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Chalifoux N, Ko T, Slovis J, Spelde A, Kilbaugh T, Mavroudis CD. Cerebral Autoregulation: A Target for Improving Neurological Outcomes in Extracorporeal Life Support. Neurocrit Care 2024:10.1007/s12028-024-02002-5. [PMID: 38811513 DOI: 10.1007/s12028-024-02002-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 04/18/2024] [Indexed: 05/31/2024]
Abstract
Despite improvements in survival after illnesses requiring extracorporeal life support, cerebral injury continues to hinder successful outcomes. Cerebral autoregulation (CA) is an innate protective mechanism that maintains constant cerebral blood flow in the face of varying systemic blood pressure. However, it is impaired in certain disease states and, potentially, following initiation of extracorporeal circulatory support. In this review, we first discuss patient-related factors pertaining to venovenous and venoarterial extracorporeal membrane oxygenation (ECMO) and their potential role in CA impairment. Next, we examine factors intrinsic to ECMO that may affect CA, such as cannulation, changes in pulsatility, the inflammatory and adaptive immune response, intracranial hemorrhage, and ischemic stroke, in addition to ECMO management factors, such as oxygenation, ventilation, flow rates, and blood pressure management. We highlight potential mechanisms that lead to disruption of CA in both pediatric and adult populations, the challenges of measuring CA in these patients, and potential associations with neurological outcome. Altogether, we discuss individualized CA monitoring as a potential target for improving neurological outcomes in extracorporeal life support.
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Affiliation(s)
- Nolan Chalifoux
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
- Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Tiffany Ko
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Julia Slovis
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Audrey Spelde
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Todd Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Constantine D Mavroudis
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
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Cheng P, Wang H, Guo L, Wang M, Xu H, Gu P, Wu J, Yang M. Survival and neurological function in patients treated with extracorporeal membrane oxygenation and therapeutic hypothermia: a protocol for updating a systematic review. BMJ Open 2024; 14:e081207. [PMID: 38531575 PMCID: PMC10966782 DOI: 10.1136/bmjopen-2023-081207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 03/08/2024] [Indexed: 03/28/2024] Open
Abstract
INTRODUCTION The widespread application of extracorporeal membrane oxygenation (ECMO) has enhanced clinical outcomes for patients experiencing cardiac arrest. However, its effectiveness is still limited and falls short of the desired level. Therapeutic hypothermia, which maintains body temperatures between 32°C and 36°C in cardiac arrest patients treated with ECMO, has been proposed as a potential means of neuroprotection and increased survival rates. Nevertheless, it remains controversial, and its impact on patient complications has yet to be fully understood. Thus, this paper aims to update the protocol for a systematic review of patients treated with ECMO and therapeutic hypothermia, in order to explore its effects on survival and neurological function. METHOD AND ANALYSIS This protocol has been developed in compliance with the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols 2015. The following databases will be systematically searched: PubMed, Web of Science, Cochrane Library, Embase, Ovid, CNKI, Wanfang and China Biology Medicine Disc. The database search strategy will use a combination of subject terms and free-text keywords. The search will encompass articles from the inception of each database up to 15 June 2023. Inclusion criteria encompass randomised controlled trials, cohort studies, case-control studies and quasi-experimental studies. Two researchers will independently review articles and extract relevant data based on these criteria. Any disagreements will be resolved through discussion. Data analysis will be performed using Review Manager software. ETHICS AND DISSEMINATION Since no patient data were collected in this study, ethical approval was not required. Research findings will be released in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42023435353.
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Affiliation(s)
- Pengfei Cheng
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Haizhen Wang
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Luyao Guo
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Meiling Wang
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - He Xu
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Peipei Gu
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jinjing Wu
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Minfei Yang
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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Kang JK, Darby Z, Bleck TP, Whitman GJR, Kim BS, Cho SM. Post-Cardiac Arrest Care in Adult Patients After Extracorporeal Cardiopulmonary Resuscitation. Crit Care Med 2024; 52:483-494. [PMID: 37921532 PMCID: PMC10922987 DOI: 10.1097/ccm.0000000000006102] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
OBJECTIVES Extracorporeal cardiopulmonary resuscitation (ECPR) serves as a lifesaving intervention for patients experiencing refractory cardiac arrest. With its expanding usage, there is a burgeoning focus on improving patient outcomes through optimal management in the acute phase after cannulation. This review explores systematic post-cardiac arrest management strategies, associated complications, and prognostication in ECPR patients. DATA SOURCES A PubMed search from inception to 2023 using search terms such as post-cardiac arrest care, ICU management, prognostication, and outcomes in adult ECPR patients was conducted. STUDY SELECTION Selection includes original research, review articles, and guidelines. DATA EXTRACTION Information from relevant publications was reviewed, consolidated, and formulated into a narrative review. DATA SYNTHESIS We found limited data and no established clinical guidelines for post-cardiac arrest care after ECPR. In contrast to non-ECPR patients where systematic post-cardiac arrest care is shown to improve the outcomes, there is no high-quality data on this topic after ECPR. This review outlines a systematic approach, albeit limited, for ECPR care, focusing on airway/breathing and circulation as well as critical aspects of ICU care, including analgesia/sedation, mechanical ventilation, early oxygen/C o2 , and temperature goals, nutrition, fluid, imaging, and neuromonitoring strategy. We summarize common on-extracorporeal membrane oxygenation complications and the complex nature of prognostication and withdrawal of life-sustaining therapy in ECPR. Given conflicting outcomes in ECPR randomized controlled trials focused on pre-cannulation care, a better understanding of hemodynamic, neurologic, and metabolic abnormalities and early management goals may be necessary to improve their outcomes. CONCLUSIONS Effective post-cardiac arrest care during the acute phase of ECPR is paramount in optimizing patient outcomes. However, a dearth of evidence to guide specific management strategies remains, indicating the necessity for future research in this field.
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Affiliation(s)
- Jin Kook Kang
- Division of Cardiac Surgery, Department of Surgery, Johns
Hopkins Hospital, Baltimore, MD
| | - Zachary Darby
- Division of Cardiac Surgery, Department of Surgery, Johns
Hopkins Hospital, Baltimore, MD
| | - Thomas P. Bleck
- Davee Department of Neurology, Northwestern University
Feinberg School of Medicine, Chicago IL 60611
| | - Glenn J. R. Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns
Hopkins Hospital, Baltimore, MD
| | - Bo Soo Kim
- Division of Cardiac Surgery, Department of Surgery, Johns
Hopkins Hospital, Baltimore, MD
- Division of Pulmonary and Critical Care Medicine, Johns
Hopkins Hospital, Baltimore, MD
| | - Sung-Min Cho
- Division of Cardiac Surgery, Department of Surgery, Johns
Hopkins Hospital, Baltimore, MD
- Division of Neurosciences Critical Care, Departments of
Neurology, Surgery, Anesthesiology and Critical Care Medicine, Johns Hopkins
Hospital, Baltimore, MD
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Kim JH, Kim JG, Kang GH, Jang YS, Kim W, Choi HY, Lee Y, Ahn C. Target Temperature Management Effect on the Clinical Outcome of Patients with Out-of-Hospital Cardiac Arrest Treated with Extracorporeal Cardiopulmonary Resuscitation: A Nationwide Observational Study. J Pers Med 2024; 14:185. [PMID: 38392618 PMCID: PMC10890305 DOI: 10.3390/jpm14020185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 01/28/2024] [Accepted: 02/05/2024] [Indexed: 02/24/2024] Open
Abstract
This study aimed to investigate whether targeted temperature management (TTM) could enhance outcomes in patients with out-of-hospital cardiac arrest (OHCA) treated with extracorporeal cardiopulmonary resuscitation (ECPR) for refractory cardiac arrest. Using a nationwide OHCA registry, adult patients with witnessed OHCA of presumed cardiac origin who underwent ECPR at the emergency department between 2008 and 2021 were included. We examined the effect of ECPR with TTM on survival and neurological outcomes at hospital discharge using propensity score matching and multivariable logistic regression compared with patients treated with ECPR without TTM. Odds ratios and 95% confidence intervals were determined. A total of 399 ECPR cases were analyzed among 380,239 patients with OHCA. Of these, 330 underwent ECPR without TTM and 69 with TTM. After propensity score matching, 69 matched pairs of patients were included in the analysis. No significant differences in survival and good neurological outcomes between the two groups were observed. In the multivariable logistic regression, no significant differences were observed in survival and neurological outcomes between ECPR with and without TTM. Among the patients who underwent ECPR after OHCA, ECPR with TTM did not improve outcomes compared with ECPR without TTM.
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Affiliation(s)
- Jae-Hee Kim
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1, Singil-ro, Yeongdeungpo-gu, Seoul 07441, Republic of Korea
| | - Jae-Guk Kim
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1, Singil-ro, Yeongdeungpo-gu, Seoul 07441, Republic of Korea
| | - Gu-Hyun Kang
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1, Singil-ro, Yeongdeungpo-gu, Seoul 07441, Republic of Korea
| | - Yong-Soo Jang
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1, Singil-ro, Yeongdeungpo-gu, Seoul 07441, Republic of Korea
| | - Wonhee Kim
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1, Singil-ro, Yeongdeungpo-gu, Seoul 07441, Republic of Korea
| | - Hyun-Young Choi
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1, Singil-ro, Yeongdeungpo-gu, Seoul 07441, Republic of Korea
| | - Yoonje Lee
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1, Singil-ro, Yeongdeungpo-gu, Seoul 07441, Republic of Korea
| | - Chiwon Ahn
- Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul 06974, Republic of Korea
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Taccone FS, Dankiewicz J, Cariou A, Lilja G, Asfar P, Belohlavek J, Boulain T, Colin G, Cronberg T, Frat JP, Friberg H, Grejs AM, Grillet G, Girardie P, Haenggi M, Hovdenes J, Jakobsen JC, Levin H, Merdji H, Njimi H, Pelosi P, Rylander C, Saxena M, Thomas M, Young PJ, Wise MP, Nielsen N, Lascarrou JB. Hypothermia vs Normothermia in Patients With Cardiac Arrest and Nonshockable Rhythm: A Meta-Analysis. JAMA Neurol 2024; 81:126-133. [PMID: 38109117 PMCID: PMC10728804 DOI: 10.1001/jamaneurol.2023.4820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 10/06/2023] [Indexed: 12/19/2023]
Abstract
Importance International guidelines recommend body temperature control below 37.8 °C in unconscious patients with out-of-hospital cardiac arrest (OHCA); however, a target temperature of 33 °C might lead to better outcomes when the initial rhythm is nonshockable. Objective To assess whether hypothermia at 33 °C increases survival and improves function when compared with controlled normothermia in unconscious adults resuscitated from OHCA with initial nonshockable rhythm. Data Sources Individual patient data meta-analysis of 2 multicenter, randomized clinical trials (Targeted Normothermia after Out-of-Hospital Cardiac Arrest [TTM2; NCT02908308] and HYPERION [NCT01994772]) with blinded outcome assessors. Unconscious patients with OHCA and an initial nonshockable rhythm were eligible for the final analysis. Study Selection The study cohorts had similar inclusion and exclusion criteria. Patients were randomized to hypothermia (target temperature 33 °C) or normothermia (target temperature 36.5 to 37.7 °C), according to different study protocols, for at least 24 hours. Additional analyses of mortality and unfavorable functional outcome were performed according to age, sex, initial rhythm, presence or absence of shock on admission, time to return of spontaneous circulation, lactate levels on admission, and the cardiac arrest hospital prognosis score. Data Extraction and Synthesis Only patients who experienced OHCA and had a nonshockable rhythm with all causes of cardiac arrest were included. Variables from the 2 studies were available from the original data sets and pooled into a unique database and analyzed. Clinical outcomes were harmonized into a single file, which was checked for accuracy of numbers, distributions, and categories. The last day of follow-up from arrest was recorded for each patient. Adjustment for primary outcome and functional outcome was performed using age, gender, time to return of spontaneous circulation, and bystander cardiopulmonary resuscitation. Main Outcomes and Measures The primary outcome was mortality at 3 months; secondary outcomes included unfavorable functional outcome at 3 to 6 months, defined as a Cerebral Performance Category score of 3 to 5. Results A total of 912 patients were included, 490 from the TTM2 trial and 422 from the HYPERION trial. Of those, 442 had been assigned to hypothermia (48.4%; mean age, 65.5 years; 287 males [64.9%]) and 470 to normothermia (51.6%; mean age, 65.6 years; 327 males [69.6%]); 571 patients had a first monitored rhythm of asystole (62.6%) and 503 a presumed noncardiac cause of arrest (55.2%). At 3 months, 354 of 442 patients in the hypothermia group (80.1%) and 386 of 470 patients in the normothermia group (82.1%) had died (relative risk [RR] with hypothermia, 1.04; 95% CI, 0.89-1.20; P = .63). On the last day of follow-up, 386 of 429 in the hypothermia group (90.0%) and 413 of 463 in the normothermia group (89.2%) had an unfavorable functional outcome (RR with hypothermia, 0.99; 95% CI, 0.87-1.15; P = .97). The association of hypothermia with death and functional outcome was consistent across the prespecified subgroups. Conclusions and Relevance In this individual patient data meta-analysis, including unconscious survivors from OHCA with an initial nonshockable rhythm, hypothermia at 33 °C did not significantly improve survival or functional outcome.
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Affiliation(s)
- Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
- After ROSC Network
| | - Josef Dankiewicz
- Cardiology Department, Lund University, Skåne University Hospital Lund, Lund, Sweden
| | - Alain Cariou
- After ROSC Network
- Department of Intensive Care, Paris Cité University, Cochin Hospital (APHP), Paris, France
| | - Gisela Lilja
- Neurology Department of Clinical Sciences, Lund University, Lund, Sweden
- Neurology Department, Skåne University Hospital, Lund, Sweden
| | - Pierre Asfar
- Département de Médecine Intensive Réanimation, CHU Angers, Angers, France
| | - Jan Belohlavek
- 2nd Department of Medicine, Cardiovascular Medicine, 1st Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Thierry Boulain
- Medical Intensive Care Unit, Centre Hospitalier Régional, d’Orléans, Hôpital de la Source, Orléans, France
| | - Gwenhael Colin
- District Hospital Center, Medical-Surgical Intensive Care Unit, La Roche-sur-Yon, France
| | - Tobias Cronberg
- Neurology Department of Clinical Sciences, Lund University, Lund, Sweden
- Neurology Department, Skåne University Hospital, Lund, Sweden
| | - Jean-Pierre Frat
- INSERM CIC 1402, groupe IS-ALIVE, Université de Poitiers, Poitiers, France
| | - Hans Friberg
- Department of Clinical Sciences, Anesthesiology and Intensive Care, Lund University, Lund, Sweden
- Skåne University Hospital, Intensive and Perioperative Care, Malmö, Sweden
| | - Anders M. Grejs
- Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Guillaume Grillet
- Medical-Surgical Intensive Care Unit, District Hospital Center, Lorient, France
| | - Patrick Girardie
- Médecine Intensive Réanimation, CHU Lille, Université de Lille, Faculté de Médicine, Lille, France
| | - Matthias Haenggi
- Department of Intensive Care Medicine, Bern University Hospital (Inselspital), University of Bern, Bern, Switzerland
| | - Jan Hovdenes
- Department of Anesthesia and Intensive Care, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Helena Levin
- Department of Research & Education, Lund University and Skåne University Hospital, Lund, Sweden
| | - Hamid Merdji
- Service de Médecine Intensive-Réanimation, Nouvel Hôpital Civil, Hôpitaux universitaires de Strasbourg, Strasbourg, France
- INSERM, UMR 1260, Regenerative Nanomedicine, Fédération de Médecine Translationnelle de Strasbourg, Université de Strasbourg (UNISTRA), Strasbourg, France
| | - Hassane Njimi
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Paolo Pelosi
- Department of Anesthesiology and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Christian Rylander
- Anaesthesia and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Manoj Saxena
- Critical Care and Trauma Division, George Institute for Global Health, Sydney, New South Wales, Australia
- Department of Intensive Care Medicine, St George Hospital, Kogarah, New South Wales, Australia
| | - Matt Thomas
- Department of Anaesthesia, Southmead Hospital, Bristol, United Kingdom
| | - Paul J. Young
- Department of Intensive Care, Wellington Regional Hospital, Capital and Coast District Health Board, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Matt P. Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, United Kingdom
| | - Niklas Nielsen
- INSERM CIC 1402, groupe IS-ALIVE, Université de Poitiers, Poitiers, France
| | - Jean-Baptiste Lascarrou
- After ROSC Network
- Medecine Intensive Reanimation, CHU Nantes, Nantes, France
- Université Paris Cité, INSERM, PARCC, 75015 Paris, France
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Jeung KW, Jung YH, Gumucio JA, Salcido DD, Menegazzi JJ. Benefits, key protocol components, and considerations for successful implementation of extracorporeal cardiopulmonary resuscitation: a review of the recent literature. Clin Exp Emerg Med 2023; 10:265-279. [PMID: 37439142 PMCID: PMC10579726 DOI: 10.15441/ceem.23.063] [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: 05/24/2023] [Revised: 06/04/2023] [Accepted: 06/05/2023] [Indexed: 07/14/2023] Open
Abstract
The application of venoarterial extracorporeal membrane oxygenation (ECMO) in patients unresponsive to conventional cardiopulmonary resuscitation (CPR) has significantly increased in recent years. To date, three published randomized trials have investigated the use of extracorporeal CPR (ECPR) in adults with refractory out-of-hospital cardiac arrest. Although these trials reported inconsistent results, they suggest that ECPR may have a significant survival benefit over conventional CPR in selected patients only when performed with strict protocol adherence in experienced emergency medical services-hospital systems. Several studies suggest that identifying suitable ECPR candidates and reducing the time from cardiac arrest to ECMO initiation are key to successful outcomes. Prehospital ECPR or the rendezvous approach may allow more patients to receive ECPR within acceptable timeframes than ECPR initiation on arrival at a capable hospital. ECPR is only one part of the system of care for resuscitation of cardiac arrest victims. Optimizing the chain of survival is critical to improving outcomes of patients receiving ECPR. Further studies are needed to find the optimal strategy for the use of ECPR.
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Affiliation(s)
- Kyung Woon Jeung
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Yong Hun Jung
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Jorge Antonio Gumucio
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - David D. Salcido
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - James J. Menegazzi
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Hoyler M, Baidya J, Rippon B, Debois W, Srivastava A, Iannacone E, Girardi NI. Temperature Outcomes without heater cooler units in adult patients supported with extracorporeal membrane oxygenation: A retrospective cohort study. Perfusion 2023:2676591231195694. [PMID: 37559410 DOI: 10.1177/02676591231195694] [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: 08/11/2023]
Abstract
INTRODUCTION Heater-cooler units (HCUs) are frequently incorporated into extracorporeal membrane oxygenation (ECMO) circuits to help maintain patient normothermia. However, these devices may be associated with increased cost and infection risk. This study describes our institution's experience managing adult ECMO patients without the routine use of in-circuit HCUs. METHODS We performed a retrospective analysis of adult patients treated with veno-venous (VV) or veno-arterial (VA) ECMO at our institution. The primary outcomes were rates of HCU use and the relative duration of the ECMO treatment course in which patients maintained normothermia (36-37.5°C), with and without HCUs. Secondary outcomes of mortality and ECMO-related complications were planned across HCU and non-HCU groups; exploratory analyses were performed across a 75% "ECMO time in normothermia" threshold. RESULTS Among a cohort of 71 patients, zero (0%) were managed with in-circuit HCUs. A majority of ECMO patient-hours were spent in the normothermic range. Median and mean percentages of ECMO normothermia time were 75% (IQR 49%-81%) and 62% (SD ± 27%). Twenty-nine patients (40%) met the threshold of 75% ECMO normothermia time, as used to evaluate secondary outcomes. At this threshold, mortality risk was significantly higher among the non-normothermic cohort; other ECMO-related complications did not vary significantly. CONCLUSIONS In the absence of HCU use, the majority of ECMO patient-hours were spent in normothermia. However, only a minority of patients achieved normothermia for at least 75% of their ECMO course. In-circuit HCUs may be required to maintain high percentages of normothermic time in adult EMCO patients.
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Affiliation(s)
- Marguerite Hoyler
- Department of Anesthesiology, Weill Cornell Medical Center, New York, NY, USA
| | - Joydeep Baidya
- Department of Anesthesiology, Weill Cornell Medical Center, New York, NY, USA
| | - Brady Rippon
- Center for Perioperative Outcomes, Department of Anesthesiology, Weill Cornell Medical Center, New York, NY, USA
| | | | - Ankur Srivastava
- Department of Anesthesiology, Weill Cornell Medical Center, New York, NY, USA
| | - Erin Iannacone
- Department of Cardiothoracic Surgery, Weill Cornell Medical Center, New York, NY, USA
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Nedelea PL, Manolescu E, Ciumanghel AI, Constantin M, Hauta A, Sirbu O, Ionescu L, Blaj M, Corlade-Andrei M, Sorodoc V, Cimpoesu D. The Beginning of an ECLS Center: First Successful ECPR in an Emergency Department in Romania-Case-Based Review. J Clin Med 2023; 12:4922. [PMID: 37568324 PMCID: PMC10419366 DOI: 10.3390/jcm12154922] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/01/2023] [Accepted: 07/20/2023] [Indexed: 08/13/2023] Open
Abstract
According to the latest international resuscitation guidelines, extracorporeal cardiopulmonary resuscitation (ECPR) involves the utilization of extracorporeal membrane oxygenation (ECMO) in specific patients experiencing cardiac arrest, and it can be considered in situations where standard cardiopulmonary resuscitation efforts fail if they have a potentially reversible underlying cause, among which we can also find hypothermia. In cases of cardiac arrest, both witnessed and unwitnessed, hypothermic patients have higher chances of survival and favorable neurological outcomes compared to normothermic patients. ECPR is a multifaceted procedure that requires a proficient team, specialized equipment, and comprehensive multidisciplinary support within a healthcare system. However, it also carries the risk of severe, life-threatening complications. With the increasing use of ECPR in recent years and the growing number of centers implementing this technique outside the intensive care units, significant uncertainties persist in both prehospital and emergency department (ED) settings. Proper organization is crucial for an ECPR program in emergency settings, especially given the challenges and complexities of these treatments, which were previously not commonly used in ED. Therefore, within a narrative review, we have incorporated the initial case of ECPR in an ED in Romania, featuring a successful resuscitation in the context of severe hypothermia (20 °C) and a favorable neurological outcome (CPC score of 1).
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Affiliation(s)
- Paul Lucian Nedelea
- Department of Emergency Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Emergency Department, “St. Spiridon” Emergency Clinical County Hospital, 700111 Iasi, Romania
| | - Emilian Manolescu
- Department of Emergency Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Emergency Department, “St. Spiridon” Emergency Clinical County Hospital, 700111 Iasi, Romania
| | - Adi-Ionut Ciumanghel
- Department of Emergency Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Anesthesia Intensive Care Unit, “St. Spiridon” Emergency Clinical County Hospital, 700111 Iasi, Romania
| | - Mihai Constantin
- 2nd Internal Medicine Clinic, “St. Spiridon” Emergency Clinical County Hospital, 700111 Iasi, Romania
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Alexandra Hauta
- Department of Emergency Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Oana Sirbu
- 2nd Internal Medicine Clinic, “St. Spiridon” Emergency Clinical County Hospital, 700111 Iasi, Romania
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Lidia Ionescu
- 3rd Surgery Clinic, “St. Spiridon” Emergency Clinical County Hospital, 700111 Iasi, Romania
| | - Mihaela Blaj
- Anesthesia Intensive Care Unit, “St. Spiridon” Emergency Clinical County Hospital, 700111 Iasi, Romania
| | | | - Victorita Sorodoc
- 2nd Internal Medicine Clinic, “St. Spiridon” Emergency Clinical County Hospital, 700111 Iasi, Romania
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Diana Cimpoesu
- Department of Emergency Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Emergency Department, “St. Spiridon” Emergency Clinical County Hospital, 700111 Iasi, Romania
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9
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Khanduja S, Kim J, Kang JK, Feng CY, Vogelsong MA, Geocadin RG, Whitman G, Cho SM. Hypoxic-Ischemic Brain Injury in ECMO: Pathophysiology, Neuromonitoring, and Therapeutic Opportunities. Cells 2023; 12:1546. [PMID: 37296666 PMCID: PMC10252448 DOI: 10.3390/cells12111546] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/02/2023] [Accepted: 06/03/2023] [Indexed: 06/12/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO), in conjunction with its life-saving benefits, carries a significant risk of acute brain injury (ABI). Hypoxic-ischemic brain injury (HIBI) is one of the most common types of ABI in ECMO patients. Various risk factors, such as history of hypertension, high day 1 lactate level, low pH, cannulation technique, large peri-cannulation PaCO2 drop (∆PaCO2), and early low pulse pressure, have been associated with the development of HIBI in ECMO patients. The pathogenic mechanisms of HIBI in ECMO are complex and multifactorial, attributing to the underlying pathology requiring initiation of ECMO and the risk of HIBI associated with ECMO itself. HIBI is likely to occur in the peri-cannulation or peri-decannulation time secondary to underlying refractory cardiopulmonary failure before or after ECMO. Current therapeutics target pathological mechanisms, cerebral hypoxia and ischemia, by employing targeted temperature management in the case of extracorporeal cardiopulmonary resuscitation (eCPR), and optimizing cerebral O2 saturations and cerebral perfusion. This review describes the pathophysiology, neuromonitoring, and therapeutic techniques to improve neurological outcomes in ECMO patients in order to prevent and minimize the morbidity of HIBI. Further studies aimed at standardizing the most relevant neuromonitoring techniques, optimizing cerebral perfusion, and minimizing the severity of HIBI once it occurs will improve long-term neurological outcomes in ECMO patients.
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Affiliation(s)
- Shivalika Khanduja
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (S.K.); (J.K.K.); (G.W.)
| | - Jiah Kim
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (J.K.); (C.-Y.F.)
| | - Jin Kook Kang
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (S.K.); (J.K.K.); (G.W.)
| | - Cheng-Yuan Feng
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (J.K.); (C.-Y.F.)
| | - Melissa Ann Vogelsong
- Department of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA;
| | - Romergryko G. Geocadin
- Divisions of Neurosciences Critical Care, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA;
| | - Glenn Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (S.K.); (J.K.K.); (G.W.)
| | - Sung-Min Cho
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (S.K.); (J.K.K.); (G.W.)
- Divisions of Neurosciences Critical Care, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA;
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10
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Sanford EL, Bhaskar P, Li X, Thiagarajan R, Raman L. Hypothermia after Extracorporeal Cardiopulmonary Resuscitation Not Associated with Improved Neurologic Complications or Survival in Children: an Analysis of the ELSO Registry. Resuscitation 2023:109852. [PMID: 37245646 DOI: 10.1016/j.resuscitation.2023.109852] [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: 03/21/2023] [Revised: 04/26/2023] [Accepted: 05/17/2023] [Indexed: 05/30/2023]
Abstract
AIM To analyze the association between hypothermia and neurologic complications among children who were treated with extracorporeal cardiopulmonary resuscitation (ECPR) using the Extracorporeal Life Support Organization (ELSO) international registry METHODS: We conducted a retrospective, multicenter, database study utilizing ELSO data for ECPR encounters from January 1, 2011, through December 31, 2019. Exclusion criteria included multiple ECMO runs and lack of variable data. The primary exposure was hypothermia under 34 degrees Celsius for greater than 24 hours. The primary outcome, determined a priori, was a composite of neurologic complications defined by ELSO registry including brain death, seizures, infarction, hemorrhage, diffuse ischemia. Secondary outcomes were mortality on ECMO and mortality prior to hospital discharge. Multivariable logistic regression determined the odds of neurologic complications, mortality on ECMO or prior to hospital discharge associated with hypothermia after adjustment for available pertinent covariables. RESULTS Of the 2,289 ECPR encounters, no difference in odds of neurologic complications were found between the hypothermia and non-hypothermia groups (AOR 1.10, 95% CI 0.80-1.51). However, hypothermia exposure was associated with decreased odds of mortality on ECMO (AOR 0.76, 95% CI 0.59-0.97), but no difference in mortality prior to hospital discharge (AOR 0.96, 95% CI 0.76-1.21) CONCLUSION: Analysis of a large, multicenter, international dataset demonstrates that hypothermia for greater than 24 hours among children who undergo ECPR is not associated with decreased neurologic complications or mortality benefit at time of hospital discharge.
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Affiliation(s)
- Ethan L Sanford
- Division of Critical Care, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States; Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Children's Medical Center, Dallas, TX, USA; Outcomes Research Consortium.
| | - Priya Bhaskar
- Division of Critical Care, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Xilong Li
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Ravi Thiagarajan
- Division of Cardiovascular Critical Care, Department of Pediatrics, Harvard University, Boston, MA, United States
| | - Lakshmi Raman
- Division of Critical Care, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
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11
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Moreau A, Levy B, Annoni F, Lorusso R, Su F, Belliato M, Taccone FS. The use of induced hypothermia in extracorporeal membrane oxygenation: A narrative review. Resusc Plus 2023; 13:100360. [PMID: 36793940 PMCID: PMC9922920 DOI: 10.1016/j.resplu.2023.100360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 12/28/2022] [Accepted: 01/09/2023] [Indexed: 01/29/2023] Open
Abstract
Despite venovenous or venoarterial extracorporeal membrane oxygenation (ECMO) being increasingly used in patients with severe acute respiratory disease syndrome, severe cardiogenic shock, and refractory cardiac arrest, mortality rates still remain high mainly because of the severity of the underlying disease and the numerous complications associated with initiation of ECMO. Induced hypothermia might minimize several pathological pathways present in patients requiring ECMO; even though numerous studies conducted in the experimental setting have reported promising results, there are currently no recommendations suggesting the routine use of this therapy in patients requiring ECMO. In this review, we summarized the existing evidence on the use of induced hypothermia in patients requiring ECMO. Induced hypothermia was a feasible and relatively safe intervention in this setting; however, the effects on clinical outcomes remain uncertain. Whether controlled normothermia has an impact on these patients compared with no temperature control remains unknown. Further randomized controlled trials are required to better understand the role and impact of such therapy in patients requiring ECMO according to the underlying disease.
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Affiliation(s)
- Anthony Moreau
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium,Laboratoire Expérimental des Soins Intensifs, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Bruno Levy
- Service de Médecine Intensive et Réanimation Brabois, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, Vandoeuvre-les-Nancy, France,INSERM U1116, Faculté de Médecine, Université de Lorraine, 54000 Nancy, France
| | - Filippo Annoni
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium,Laboratoire Expérimental des Soins Intensifs, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Fuhong Su
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium,Laboratoire Expérimental des Soins Intensifs, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Mirko Belliato
- UOC AR 2-Anestesia e Rianimazione Cardiotoracica Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium,Laboratoire Expérimental des Soins Intensifs, Université Libre de Bruxelles (ULB), Brussels, Belgium,Corresponding author at: Department of Intensive Care, Hopital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070 Brussels, Belgium.
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12
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Justice CN, Halperin HR, Vanden Hoek TL, Geocadin RG. Extracorporeal cardiopulmonary resuscitation (eCPR) and cerebral perfusion: A narrative review. Resuscitation 2023; 182:109671. [PMID: 36549433 PMCID: PMC9877198 DOI: 10.1016/j.resuscitation.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 12/12/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
Extracorporeal cardiopulmonary resuscitation (eCPR) is emerging as an effective, lifesaving resuscitation strategy for select patients with prolonged or refractory cardiac arrest. Currently, a paucity of evidence-based recommendations is available to guide clinical management of eCPR patients. Despite promising results from initial clinical trials, neurological injury remains a significant cause of morbidity and mortality. Neuropathology associated with utilization of an extracorporeal circuit may interact significantly with the consequences of a prolonged low-flow state that typically precedes eCPR. In this narrative review, we explore current gaps in knowledge about cerebral perfusion over the course of cardiac arrest and resuscitation with a focus on patients treated with eCPR. We found no studies which investigated regional cerebral blood flow or cerebral autoregulation in human cohorts specific to eCPR. Studies which assessed cerebral perfusion in clinical eCPR were small and limited to near-infrared spectroscopy. Furthermore, no studies prospectively or retrospectively evaluated the relationship between epinephrine and neurological outcomes in eCPR patients. In summary, the field currently lacks a comprehensive understanding of how regional cerebral perfusion and cerebral autoregulation are temporally modified by factors such as pre-eCPR low-flow duration, vasopressors, and circuit flow rate. Elucidating these critical relationships may inform future strategies aimed at improving neurological outcomes in patients treated with lifesaving eCPR.
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Affiliation(s)
- Cody N Justice
- Center for Advanced Resuscitation Medicine, Department of Emergency Medicine, Center for Cardiovascular Research, University of Illinois at Chicago, Chicago, IL USA
| | - Henry R Halperin
- Departments of Medicine, Radiology and Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Terry L Vanden Hoek
- Center for Advanced Resuscitation Medicine, Department of Emergency Medicine, Center for Cardiovascular Research, University of Illinois at Chicago, Chicago, IL USA
| | - Romergryko G Geocadin
- Departments of Neurology, Anesthesiology-Critical Care Medicine, and Neurosurgery, Johns Hopkins University, Baltimore, MD, USA.
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13
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Payal N, Sharma L, Sharma A, Hobanii YH, Hakami MA, Ali N, Rashid S, Sachdeva M, Gulati M, Yadav S, Chigurupati S, Singh A, Khan H, Behl T. Understanding the Therapeutic Approaches for Neuroprotection. Curr Pharm Des 2023; 29:3368-3384. [PMID: 38151849 DOI: 10.2174/0113816128275761231103102125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 10/07/2023] [Indexed: 12/29/2023]
Abstract
The term "neurodegenerative disorders" refers to a group of illnesses in which deterioration of nerve structure and function is a prominent feature. Cognitive capacities such as memory and decision-making deteriorate as a result of neuronal damage. The primary difficulty that remains is safeguarding neurons since they do not proliferate or regenerate spontaneously and are therefore not substituted by the body after they have been damaged. Millions of individuals throughout the world suffer from neurodegenerative diseases. Various pathways lead to neurodegeneration, including endoplasmic reticulum stress, calcium ion overload, mitochondrial dysfunction, reactive oxygen species generation, and apoptosis. Although different treatments and therapies are available for neuroprotection after a brain injury or damage, the obstacles are inextricably connected. Several studies have revealed the pathogenic effects of hypothermia, different breathed gases, stem cell treatments, mitochondrial transplantation, multi-pharmacological therapy, and other therapies that have improved neurological recovery and survival outcomes after brain damage. The present review highlights the use of therapeutic approaches that can be targeted to develop and understand significant therapies for treating neurodegenerative diseases.
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Affiliation(s)
- Nazrana Payal
- Department of Pharmacy, School of Biotechnology, Shoolini University of Biotechnology and Management Sciences, Solan, Himachal Pradesh, India
| | - Lalit Sharma
- Department of Pharmacology, School of Pharmaceutical Sciences, Shoolini University, Solan, Himachal Pradesh, India
| | - Aditi Sharma
- Department of Pharmacology, School of Pharmaceutical Sciences, Shoolini University, Solan, Himachal Pradesh, India
| | - Yahya Hosan Hobanii
- Department of Pharmacy, College of Applied Medical Sciences, Jazan University, Jazan, Saudi Arabia
| | | | - Nemat Ali
- Department of Pharmacology and Toxicology, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Summya Rashid
- Department of Pharmacology & Toxicology, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | - Monika Sachdeva
- Department of Pharmacy, Fatima College of Health Sciences, Al Ain, United Arab Emirates
| | - Monica Gulati
- School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, Punjab 1444411, India
- ARCCIM, Faculty of Health, University of Technology, Sydney, Ultimo, NSW 2007, Australia
| | - Shivam Yadav
- School of Pharmacy, Babu Banarasi Das University, Lucknow, Uttar Pradesh, India
| | - Sridevi Chigurupati
- Department of Medicinal Chemistry and Pharmacognosy, College of Pharmacy, Qassim University, Buraydah 52571, Kingdom of Saudi Arabia
- Department of Biotechnology, Saveetha School of Engineering, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Saveetha Nagar, Thandalam, Chennai 602105, India
| | - Abhiav Singh
- Department of Pharmacy, Indian Council of Medical Research, New Delhi, India
| | - Haroon Khan
- Department of Pharmacy, Abdul Wali Khan University, Mardan 23200, Pakistan
| | - Tapan Behl
- Department of Pharmacy, School of Health Sciences and Technology, University of Petroleum and Energy Studies, Bidholi, Dehradun, Uttarakhand, India
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14
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Watanabe M, Matsuyama T, Miyamoto Y, Kitamura T, Komukai S, Ohta B. The impact of different targeted temperatures on out-of-hospital cardiac arrest outcomes in patients receiving extracorporeal membrane oxygenation: a nationwide cohort study. Crit Care 2022; 26:380. [PMID: 36482479 PMCID: PMC9733046 DOI: 10.1186/s13054-022-04256-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/25/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Targeted temperature management (TTM) is recommended in the management of out-of-hospital cardiac arrest (OHCA) when coma persists after the return of spontaneous circulation. In the setting of extracorporeal membrane oxygenation (ECMO) for OHCA patients, TTM is associated with good neurological outcomes and is recommended in the Extracorporeal Life Support Organization guidelines. However, the optimal targeted temperature for these patients has not yet been adequately investigated. This study aimed to compare the impact of different targeted temperatures on the outcomes in OHCA patients receiving ECMO. METHODS This was a retrospective analysis of data from the Japanese Association for Acute Medicine (JAAM)-OHCA Registry, a multicentre nationwide prospective database in Japan in which 103 institutions providing emergency care participated. OHCA patients aged ≥ 18 years who required ECMO with TTM between June 2014 and December 2019 were included in our analysis. The primary outcome was 30-day survival with favourable neurological outcomes, defined as a Glasgow-Pittsburgh cerebral performance category score of 1 or 2. Patients were divided into two groups according to their targeted temperature: normothermic TTM (n-TTM) (35-36 °C) and hypothermic TTM (h-TTM) (32-34 °C). We compared the outcomes between the two targeted temperature groups using multivariable logistic regression and inverse probability weighting (IPW). RESULTS A total of 890 adult OHCA patients who received ECMO and TTM were eligible for our analysis. Of these patients, 249 (28%) and 641 (72%) were treated with n-TTM and h-TTM, respectively. The proportions of patients with 30-day favourable neurological outcomes were 16.5% (41/249) and 15.9% (102/641), in the n-TTM and h-TTM groups, respectively. No difference in neurological outcomes was observed in the multiple regression analysis [adjusted odds ratio 0.91, 95% confidence interval (CI) 0.58-1.43], and the result was constant in the IPW (odds ratio 1.01, 95% CI 0.67-1.54). CONCLUSION No difference was observed between n-TTM and h-TTM in OHCA patients receiving TTM with ECMO. The current understanding that changes to the targeted temperature have little impact on the outcome of patients may remain true regardless of ECMO use.
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Affiliation(s)
- Makoto Watanabe
- grid.272458.e0000 0001 0667 4960Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566 Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan.
| | - Yuki Miyamoto
- grid.272458.e0000 0001 0667 4960Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566 Japan
| | - Tetsuhisa Kitamura
- grid.136593.b0000 0004 0373 3971Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka Suita, Osaka, 565-0871 Japan
| | - Sho Komukai
- grid.136593.b0000 0004 0373 3971Division of Biomedical Statistics Department of Integrated Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Bon Ohta
- grid.272458.e0000 0001 0667 4960Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566 Japan
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15
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Arterial Carbon Dioxide and Acute Brain Injury in Venoarterial Extracorporeal Membrane Oxygenation. ASAIO J 2022; 68:1501-1507. [PMID: 35671442 PMCID: PMC9477972 DOI: 10.1097/mat.0000000000001699] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Acute brain injury (ABI) occurs frequently in patients receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO). We examined the association between peri-cannulation arterial carbon dioxide tension (PaCO 2 ) and ABI with granular blood gas data. We retrospectively analyzed adult patients who underwent VA-ECMO at a tertiary care center with standardized neuromonitoring. Pre- and post-cannulation PaCO 2 were defined as the mean of all PaCO 2 values in the 12 hours before and after cannulation, respectively. Peri-cannulation PaCO 2 drop (∆PaCO 2 ) equaled pre- minus post-cannulation PaCO 2 . ABI included intracranial hemorrhage (ICH), ischemic stroke, hypoxic-ischemic brain injury, cerebral edema, seizure, and brain death. Univariable logistic regression analysis was performed for the presence of ABI. Out of 129 VA-ECMO patients (median age = 60, 63% male), 43 (33%) patients experienced ABI. Patients had a median of 11 (interquartile range: 8-14) peri-cannulation PaCO 2 values. Comparing patients with and without ABI, pre-cannulation (39 vs. 42 mm Hg; p = 0.38) and post-cannulation (37 vs. 36 mm Hg; p = 0.82) PaCO 2 were not different. However, higher pre-cannulation PaCO 2 (odds ratio [OR] = 2.10; 95% confidence interval [CI] = 1.10-4.00; p = 0.02) and larger ∆PaCO 2 (OR = 2.69; 95% CI = 1.18-6.13; p = 0.02) were associated with ICH. In conclusion, in a cohort with granular arterial blood gas (ABG) data and a standardized neuromonitoring protocol, higher pre-cannulation PaCO 2 and larger ∆PaCO 2 were associated with increased prevalence of ICH.
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16
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Sakurai T, Kaneko T, Yamada S, Takahashi T. Extracorporeal cardiopulmonary resuscitation with temperature management could improve the neurological outcomes of out-of-hospital cardiac arrest: a retrospective analysis of a nationwide multicenter observational study in Japan. J Intensive Care 2022; 10:30. [PMID: 35715837 PMCID: PMC9204895 DOI: 10.1186/s40560-022-00622-7] [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: 04/09/2022] [Accepted: 06/09/2022] [Indexed: 11/10/2022] Open
Abstract
Background Target temperature management (TTM) is an effective component of treating out-of-hospital cardiac arrest (OHCA) after return of spontaneous circulation in conventional cardiopulmonary resuscitation. However, therapeutic hypothermia (32–34 °C TTM) is not recommended based on the results of recent studies. Extracorporeal cardiopulmonary resuscitation (ECPR) with veno-arterial extracorporeal membrane oxygenation is another promising therapy for OHCA, but few studies have examined the effectiveness of ECPR with TTM. Therefore, we hypothesized that ECPR with TTM could have the effectiveness to improve the neurological outcomes for adults following witnessed OHCA, in comparison to ECPR without TTM. Methods We performed retrospective subanalyses of the Japanese Association for Acute Medicine OHCA registry. We focused on adults who underwent ECPR for witnessed OHCA. We performed univariate (the Mann–Whitney U test and Fisher’s exact test), multivariable (logistic regression analyses), and propensity score analyses (the inverse probability of the treatment-weighting method) with to compare the neurological outcomes between patients with or without TTM, among all eligible patients, patients with a cardiogenic cause, and patients divided into subgroups according to the interval from collapse to pump start (ICPS) (> 30, > 45, or > 60 min). Results We analyzed data for 977 patients. Among 471 patients treated with TTM, the target temperature was therapeutic hypothermia in 70%, and the median interval from collapse to target temperature was 249 min. Propensity score analysis showed a positive association between TTM and favorable neurological outcomes in all patients (odds ratio 1.546 [95% confidence interval 1.046–2.286], P = 0.029), and in patients with ICPS of > 30 or > 45 min, but not in those with ICPS of > 60 min. The propensity score analysis also showed a positive association between TTM and favorable neurological outcomes in patients with a cardiogenic cause (odds ratio 1.655 [95% confidence interval 1.096–2.500], P = 0.017), including in all ICPS subgroups (> 30, > 45, and > 60 min). Conclusion Within patients who underwent ECPR following OHCA, ECPR with TTM could show the potential of improvement in the neurological outcomes, compared to ECPR without TTM.
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Affiliation(s)
- Toshihiro Sakurai
- Emergency and Critical Care Center, Kumamoto Medical Center, Kumamoto, Japan
| | - Tadashi Kaneko
- Emergency and Critical Care Center, Mie University Hospital, Tsu, Japan.
| | - Shu Yamada
- Emergency and Critical Care Center, Kumamoto Medical Center, Kumamoto, Japan
| | - Takeshi Takahashi
- Emergency and Critical Care Center, Kumamoto Medical Center, Kumamoto, Japan
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17
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Paal P, Pasquier M, Darocha T, Lechner R, Kosinski S, Wallner B, Zafren K, Brugger H. Accidental Hypothermia: 2021 Update. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:501. [PMID: 35010760 PMCID: PMC8744717 DOI: 10.3390/ijerph19010501] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 12/08/2021] [Accepted: 12/09/2021] [Indexed: 12/13/2022]
Abstract
Accidental hypothermia is an unintentional drop of core temperature below 35 °C. Annually, thousands die of primary hypothermia and an unknown number die of secondary hypothermia worldwide. Hypothermia can be expected in emergency patients in the prehospital phase. Injured and intoxicated patients cool quickly even in subtropical regions. Preventive measures are important to avoid hypothermia or cooling in ill or injured patients. Diagnosis and assessment of the risk of cardiac arrest are based on clinical signs and core temperature measurement when available. Hypothermic patients with risk factors for imminent cardiac arrest (temperature < 30 °C in young and healthy patients and <32 °C in elderly persons, or patients with multiple comorbidities), ventricular dysrhythmias, or systolic blood pressure < 90 mmHg) and hypothermic patients who are already in cardiac arrest, should be transferred directly to an extracorporeal life support (ECLS) centre. If a hypothermic patient arrests, continuous cardiopulmonary resuscitation (CPR) should be performed. In hypothermic patients, the chances of survival and good neurological outcome are higher than for normothermic patients for witnessed, unwitnessed and asystolic cardiac arrest. Mechanical CPR devices should be used for prolonged rescue, if available. In severely hypothermic patients in cardiac arrest, if continuous or mechanical CPR is not possible, intermittent CPR should be used. Rewarming can be accomplished by passive and active techniques. Most often, passive and active external techniques are used. Only in patients with refractory hypothermia or cardiac arrest are internal rewarming techniques required. ECLS rewarming should be performed with extracorporeal membrane oxygenation (ECMO). A post-resuscitation care bundle should complement treatment.
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Affiliation(s)
- Peter Paal
- Department of Anesthesiology and Intensive Care Medicine, St. John of God Hospital, Paracelsus Medical University, 5020 Salzburg, Austria
- International Commission for Mountain Emergency Medicine (ICAR MedCom), 8302 Kloten, Switzerland; (M.P.); (K.Z.); (H.B.)
| | - Mathieu Pasquier
- International Commission for Mountain Emergency Medicine (ICAR MedCom), 8302 Kloten, Switzerland; (M.P.); (K.Z.); (H.B.)
- Department of Emergency Medicine, Lausanne University Hospital, 1011 Lausanne, Switzerland
| | - Tomasz Darocha
- Department of Anesthesiology and Intensive Care, Medical University of Silesia, 40-001 Katowice, Poland;
| | - Raimund Lechner
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Military Hospital, 89081 Ulm, Germany;
| | - Sylweriusz Kosinski
- Faculty of Health Sciences, Jagiellonian University Medical College, 34-500 Krakow, Poland;
| | - Bernd Wallner
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria;
| | - Ken Zafren
- International Commission for Mountain Emergency Medicine (ICAR MedCom), 8302 Kloten, Switzerland; (M.P.); (K.Z.); (H.B.)
- Department of Emergency Medicine, Alaska Native Medical Center, Anchorage, AK 99508, USA
- Department of Emergency Medicine, Stanford University Medical Center, Stanford University, Palo Alto, CA 94304, USA
| | - Hermann Brugger
- International Commission for Mountain Emergency Medicine (ICAR MedCom), 8302 Kloten, Switzerland; (M.P.); (K.Z.); (H.B.)
- Institute of Mountain Emergency Medicine, Eurac Research, 39100 Bolzano, Italy
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria
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Watanabe M, Matsuyama T, Oe H, Sasaki M, Nakamura Y, Miyamoto Y, Okada N, Kitamura T, Ohta B. Impact of cooling method on the outcome of initial shockable or non-shockable out of hospital cardiac arrest patients receiving target temperature management: a nationwide multicentre cohort study. Ann Intensive Care 2021; 11:163. [PMID: 34825993 PMCID: PMC8626556 DOI: 10.1186/s13613-021-00953-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 11/15/2021] [Indexed: 01/27/2023] Open
Abstract
Background Little is known about the effectiveness of surface cooling (SC) and endovascular cooling (EC) on the outcome of out-of-hospital cardiac arrest (OHCA) patients receiving target temperature management (TTM) according to their initial rhythm. Methods We retrospectively analysed data from the Japanese Association for Acute Medicine Out‐of‐Hospital Cardiac Arrest registry, a multicentre, prospective nationwide database in Japan. For our analysis, OHCA patients aged ≥ 18 years who were treated with TTM between June 2014 and December 2017 were included. The primary outcome was 30-day survival with favourable neurological outcome defined as a Glasgow–Pittsburgh cerebral performance category score of 1 or 2. Cooling methods were divided into the following groups: SC (ice packs, fans, air blankets, and surface gel pads) and EC (endovascular catheters and any dialysis technique). We investigated the efficacy of the two categories of cooling methods in two different patient groups divided according to their initially documented rhythm at the scene (shockable or non-shockable) using multivariable logistic regression analysis and propensity score analysis with inverse probability weighting (IPW). Results In the final analysis, 1082 patients were included. Of these, 513 (47.4%) had an initial shockable rhythm and 569 (52.6%) had an initial non-shockable rhythm. The proportion of patients with favourable neurological outcomes in SC and EC was 59.9% vs. 58.3% (264/441 vs. 42/72), and 11.8% (58/490) vs. 21.5% (17/79) in the initial shockable patients and the initial non-shockable patients, respectively. In the multivariable logistic regression analysis, differences between the two cooling methods were not observed among the initial shockable patients (adjusted odd ratio [AOR] 1.51, 95% CI 0.76–3.03), while EC was associated with better neurological outcome among the initial non-shockable patients (AOR 2.21, 95% CI 1.19–4.11). This association was constant in propensity score analysis with IPW (OR 1.40, 95% CI 0.83–2.36; OR 1.87, 95% CI 1.01–3.47 among the initial shockable and non-shockable patients, respectively). Conclusion We suggested that the use of EC was associated with better neurological outcomes in OHCA patients with initial non-shockable rhythm, but not in those with initial shockable rhythm. A TTM implementation strategy based on initial rhythm may be important. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00953-y.
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Affiliation(s)
- Makoto Watanabe
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan.
| | - Hikaru Oe
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Makoto Sasaki
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Yuki Nakamura
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Yuki Miyamoto
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Nobunaga Okada
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Bon Ohta
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan
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[Extracorporeal life support (ECLS): 2021 update]. Med Klin Intensivmed Notfmed 2021; 117:61-63. [PMID: 34820698 DOI: 10.1007/s00063-021-00883-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2021] [Indexed: 10/19/2022]
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