4%, p < 0.001) and percutaneous coronary interventions (44.8% vs 49.5%, p < 0.001), with higher rates of mechanical circulatory support, pulmonary artery catheterization, and invasive mechanical ventilation compared to AMI-CS admissions without respiratory infections (all p < 0.001). The in-hospital mortality was lower among AMI-CS admissions with respiratory infections (31.6% vs 38.4%, adjusted OR 0.58 [95% CI 0.57-0.59], p < 0.001). Admissions with respiratory infections had longer lengths of hospital stay (127-20 vs 63-11 days, p < 0.001), higher hospitalization costs and less frequent discharges to home (27.1% vs 44.7%, p < 0.001). CONCLUSIONS Respiratory infections in AMI-CS admissions were associated with higher resource utilization but lower in-hospital mortality.
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Affiliation(s)
| | | | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rajkumar Doshi
- Department of Medicine, University of Nevada School of Medicine, Reno, NV, USA
| | - Saraschandra Vallabhajosyula
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
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Zimmermann GS, Palm J, Lahmann AL, Peltz F, Okrojek R, Weis F, Müller A, Ziegler T, Steger A, Haller B, Hoppmann P, Laugwitz KL, Hautmann H. Early Bronchoscopy Improves Extubation Rates after Out-of-Hospital Cardiac Arrest: A Retrospective Cohort Analysis. J Clin Med 2021; 10:jcm10143055. [PMID: 34300221 PMCID: PMC8306153 DOI: 10.3390/jcm10143055] [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: 06/15/2021] [Revised: 07/05/2021] [Accepted: 07/08/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Patients suffering from out-of-hospital cardiac arrest (OHCA) frequently receive a bronchoscopy after being admitted to the ICU. We investigated the optimal timing and the outcome in these patients. METHODS All patients who suffered from OHCA and were treated in our ICU from January 2013 to December 2018 were retrospectively analyzed. The data were collected from the patients' medical files, and included duration of mechanical ventilation, antibiotics, microbiological test results and neurological outcome. The outcome was the effect of early bronchoscopy (≤48 h after administration) on the rate of intubated patients on day five and day seven. RESULTS From January 2013 to December 2018, 190 patients were admitted with OHCA. Bronchoscopy was performed in 111 patients out of the 164 patients who survived the first day. Late bronchoscopy >48 h was associated with higher rates of intubation on day five (OR 4.94; 95% CI 1.2-36.72, 86.7% vs. 55.0%, p = 0.036) and day seven (OR 4.96; 95% CI 1.38-24.69; 80.0% vs. 43.3%, p = 0.019). CONCLUSION This study shows that patients who suffered from OHCA might have a better outcome if they receive a bronchoscopy early after hospital admission. Our data suggests an association of early bronchoscopy with a shorter intubation period.
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Affiliation(s)
- Gregor S. Zimmermann
- Department of Internal Medicine I, School of Medicine & Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (J.P.); (F.P.); (R.O.); (F.W.); (A.M.); (T.Z.); (A.S.); (P.H.); (K.-L.L.); (H.H.)
- Correspondence:
| | - Jana Palm
- Department of Internal Medicine I, School of Medicine & Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (J.P.); (F.P.); (R.O.); (F.W.); (A.M.); (T.Z.); (A.S.); (P.H.); (K.-L.L.); (H.H.)
| | - Anna Lena Lahmann
- Department of Cardiology, German Heart Center Munich, Technical University of Munich, 80636 Munich, Germany;
| | - Friedhelm Peltz
- Department of Internal Medicine I, School of Medicine & Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (J.P.); (F.P.); (R.O.); (F.W.); (A.M.); (T.Z.); (A.S.); (P.H.); (K.-L.L.); (H.H.)
| | - Rainer Okrojek
- Department of Internal Medicine I, School of Medicine & Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (J.P.); (F.P.); (R.O.); (F.W.); (A.M.); (T.Z.); (A.S.); (P.H.); (K.-L.L.); (H.H.)
| | - Florian Weis
- Department of Internal Medicine I, School of Medicine & Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (J.P.); (F.P.); (R.O.); (F.W.); (A.M.); (T.Z.); (A.S.); (P.H.); (K.-L.L.); (H.H.)
| | - Arne Müller
- Department of Internal Medicine I, School of Medicine & Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (J.P.); (F.P.); (R.O.); (F.W.); (A.M.); (T.Z.); (A.S.); (P.H.); (K.-L.L.); (H.H.)
| | - Tilman Ziegler
- Department of Internal Medicine I, School of Medicine & Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (J.P.); (F.P.); (R.O.); (F.W.); (A.M.); (T.Z.); (A.S.); (P.H.); (K.-L.L.); (H.H.)
| | - Alexander Steger
- Department of Internal Medicine I, School of Medicine & Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (J.P.); (F.P.); (R.O.); (F.W.); (A.M.); (T.Z.); (A.S.); (P.H.); (K.-L.L.); (H.H.)
| | - Bernhard Haller
- Institute of Medical Informatics, Statistics and Epidemiology, Technical University of Munich, 81675 Munich, Germany;
| | - Petra Hoppmann
- Department of Internal Medicine I, School of Medicine & Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (J.P.); (F.P.); (R.O.); (F.W.); (A.M.); (T.Z.); (A.S.); (P.H.); (K.-L.L.); (H.H.)
| | - Karl-Ludwig Laugwitz
- Department of Internal Medicine I, School of Medicine & Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (J.P.); (F.P.); (R.O.); (F.W.); (A.M.); (T.Z.); (A.S.); (P.H.); (K.-L.L.); (H.H.)
| | - Hubert Hautmann
- Department of Internal Medicine I, School of Medicine & Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (J.P.); (F.P.); (R.O.); (F.W.); (A.M.); (T.Z.); (A.S.); (P.H.); (K.-L.L.); (H.H.)
- Department of Internal Medicine, Klinik Ottobeuren, 87724 Ottobeuren, Germany
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. Postreanimationsbehandlung. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00892-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Wang W, Li R, Miao W, Evans C, Lu L, Lyu J, Li X, Warner DS, Zhong X, Hoffmann U, Sheng H, Yang W. Development and Evaluation of a Novel Mouse Model of Asphyxial Cardiac Arrest Revealed Severely Impaired Lymphopoiesis After Resuscitation. J Am Heart Assoc 2021; 10:e019142. [PMID: 34013738 PMCID: PMC8483518 DOI: 10.1161/jaha.120.019142] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Animal disease models represent the cornerstone in basic cardiac arrest (CA) research. However, current experimental models of CA and resuscitation in mice are limited. In this study, we aimed to develop a mouse model of asphyxial CA followed by cardiopulmonary resuscitation (CPR), and to characterize the immune response after asphyxial CA/CPR. Methods and Results CA was induced in mice by switching from an O2/N2 mixture to 100% N2 gas for mechanical ventilation under anesthesia. Real-time measurements of blood pressure, brain tissue oxygen, cerebral blood flow, and ECG confirmed asphyxia and ensuing CA. After a defined CA period, mice were resuscitated with intravenous epinephrine administration and chest compression. We subjected young adult and aged mice to this model, and found that after CA/CPR, mice from both groups exhibited significant neurologic deficits compared with sham mice. Analysis of post-CA brain confirmed neuroinflammation. Detailed characterization of the post-CA immune response in the peripheral organs of both young adult and aged mice revealed that at the subacute phase following asphyxial CA/CPR, the immune system was markedly suppressed as manifested by drastic atrophy of the spleen and thymus, and profound lymphopenia. Finally, our data showed that post-CA systemic lymphopenia was accompanied with impaired T and B lymphopoiesis in the thymus and bone marrow, respectively. Conclusions In this study, we established a novel validated asphyxial CA model in mice. Using this new model, we further demonstrated that asphyxial CA/CPR markedly affects both the nervous and immune systems, and notably impairs lymphopoiesis of T and B cells.
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Affiliation(s)
- Wei Wang
- Department of Anesthesiology Center for Perioperative Organ Protection Duke University Medical Center Durham NC
| | - Ran Li
- Department of Anesthesiology Center for Perioperative Organ Protection Duke University Medical Center Durham NC
| | - Wanying Miao
- Department of Anesthesiology Center for Perioperative Organ Protection Duke University Medical Center Durham NC
| | - Cody Evans
- Department of Anesthesiology Center for Perioperative Organ Protection Duke University Medical Center Durham NC
| | - Liping Lu
- Department of Anesthesiology Center for Perioperative Organ Protection Duke University Medical Center Durham NC
| | - Jingjun Lyu
- Department of Anesthesiology Center for Perioperative Organ Protection Duke University Medical Center Durham NC
| | - Xuan Li
- Department of Anesthesiology Center for Perioperative Organ Protection Duke University Medical Center Durham NC
| | - David S Warner
- Department of Anesthesiology Center for Perioperative Organ Protection Duke University Medical Center Durham NC
| | - Xiaoping Zhong
- Department of Pediatrics Duke University Medical Center Durham NC
| | - Ulrike Hoffmann
- Department of Anesthesiology Center for Perioperative Organ Protection Duke University Medical Center Durham NC
| | - Huaxin Sheng
- Department of Anesthesiology Center for Perioperative Organ Protection Duke University Medical Center Durham NC
| | - Wei Yang
- Department of Anesthesiology Center for Perioperative Organ Protection Duke University Medical Center Durham NC
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Bacterial Pneumonia in Brain-Dead Patients: Clinical Features and Impact on Lung Suitability for Donation. Crit Care Med 2021; 48:1760-1770. [PMID: 33009101 DOI: 10.1097/ccm.0000000000004631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To appraise the epidemiological features of bacterial pneumonia and its impact on lung suitability for donation in brain-dead patients managed with protective ventilatory settings. DESIGN Retrospective observational study. SETTING Six ICUs from two university-affiliated hospitals. PATIENTS Brain-dead adult patients managed in the participating ICUs over a 4-year period. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among the 231 included patients, 145 (62.8%) were classified as ideal or extended-criteria potential lung donors at ICU admission and the remaining 86 patients having baseline contraindication for donation. Culture-proven aspiration pneumonia and early-onset ventilator-associated pneumonia occurred in 54 patients (23.4%) and 15 patients (6.5%), respectively (overall pneumonia incidence, 29.9%). Staphylococcus aureus and Enterobacterales were the most common pathogens. Using mixed-effects Cox proportional hazard models, age (adjusted hazard ratio, 0.98; 95% CI [0.96-0.99]), anoxic brain injury (3.55 [1.2-10.5]), aspiration (2.29 [1.22-4.29]), and not receiving antimicrobial agents at day 1 (3.56 [1.94-6.53]) were identified as independent predictors of pneumonia occurrence in the whole study population. Analyses restricted to potential lung donors yielded similar results. Pneumonia was associated with a postadmission decrease in the PaO2/FIO2 ratio and lower values at brain death, in the whole study population (estimated marginal mean, 294 [264-323] vs 365 [346-385] mm Hg in uninfected patients; p = 0.0005) as in potential lung donors (299 [248-350] vs 379 [350-408] mm Hg; p = 0.04; linear mixed models). Lungs were eventually retrieved in 31 patients (34.4%) among the 90 potential lung donors with at least one other organ harvested (pneumonia prevalence in lung donors (9.7%) vs nondonors (49.2%); p = 0.0002). CONCLUSIONS Pneumonia occurs in one-third of brain-dead patients and appears as the main reason for lung nonharvesting in those presenting as potential lung donors. The initiation of antimicrobial prophylaxis upon the first day of the ICU stay in comatose patients with severe brain injury could enlarge the pool of actual lung donors.
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care. Intensive Care Med 2021; 47:369-421. [PMID: 33765189 PMCID: PMC7993077 DOI: 10.1007/s00134-021-06368-4] [Citation(s) in RCA: 417] [Impact Index Per Article: 139.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/08/2021] [Indexed: 12/13/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation and organ donation.
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Affiliation(s)
- Jerry P. Nolan
- University of Warwick, Warwick Medical School, Coventry, CV4 7AL UK
- Royal United Hospital, Bath, BA1 3NG UK
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
- Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W. Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC), Université Catholique de Louvain, Brussels, Belgium
- Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Division of Health Sciences, Warwick Medical School, University of Warwick, Room A108, Coventry, CV4 7AL UK
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Véronique R. M. Moulaert
- Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Markus B. Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB UK
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Mariero Olasveengen T, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care. Resuscitation 2021; 161:220-269. [PMID: 33773827 DOI: 10.1016/j.resuscitation.2021.02.012] [Citation(s) in RCA: 337] [Impact Index Per Article: 112.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation, and organ donation.
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Affiliation(s)
- Jerry P Nolan
- University of Warwick, Warwick Medical School, Coventry CV4 7AL, UK; Royal United Hospital, Bath, BA1 3NG, UK.
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy; Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W Böttiger
- University Hospital of Cologne, Kerpener Straße 62, D-50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC) Université Catholique de Louvain, Brussels, Belgium; Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Room A108, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Gisela Lilja
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden
| | - Véronique R M Moulaert
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB, UK
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Latif RK, Clifford SP, Byrne KR, Maggard B, Chowhan Y, Saleem J, Huang J. Hyperoxia After Return of Spontaneous Circulation in Cardiac Arrest Patients. J Cardiothorac Vasc Anesth 2021; 36:1419-1428. [PMID: 33875350 DOI: 10.1053/j.jvca.2021.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/10/2021] [Accepted: 03/03/2021] [Indexed: 11/11/2022]
Abstract
Current guidelines emphasize the use of 100% oxygen during cardiopulmonary resuscitation after cardiac arrest. When patients are ventilated for variable periods after return of spontaneous circulation (ROSC), hyperoxia causes increased morbidity and mortality by overproduction of reactive oxygen species. Various patient, volunteer, and animal studies have shown the harmful effects of hyperoxia. This mini-review article aims to expand the potential clinical spectrum of hyperoxia on individual organ systems leading to organ dysfunction. A framework to achieve and maintain normoxia after ROSC is proposed. Despite the harmful considerations of hyperoxia in critically ill patients, additional safety studies including dose-effect, level and onset of the reactive oxygen species effect, and safe hyperoxia applicability period after ROSC, need to be performed in various animal and human models to further elucidate the role of oxygen therapy after cardiac arrest.
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Affiliation(s)
- Rana K Latif
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY; Paris Simulation Center, Office of Medical Education, University of Louisville School of Medicine, Louisville, KY; Outcomes Research Consortium, Cleveland, OH.
| | - Sean P Clifford
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY
| | - Keith R Byrne
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY
| | - Brittany Maggard
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY
| | - Yaruk Chowhan
- Xavier University School of Medicine, Oranjestad, Aruba
| | - Jawad Saleem
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY
| | - Jiapeng Huang
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY; Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY
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Chiu WT, Lin KC, Tsai MS, Hsu CH, Wang CH, Kuo LK, Chien YS, Wu CH, Lai CH, Huang WC, Wang CH, Wang TL, Hsu HH, Lin JJ, Hwang JJ, Ng CJ, Choi WM, Huang CH. Post-cardiac arrest care and targeted temperature management: A consensus of scientific statement from the Taiwan Society of Emergency & Critical Care Medicine, Taiwan Society of Critical Care Medicine and Taiwan Society of Emergency Medicine. J Formos Med Assoc 2021; 120:569-587. [PMID: 32829996 DOI: 10.1016/j.jfma.2020.07.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 06/07/2020] [Accepted: 07/26/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Post-cardiac arrest care is critically important in bringing cardiac arrest patients to functional recovery after the detrimental event. More high quality studies are published and evidence is accumulated for the post-cardiac arrest care in the recent years. It is still a challenge for the clinicians to integrate these scientific data into the real clinical practice for such a complicated intensive care involving many different disciplines. METHODS With the cooperation of the experienced experts from all disciplines relevant to post-cardiac arrest care, the consensus of the scientific statement was generated and supported by three major scientific groups for emergency and critical care in post-cardiac arrest care. RESULTS High quality post-cardiac arrest care, including targeted temperature management, early evaluation of possible acute coronary event and intensive care for hemodynamic and respiratory care are inevitably needed to get full recovery for cardiac arrest. Management of these critical issues were reviewed and proposed in the consensus CONCLUSION: The goal of the statement is to provide help for the clinical physician to achieve better quality and evidence-based care in post-cardiac arrest period.
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Affiliation(s)
- Wei-Ting Chiu
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taiwan; Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan, ROC
| | - Kun-Chang Lin
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Min-Shan Tsai
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Chih-Hsin Hsu
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital Dou Liou Branch, College of Medicine, National Cheng Kung University, Taiwan
| | - Chen-Hsu Wang
- Attending Physician, Coronary Care Unit, Cardiovascular Center, Cathay General Hospital, Taipei, Taiwan
| | - Li-Kuo Kuo
- Department of Critical Care Medicine, MacKay Memorial Hospital, Taipei Branch, Taiwan; Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
| | - Yu-San Chien
- Department of Critical Care Medicine, MacKay Memorial Hospital, Taipei Branch, Taiwan
| | - Cheng-Hsueh Wu
- Department of Critical Care Medicine, Taipei Veterans General Hospital, National Yang-Ming University, Taipei, Taiwan
| | - Chih-Hung Lai
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan; Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Chun Huang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan
| | - Chih-Hsien Wang
- Cardiovascular Surgery, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Tzong-Luen Wang
- Chang Bing Show Chwang Memorial Hospital, Changhua, Taiwan; School of Medicine and Law, Fu-Jen Catholic University, New Taipei City, Taiwan
| | - Hsin-Hui Hsu
- Department of Critical Care Medicine, Changhua Christian Hospital, Taiwan
| | - Jen-Jyh Lin
- Division of Cardiology, Department of Medicine, China Medical University Hospital, Taichung, Taiwan; Department of Respiratory Therapy, China Medical University, Taichung, Taiwan, ROC
| | - Juey-Jen Hwang
- Cardiovascular Division, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taiwan
| | - Chip-Jin Ng
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou and Chang Gung University College of Medicine, Tao-Yuan, Taiwan
| | - Wai-Mau Choi
- Department of Emergency Medicine, Hsinchu MacKay Memorial Hospital, Taiwan
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan; Cardiovascular Division, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taiwan.
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Mecklenburg A, Stamm J, Angriman F, Del Sorbo L, Fan E, Soeffker G, Bernhardt A, Reichenspurner H, Schrage B, Westermann D, Braune S, Kluge S. Impact of therapeutic hypothermia on bleeding events in adult patients treated with extracorporeal life support peri-cardiac arrest. J Crit Care 2020; 62:12-18. [PMID: 33227591 DOI: 10.1016/j.jcrc.2020.11.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 11/04/2020] [Accepted: 11/12/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Whether therapeutic hypothermia (TH) adds to the risk of bleeding in patients on extracorporeal life support (ECLS) peri-cardiac arrest remains unknown. MATERIAL AND METHODS Single center retrospective study on patients receiving veno-arterial ECLS peri-cardiac arrest ± TH at 32-34 °C (January 2009-December 2015). PRIMARY OUTCOME major bleeding (including intracerebral hemorrhage, ICH) < 72 h of cardiac arrest. Logistic regression and marginal structural models were used to analyze associations with major bleeding. RESULTS Of 66 patients receiving ECLS, 36 were treated with TH. Major bleeding occurred in 14 patients (39%) treated with ECLS+TH and in 17 patients (57%) with ECLS alone. ICH was reported in 3 (8%) and one patient (3%), respectively. There was no difference in mortality, but lung injury occurred more often in ECLS+TH. A platelet count <60 × 109/L but not TH was associated with major bleeding (including ICH). The estimated causal risk ratio of TH on the occurrence of major bleeding (including ICH) at 72 h post cardiac arrest was 0.95 (95%CI 0.62-1.45). CONCLUSIONS Bleeding complications were common in our study. However, TH (32-34 °C) was not associated with an increased risk of major bleeding in patients on ECLS peri-cardiac arrest.
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Affiliation(s)
- Anne Mecklenburg
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany; Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, 585 University Avenue, Toronto, ON M5G 2N2, Canada.
| | - Johannes Stamm
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Federico Angriman
- Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, 585 University Avenue, Toronto, ON M5G 2N2, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, 585 University Avenue, Toronto, ON M5G 2N2, Canada
| | - Gerold Soeffker
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Alexander Bernhardt
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany
| | - Herrmann Reichenspurner
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany
| | - Benedikt Schrage
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany
| | - Dirk Westermann
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany
| | - Stephan Braune
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
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Soar J, Berg KM, Andersen LW, Böttiger BW, Cacciola S, Callaway CW, Couper K, Cronberg T, D'Arrigo S, Deakin CD, Donnino MW, Drennan IR, Granfeldt A, Hoedemaekers CWE, Holmberg MJ, Hsu CH, Kamps M, Musiol S, Nation KJ, Neumar RW, Nicholson T, O'Neil BJ, Otto Q, de Paiva EF, Parr MJA, Reynolds JC, Sandroni C, Scholefield BR, Skrifvars MB, Wang TL, Wetsch WA, Yeung J, Morley PT, Morrison LJ, Welsford M, Hazinski MF, Nolan JP. Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2020; 156:A80-A119. [PMID: 33099419 PMCID: PMC7576326 DOI: 10.1016/j.resuscitation.2020.09.012] [Citation(s) in RCA: 129] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations for advanced life support includes updates on multiple advanced life support topics addressed with 3 different types of reviews. Topics were prioritized on the basis of both recent interest within the resuscitation community and the amount of new evidence available since any previous review. Systematic reviews addressed higher-priority topics, and included double-sequential defibrillation, intravenous versus intraosseous route for drug administration during cardiac arrest, point-of-care echocardiography for intra-arrest prognostication, cardiac arrest caused by pulmonary embolism, postresuscitation oxygenation and ventilation, prophylactic antibiotics after resuscitation, postresuscitation seizure prophylaxis and treatment, and neuroprognostication. New or updated treatment recommendations on these topics are presented. Scoping reviews were conducted for anticipatory charging and monitoring of physiological parameters during cardiopulmonary resuscitation. Topics for which systematic reviews and new Consensuses on Science With Treatment Recommendations were completed since 2015 are also summarized here. All remaining topics reviewed were addressed with evidence updates to identify any new evidence and to help determine which topics should be the highest priority for systematic reviews in the next 1 to 2 years.
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Abstract
OBJECTIVES To determine the association between targeted temperature management goal temperature of 33°C versus 36°C and neurologic outcome after out-of-hospital cardiac arrest. DESIGN This was a retrospective, before-and-after, cohort study. SETTING Urban, academic, level 1 trauma center from 2010 to 2017. PATIENTS Adults with nontraumatic out-of-hospital cardiac arrest who received targeted temperature management. INTERVENTIONS Our primary exposure was targeted temperature management goal temperature, which was changed from 33°C to 36°C in April of 2014 at the study hospital. Primary outcome was neurologically intact survival to discharge. Secondary outcomes included hospital mortality and care processes. MEASUREMENTS AND MAIN RESULTS Of 782 out-of-hospital cardiac arrest patients transported to the study hospital, 453 (58%) received targeted temperature management. Of these, 258 (57%) were treated during the 33°C period (targeted temperature management 33°C) and 195 (43%) were treated during the 36°C period (targeted temperature management 36°C). Patients treated during targeted temperature management 33°C were older (57 vs 52 yr; p < 0.05) and had more arrests of cardiac etiology (45% vs 35%; p < 0.05), but otherwise had similar baseline characteristics, including initial cardiac rhythm. A total of 40% of patients treated during targeted temperature management 33°C survived with favorable neurologic outcome, compared with 30% in the targeted temperature management 36°C group (p < 0.05). After adjustment for demographic and cardiac arrest characteristics, targeted temperature management 33°C was associated with increased odds of neurologically intact survival to discharge (odds ratio, 1.79; 95% CI, 1.09-2.94). Targeted temperature management 33°C was not associated with significantly improved hospital mortality. Targeted temperature management was implemented faster (1.9 vs 3.5 hr from 911 call; p < 0.001) and more frequently in the emergency department during the targeted temperature management 33°C period (87% vs 55%; p < 0.001). CONCLUSIONS Comatose, adult out-of-hospital cardiac arrest patients treated during the targeted temperature management 33°C period had higher odds of neurologically intact survival to hospital discharge compared with those treated during the targeted temperature management 36°C period. There was no significant difference in hospital mortality.
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42
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Berg KM, Soar J, Andersen LW, Böttiger BW, Cacciola S, Callaway CW, Couper K, Cronberg T, D’Arrigo S, Deakin CD, Donnino MW, Drennan IR, Granfeldt A, Hoedemaekers CW, Holmberg MJ, Hsu CH, Kamps M, Musiol S, Nation KJ, Neumar RW, Nicholson T, O’Neil BJ, Otto Q, de Paiva EF, Parr MJ, Reynolds JC, Sandroni C, Scholefield BR, Skrifvars MB, Wang TL, Wetsch WA, Yeung J, Morley PT, Morrison LJ, Welsford M, Hazinski MF, Nolan JP, Issa M, Kleinman ME, Ristagno G, Arafeh J, Benoit JL, Chase M, Fischberg BL, Flores GE, Link MS, Ornato JP, Perman SM, Sasson C, Zelop CM. Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2020; 142:S92-S139. [DOI: 10.1161/cir.0000000000000893] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
This
2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations
for advanced life support includes updates on multiple advanced life support topics addressed with 3 different types of reviews. Topics were prioritized on the basis of both recent interest within the resuscitation community and the amount of new evidence available since any previous review. Systematic reviews addressed higher-priority topics, and included double-sequential defibrillation, intravenous versus intraosseous route for drug administration during cardiac arrest, point-of-care echocardiography for intra-arrest prognostication, cardiac arrest caused by pulmonary embolism, postresuscitation oxygenation and ventilation, prophylactic antibiotics after resuscitation, postresuscitation seizure prophylaxis and treatment, and neuroprognostication. New or updated treatment recommendations on these topics are presented. Scoping reviews were conducted for anticipatory charging and monitoring of physiological parameters during cardiopulmonary resuscitation. Topics for which systematic reviews and new Consensuses on Science With Treatment Recommendations were completed since 2015 are also summarized here. All remaining topics reviewed were addressed with evidence updates to identify any new evidence and to help determine which topics should be the highest priority for systematic reviews in the next 1 to 2 years.
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43
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Muengtaweepongsa S, Puengcharoen S. Infections in out-of-hospital and in-hospital post-cardiac arrest patients: comment. Intern Emerg Med 2020; 15:1349-1350. [PMID: 32424635 DOI: 10.1007/s11739-020-02367-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 05/04/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Sombat Muengtaweepongsa
- Center of Excellence in Stroke, Faculty of Medicine, Thammasat University, Paholyothin Rd., Pathum Thani, 12120, Thailand.
| | - Sirinat Puengcharoen
- Center of Excellence in Stroke, Faculty of Medicine, Thammasat University, Paholyothin Rd., Pathum Thani, 12120, Thailand
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Nolan JP, Soar J, Cary N, Cooper N, Crane J, Fegan-Earl A, Lawler W, Lumb P, Rutty G. Compression asphyxia and other clinicopathological findings from the Hillsborough Stadium disaster. Emerg Med J 2020; 38:798-802. [PMID: 32883753 DOI: 10.1136/emermed-2020-209627] [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: 03/15/2020] [Revised: 07/01/2020] [Accepted: 07/04/2020] [Indexed: 11/04/2022]
Abstract
Ninety-six people died following a crowd crush at the Hillsborough Football Stadium, Sheffield, UK in 1989. The cause of death in nearly all cases was compression asphyxia. The clinical and pathological features of deaths encountered in crowds are discussed with a particular focus on the Hillsborough disaster.
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Affiliation(s)
- Jerry P Nolan
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK
| | - Nathaniel Cary
- Forensic Pathology Services, Unit 12, The Quadrangle, Wantage, UK
| | - Nigel Cooper
- Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Jack Crane
- Institute of Forensic Medicine, Queen's University Belfast, Belfast, UK
| | | | | | - Philip Lumb
- Pathology, Royal Oldham Hospital, Oldham, UK
| | - Guy Rutty
- East Midlands Forensic Pathology Unit, University of Leicester, Leicester, UK
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The Clinical Usefulness of Targeted Temperature Management in Acute Ischemic Stroke with Malignant Trait After Endovascular Thrombectomy. Neurocrit Care 2020; 34:990-999. [PMID: 32812197 DOI: 10.1007/s12028-020-01069-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 07/27/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND/OBJECTIVE Targeted temperature management (TTM) may be more beneficial after endovascular treatment (EVT) in patients with a large ischemic core. Therefore, we assessed the usefulness of TTM for such patients from a multicenter endovascular registry. METHODS Anterior circulation stroke patients who underwent endovascular recanalization were included; acute ischemic stroke with malignant traits was designated as (1) baseline Alberta Stroke Program Early CT Score (ASPECTS) below 6 and (2) diffusion-weighted imaging (DWI) lesion volume measurement (> 82 ml) or National Institutes of Health Stroke Scale score > 20 and item Ia > 0. TTM (34.5 °C) was maintained for at least 48 h. RESULTS We evaluated baseline demographics, risk factors, EVT parameters, and clinical outcomes between the TTM and non-TTM groups. Among the 548 patients, the TTM group (n = 91) significantly had a lower baseline ASPECTS (p < 0.001) and a higher DWI volume (p < 0.001) than the non-TTM group (n = 457). TTM group had a lower prevalence of favorable outcome (0-2 of modified Rankin Scale at 3 months; p = 0.008) than the non-TTM group. In a subgroup analysis of malignant trait patients (n = 80), TTM patients (n = 28) had more favorable outcome (32.1% vs. 7.7% p = 0.009) and less hemorrhagic transformation (none vs. any hemorrhage, p = 0.007) than non-TTM patients (n = 52). After adjusting for potential outcome predictors, TTM (odds ratio [OR] 4.63; confidence interval [CI] 1.20-17.89; p = 0.026) and hypertension (OR 0.18; CI 0.04-0.74; p = 0.018) were found to be independent determinants. CONCLUSIONS Our data suggest that TTM attenuates impending hemorrhagic transformation and leads to favorable clinical outcomes in EVT patients with malignant trait.
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46
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Baekgaard JS, Triba MN, Brandeis M, Steinmetz J, Cohen Y, Gorlicki J, Rasmussen LS, Deltour S, Lapostolle F, Adnet F. Early-onset pneumonia following bag-mask ventilation versus endotracheal intubation during cardiopulmonary resuscitation: A substudy of the CAAM trial. Resuscitation 2020; 154:12-18. [PMID: 32629091 DOI: 10.1016/j.resuscitation.2020.06.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 05/29/2020] [Accepted: 06/06/2020] [Indexed: 11/19/2022]
Abstract
AIM Early-onset pneumonia (EOP) is a common in-hospital complication in survivors of out-of-hospital cardiac arrest. In this substudy of the CAAM trial, we aimed to compare whether bag mask ventilation (BMV) compared to endotracheal intubation (ETI) performed during cardiopulmonary resuscitation increases the risk of developing EOP. METHODS Adult patients from the CAAM trial that survived beyond 12 h of hospitalization were included. Information about in-hospital management and outcome of study subjects was systematically collected. Our primary aim was to compare the incidence of EOP in the BMV and ETI group using a series of bivariate analysis adjusting for one variable at a time and a logistic regression controlled for survival beyond 96 h, age, gender, catecholamine administration, no flow time, and initial shockable rhythm. RESULTS Of 627 patients from the CAAM trial that survived to hospital admission, 409 patients were hospitalized beyond 12 h and thus included (202 randomized to BMV and 20 7 randomized to ETI). Patients in the BMV group had a significantly longer period of unsecured airway during prehospital cardiopulmonary resuscitation (BMV (median): 33 min; ETI (median): 17 min, p < 0.0001). No significant difference in the development of EOP according to airway management was identified on univariate analysis (BMV: 53%, ETI: 53%, Odds Ratio 1.0 [0.7-1.5], p = 1.0). We found no difference in the development of EOP according to airway management in the series of bivariate analyses or in the multivariable regression analysis either. CONCLUSION In this substudy of the CAAM trial, development of early-onset pneumonia in out-of-hospital cardiac arrest survivors did not depend on airway management technique during CPR.
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Affiliation(s)
- Josefine S Baekgaard
- Department of Anesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Denmark; Urgences et Samu 93, AP-HP, Hôpital Avicenne, Inserm U942, 93000 Bobigny, France.
| | - Mohamed N Triba
- Sorbonne Paris Cité, Equipe Nanomédecine Biomarqueurs Détection, Laboratoire de Chimie, Structures et Propriétés de Biomateriaux et d'Agents Therapeutiques, UMR CNRS 7244, University Paris 13 Bobigny, France
| | | | - Jacob Steinmetz
- Department of Anesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Denmark
| | - Yves Cohen
- Intensive Care Unit, AP-HP, Hôpital Avicenne, Inserm U942, 93000 Bobigny, France
| | - Judith Gorlicki
- Urgences et Samu 93, AP-HP, Hôpital Avicenne, Inserm U942, 93000 Bobigny, France
| | - Lars S Rasmussen
- Department of Anesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Denmark
| | - Sandrine Deltour
- Urgences et Samu 93, AP-HP, Hôpital Avicenne, Inserm U942, 93000 Bobigny, France
| | - Frédéric Lapostolle
- Urgences et Samu 93, AP-HP, Hôpital Avicenne, Inserm U942, 93000 Bobigny, France
| | - Frédéric Adnet
- Urgences et Samu 93, AP-HP, Hôpital Avicenne, Inserm U942, 93000 Bobigny, France
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Mortensen SJ, Hurley M, Blewett L, Uber A, Yassa D, MacDonald M, Patel P, Chase M, Holmberg MJ, Grossestreuer AV, Donnino MW, Cocchi MN. Infections in out-of-hospital and in-hospital post-cardiac arrest patients. Intern Emerg Med 2020; 15:701-709. [PMID: 32052366 DOI: 10.1007/s11739-020-02286-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 01/24/2020] [Indexed: 11/30/2022]
Abstract
This study aims to describe infectious complications in both out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) patients with sustained return of spontaneous circulation (ROSC) and to compare differences in antimicrobial treatment and outcomes between the two groups. This was a retrospective, single-center, observational study. Adult patients (≥ 18 years) with OHCA or IHCA who had sustained ROSC between December 2007 to March 2015 were included. Blood, urine, sputum, and other fluid cultures, as well as radiologic imaging, were obtained at the discretion of the treating clinical teams. 275 IHCA and 318 OHCA patients were included in the analysis. We found evidence of infection in 181 IHCA and 168 OHCA patients. Significant differences were found between the IHCA and OHCA group in terms of initial rhythm, duration of arrest (10 min vs. 20, p = < 0.001), targeted temperature management (30% vs. 73%, p = < 0.001), and post-arrest infection rates (66% vs 53%, p = 0.001). 95% of IHCA and 82% of OHCA patients received antimicrobial treatment in the post-cardiac arrest period. The source of infection in both groups was largely respiratory, followed by urinary. Gram-positive cocci and gram-negative rods were the most common organisms identified among subjects with culture-proven bacteremia. Infections in the post-arrest period were common in both OHCA and IHCA. We found significantly more infections in IHCA compared to OHCA patients. The most common infection category was respiratory and the most common organism isolated from sputum cultures was Staphylococcus aureus coagulase-positive. The incidence of culture-positive bacteremia was similar in both OHCA and IHCA cohorts but overall lower than previously reported.
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Affiliation(s)
- Sharri Junadi Mortensen
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA.
| | - Meredith Hurley
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
| | - Lauren Blewett
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
| | - Amy Uber
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
| | - David Yassa
- Division of Infectious Diseases, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Mary MacDonald
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
| | - Parth Patel
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
| | - Maureen Chase
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Mathias Johan Holmberg
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
- Department of Clinical Medicine, Research Center for Emergency Medicine, Aarhus University Hospital, Århus, Denmark
| | | | - Michael William Donnino
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
- Division of Pulmonary Critical Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Michael Noel Cocchi
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Division of Critical Care, Department of Anesthesia Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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48
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Affiliation(s)
| | - Pierre Fillatre
- Centre Hospitalier Universitaire de Saint-Brieuc, Saint-Brieuc, France
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49
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Sonnier M, Rittenberger JC. State-of-the-art considerations in post-arrest care. J Am Coll Emerg Physicians Open 2020; 1:107-116. [PMID: 33000021 PMCID: PMC7493544 DOI: 10.1002/emp2.12022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/14/2020] [Accepted: 01/16/2020] [Indexed: 11/10/2022] Open
Abstract
Cardiac arrest has a high rate of morbidity and mortality. Several advances in post-cardiac arrest management can improve outcome, but are time-dependent, placing the emergency physician in a critical role to both recognize the need for and initiate therapy. We present a novel perspective of both the workup and therapeutic interventions geared toward the emergency physician during the first few hours of care. We describe how the immediate care of a post-cardiac arrest patient is resource intensive and requires simultaneous evaluation for the underlying cause and intensive management to prevent further end organ damage, particularly of the central nervous system. The goal of the initial focused assessment is to rapidly determine if any reversible causes of cardiac arrest are present and to intervene when possible. Interventions performed in this acute period are aimed at preventing additional brain injury through optimizing hemodynamics, providing ventilatory support, and by using therapeutic hypothermia when indicated. After the initial phase of care, disposition is guided by available resources and the clinician's judgment. Transfer to a specialized cardiac arrest center is prudent in centers that do not have significant support or experience in the care of these patients.
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Affiliation(s)
| | - Jon C. Rittenberger
- Guthrie Robert Packer HospitalSayrePennsylvania
- Geisinger Commonwealth Medical CollegeScrantonPennsylvania
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50
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Harmon MBA, Hodiamont CJ, Dankiewicz J, Nielsen N, Schultz MJ, Horn J, Friberg H, Juffermans NP. Microbiological profile of nosocomial infections following cardiac arrest: Insights from the targeted temperature management (TTM) trial. Resuscitation 2020; 148:227-233. [PMID: 32032651 DOI: 10.1016/j.resuscitation.2019.11.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 11/06/2019] [Accepted: 11/06/2019] [Indexed: 02/02/2023]
Abstract
AIMS Infectious complications frequently occur in intensive care unit patients admitted after out-of-hospital cardiac arrest. There is debate on the effects of temperature management on the incidence of infections, as well as on the efficacy and choice of antibiotic prophylaxis. In this substudy of the targeted temperature management (TTM) trial, we describe the microbiological profile of infectious complications in patients with cardiac arrest and examined the impact of TTM at 33 °C compared to TTM at 36 °C. Furthermore we aimed to determine the association between antibiotic prophylaxis and the incidence of infections. METHODS This is a posthoc analysis of the TTM cohort. Microbiological data was retrospectively collected for the first 14-days of ICU-admission. Logistic regression was used to determine the relationship between antibiotic prophylaxis and pneumonia adjusted for mortality. RESULTS Of 696 patients included in this analysis, 158 (23%) developed pneumonia and 28 (4%) had bacteremia with a clinically relevant pathogen. Staphylococcus aureus was the most common pathogen isolated in patients with pneumonia (23%) and in patients with bacteremia (24%). Gram-negative pathogens were most common overall. TTM did not have an impact on the microbiological profile. The use of antibiotic prophylaxis was significantly associated with a reduced risk of infection (OR 0.59, 95%CI 0.43-0.79, p = 0.0005). This association remained significant after correcting for confounders (OR 0.64, 95%CI 0.46-0.90; p = 0.01). The association is not present in a model after correction for clustering within centers (aOR 0.55, 95%CI 0.20-1.47, p = 0.22). Adjustment for mortality did not influence the outcome. CONCLUSION Gram-negative pathogens are the most common causes of nosocomial infections following cardiac arrest. TTM does not impact the microbiological profile. It remains unclear whether patients in ICUs using antibiotic prophylaxis have a reduced risk of pneumonia and bacteremia that is unrelated to center effects.
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Affiliation(s)
- Matthew B A Harmon
- Department of Intensive Care, Academic Medical Centre, Amsterdam, The Netherlands; Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam, The Netherlands
| | - C J Hodiamont
- Department of Intensive Care, Academic Medical Centre, Amsterdam, The Netherlands; Department of Microbiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Josef Dankiewicz
- Department of Intensive and Perioperative Care, Skåne University Hospital, Lund, Sweden; Department of Clinical Sciences, Lund University, Getingevägen, 22185 Lund, Sweden
| | - Niklas Nielsen
- Department of Clinical Sciences, Lund University, Getingevägen, 22185 Lund, Sweden; Department of Anesthesiology and Intensive Care, Helsingborg Hospital, Helsingborg, Sweden
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Centre, Amsterdam, The Netherlands; Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam, The Netherlands; Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Janneke Horn
- Department of Intensive Care, Academic Medical Centre, Amsterdam, The Netherlands; Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam, The Netherlands
| | - Hans Friberg
- Department of Intensive and Perioperative Care, Skåne University Hospital, Lund, Sweden; Department of Clinical Sciences, Lund University, Getingevägen, 22185 Lund, Sweden
| | - Nicole P Juffermans
- Department of Intensive Care, Academic Medical Centre, Amsterdam, The Netherlands; Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam, The Netherlands.
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