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Elmer J, Rittenberger JC, Coppler PJ, Guyette FX, Doshi AA, Callaway CW. Long-term survival benefit from treatment at a specialty center after cardiac arrest. Resuscitation 2016; 108:48-53. [PMID: 27650862 DOI: 10.1016/j.resuscitation.2016.09.008] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 08/30/2016] [Accepted: 09/05/2016] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The Institute of Medicine and American Heart Association have called for tiered accreditation standards and regionalization of post-cardiac arrest care, but there is little data to support that regionalization has a durable effect on patient outcomes. We tested the effect of treatment at a high-volume center on long-term outcome after sudden cardiac arrest (SCA). METHODS We included patients hospitalized at one of 7 medical centers in Southwestern Pennsylvania after SCA from 2005 to 2013. Centers were one regional referral center with an organized systems for post-SCA care, two moderate volume tertiary care centers and 4 low-volume centers. We abstracted clinical characteristics and outcomes at hospital discharge, and for survivors to discharge we queried the National Death Index for long-term survival data. We used Cox regression to determine the unadjusted associations of baseline predictors and survival, and built an adjusted model controlling for baseline predictors. RESULTS Overall, 987 patients survived to discharge. During 2196 person-years of follow-up, median survival was 5.3 years and there were 396 deaths. In unadjusted analysis, treating center, age, arrest location, Charlson Comorbidity Index, initial rhythm, cardiac catheterization, defibrillator placement, discharge disposition, and neurological status at discharge were associated with long-term outcome. In adjusted analysis, treatment at the high-volume cardiac arrest center was associated with improved survival compared to treatment at other centers (hazards ratio 1.49, 95% confidence interval 1.19-1.86). CONCLUSION Treatment at a high-volume cardiac arrest center with organized systems for post-arrest care is associated with a substantial long-term survival benefit after hospital discharge.
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Affiliation(s)
- Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh PA, United States; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh PA, United States.
| | - Jon C Rittenberger
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh PA, United States
| | - Patrick J Coppler
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh PA, United States; Department of Physician Assistant Studies, University of the Sciences, Philadelphia, PA, United States
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh PA, United States
| | - Ankur A Doshi
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh PA, United States
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh PA, United States
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Schefold JC, Fritschi N, Fusch G, Bahonjic A, Doehner W, von Haehling S, Pschowski R, Storm C, Schroeder T. Influence of core body temperature on Tryptophan metabolism, kynurenines, and estimated IDO activity in critically ill patients receiving target temperature management following cardiac arrest. Resuscitation 2016; 107:107-14. [PMID: 27565863 DOI: 10.1016/j.resuscitation.2016.07.239] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 07/22/2016] [Accepted: 07/26/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND/AIMS Temperature control improves neurological prognosis in comatose cardiac arrest (CA) survivors. Previous reports demonstrate that most affected patients show signs of significant systemic inflammation. In an effort to better characterize potential temperature-related effects on key inflammatory pathways, we investigate the course of Tryptophan (Trp) levels, Tryptophan catabolites (including kynurenines) and indoleamine-2,3-dioxygenase (IDO)-activity in post CA patients. MATERIAL/METHODS In an observational blinded endpoint analysis, a total of n=270 serial samples from 20 post CA patients (63.1±16.6 yrs., 45% shockable rhythm, mean time to return of spontaneous circulation (ROSC) 26.6±16.0min) treated with target temperature management (TTM) were analyzed. Core body temperatures, course of Trp, Trp catabolites (incl. kynurenines), and estimated IDO-activity were followed up for a maximum of 7 days after ROSC. Patients were followed up until hospital discharge or death and functional outcome was recorded. RESULTS Over the 7-day observational interval, marked changes in Trp serum levels and IDO-activity were noted. In general, Trp serum levels but not IDO-activity seemed to parallel with the course of core body temperature. In explorative analyses, a correlation of Trp (rho=0.271 (95%-CI: 0.16-0.38, p<0.0001) and IDO-activity (rho=-0.155, 95%-CI: -0.27 to -0.037, p=0.01) with core body temperature was observed. Linear mixed effect models revealed a positive significant association of core body temperature with Trp serum levels (Likelihood ratio test χ(2)=6.35, p=0.012). In patients with good (vs. unfavorable) outcome, a tendency toward higher Trp serum levels, lower IDO-activity, and lower Kynurenic acid levels was noted. CONCLUSIONS We observed significant changes in Trp catabolism and IDO-activity that appeared temperature associated in post CA patients. Under hypothermia, decreased serum levels of Trp and increased IDO-activity were noted. We speculate from our data that IDO-induction during hypothermia contributes to the previously described increased susceptibility to infection or sepsis under reduced temperatures.
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Affiliation(s)
- Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, Bern, Switzerland; Department of Nephrology and Intensive Care Medicine, Charite University Medicine, Berlin, Germany
| | - Nora Fritschi
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Gerhard Fusch
- Department of Pediatrics, McMaster University, Hamilton, Canada
| | - Aldin Bahonjic
- Department of Pediatrics, McMaster University, Hamilton, Canada
| | - Wolfram Doehner
- Centre for Stroke Research Berlin, Charité Medical School, Berlin, Germany
| | - Stephan von Haehling
- University of Göttingen Medical School, Department of Cardiology and Pneumology, Göttingen, Germany
| | - Rene Pschowski
- Department of Nephrology and Intensive Care Medicine, Charite University Medicine, Berlin, Germany; Department of Gastroenterology, Charite University Medicine, Berlin, Germany
| | - Christian Storm
- Department of Nephrology and Intensive Care Medicine, Charite University Medicine, Berlin, Germany
| | - Tim Schroeder
- Department of Nephrology and Intensive Care Medicine, Charite University Medicine, Berlin, Germany
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Prehospital initiation of mild therapeutic hypothermia for out-of-hospital cardiac arrest (OHCA): where are we now? CAN J EMERG MED 2015; 17:227-30. [DOI: 10.1017/cem.2015.32] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Wibrandt I, Norsted K, Schmidt H, Schierbeck J. Predictors for outcome among cardiac arrest patients: the importance of initial cardiac arrest rhythm versus time to return of spontaneous circulation, a retrospective cohort study. BMC Emerg Med 2015; 15:3. [PMID: 25648841 PMCID: PMC4320834 DOI: 10.1186/s12873-015-0028-3] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 01/26/2015] [Indexed: 02/07/2023] Open
Abstract
Background In the past decade, early treatment of cardiac arrest (CA) victims has been improved in several ways, leading to more optimistic over all prognoses. However, the global survival rate after out-of-hospital CA (OHCA) is still not more than 5-10%. With a better knowledge of the predictors for outcome among CA patients, we can improve the management of CA, in order to strengthen the leads in the chain of survival. Methods A retrospective cohort study including 172 CA patients admitted to the intensive care unit (ICU) in Odense University Hospital (OUH) in a three-year period was conducted. We determined the 90-day mortality and neurological outcome at discharge for CA patients treated with therapeutic hypothermia (TH), in regard to determine the importance of the predictors for mortality and neurological outcome, with emphasize on combining initial rhythm and time to return of spontaneous circulation (ROSC). Results The overall mortality was 44% and a favorable neurological outcome was seen among 52%. Strong predictors for survival and favorable neurological outcome were ventricular tachycardia/ventricular fibrillation (VT/VF) as initial rhythm, cardiac etiology and time to ROSC < 20 minutes. Age < 60 years was a predictor for survival only. Patients with the combination of VT/VF and ROSC < 20 minutes had undeniably the best chance of both survival and a favorable neurological outcome. Conclusions We found significant predictors for both survival and neurological outcome, in which an initial rhythm of VT/VF and a cardiac etiology were the strongest.
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Affiliation(s)
- Ida Wibrandt
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark.
| | - Kristine Norsted
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark.
| | - Henrik Schmidt
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark.
| | - Jens Schierbeck
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark.
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Grunau BE. Targeted temperature management after out-of-hospital cardiac arrest: who, when, why, and how? CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2015; 61:129-134. [PMID: 25821870 PMCID: PMC4325859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To provide a succinct review of the evidence, framed for the emergency department clinician, for the application of targeted temperature management (TTM) for patients after out-of-hospital cardiac arrest (OHCA). SOURCES OF INFORMATION MEDLINE, EMBASE, and the Cochrane database were searched for prospective and retrospective studies relevant to the indications of TTM, optimal timing of TTM initiation, method of cooling, and target temperature. MAIN MESSAGE Two prospective interventional trials reported improved neurologically intact survival with the use of TTM (goal temperatures of 32°C to 34°C) compared with no temperature management in comatose OHCA patients with shockable initial cardiac arrest rhythms. A more recent, high-quality randomized controlled trial including OHCA patients with shockable and nonshockable initial rhythms compared TTM at 33°C versus TTM at 36°C. Despite the study being well powered, superiority of one target temperature over the other was not demonstrated. The benefit of TTM in patients with initial nonshockable rhythms is not clear; however, some observational studies have suggested benefit. There is no evidence that any particular method of temperature regulation is superior. The relationship between time and TTM initiation has not been well established. CONCLUSION Targeted temperature management, with a target temperature between 32°C and 36°C, as a component of comprehensive critical care is a beneficial intervention for comatose patients with return of spontaneous circulation after OHCA.
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Affiliation(s)
- Brian E. Grunau
- Correspondence: Dr Brian Grunau, Emergency Department, St Paul’s Hospital, 1081 Burrard St, Vancouver, BC V6Z 1Y6; e-mail
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Dietrichs ES, Dietrichs E. Nevroprotektiv effekt av hypotermi. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2015; 135:1646-51. [DOI: 10.4045/tidsskr.14.1250] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Kowalik R, Szczerba E, Kołtowski Ł, Grabowski M, Chojnacka K, Golecki W, Hołubek A, Opolski G. Cardiac arrest survivors treated with or without mild therapeutic hypothermia: performance status and quality of life assessment. Scand J Trauma Resusc Emerg Med 2014; 22:76. [PMID: 25496708 PMCID: PMC4273459 DOI: 10.1186/s13049-014-0076-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 12/01/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hypoxic-ischaemic encephalopathy is the main determinant of clinical outcome after cardiac arrest. The study was designed to determine long-term neurological and psychological status in cardiac arrest survivors, as well as to compare neuropsychological outcomes between patients treated with mild therapeutic hypothermia (MTH) and patients who did not undergo hypothermia treatment. METHODS The article describes a single-center, retrospective, observational study on 28 post-cardiac arrest adult patients treated in the cardiac intensive care unit who qualified for MTH vs. 37 control group patients, hospitalized at the same center following cardiac arrest in the preceding years and fulfilling criteria for induced hypothermia, but who were not treated due to unavailability of the method at that time. Disability Rating Scale (DRS), Barthel Index and RAND-36 were used to assess performance status and quality of life in both study groups after hospital discharge. RESULTS There were no statistically significant differences in physical functioning found between groups either at the end of hospital treatment or at long-term follow-up (DRS: p = 0.11; Barthel Index: p = 0.83). In long-term follow-up, MTH patients showed higher vitality (p = 0.02) and reported fewer complaints on role limitations due to emotional problems (p = 0.04) compared to the control group. No significant differences were shown between study groups in terms of physical capacity and independent functioning. CONCLUSION To conclude, in long-term follow-up, MTH patients showed higher vitality and reported fewer complaints on role limitations due to emotional problems compared to the control group. This suggest that MTH helps to preserve global brain function in cardiac arrest survivors. However, the results can be biased by a small sample size and variable observation periods.
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Mark DG, Vinson DR, Hung YY, Anderson ES, Escobar GJ, Carr BG, Abella BS, Ballard DW. Lack of improved outcomes with increased use of targeted temperature management following out-of-hospital cardiac arrest: A multicenter retrospective cohort study. Resuscitation 2014; 85:1549-56. [DOI: 10.1016/j.resuscitation.2014.08.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 08/05/2014] [Accepted: 08/11/2014] [Indexed: 11/29/2022]
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Doepp Connolly F, Reitemeier J, Storm C, Hasper D, Schreiber SJ. Duplex sonography of cerebral blood flow after cardiac arrest--a prospective observational study. Resuscitation 2013; 85:516-21. [PMID: 24384507 DOI: 10.1016/j.resuscitation.2013.12.021] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2013] [Revised: 10/09/2013] [Accepted: 12/20/2013] [Indexed: 11/17/2022]
Abstract
AIM Despite successful resuscitation, cardiac arrest (CA) often has a poor clinical prognosis. Different diagnostic tools have been established to predict patients' outcome. However, their sensitivity remains low. Assessment of cerebral perfusion by duplex ultrasound might provide additional information regarding the extent of neuronal damage. The aim of the present study was to analyse the changes of global cerebral blood flow (CBF) and intracranial blood flow parameters in the acute stage after CA and its correlation with patients' outcome. METHODS We investigated 54 patients (17-85 years, mean age: 63±17 years) after CA with return of spontaneous circulation on an intensive care unit. All patients received therapeutic hypothermia (TH) for 24 h after CA and reanimation. Serial measurements of CBF as well as intracranial blood flow velocities and pulsatility indices of the middle cerebral artery and the basal vein of Rosenthal were performed within the first 10 days using duplex ultrasound. Clinical outcome was measured using the Cerebral Performance Category. RESULTS Measurements were successful in 53 patients. CBF values differed between 210 and 1100 ml/min. 24 patients (45%) attained a good outcome. No correlation between CBF or intracranial blood flow characteristics and outcome was found. Neither cerebral hypo- nor hyperperfusion was associated with a fatal outcome. CONCLUSION Cerebral perfusion varies widely after CA. Neither hypo- nor hyperperfusion seems to be an independent risk factor for poor outcome. Duplex ultrasound of cerebral haemodynamics after CA is suitable but probably of limited prognostic value.
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Affiliation(s)
| | | | - Christian Storm
- Department of Internal Medicine, University Hospital Charité, Berlin, Germany
| | - Dietrich Hasper
- Department of Internal Medicine, University Hospital Charité, Berlin, Germany
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Delhaye C, Mahmoudi M, Waksman R. Hypothermia Therapy. J Am Coll Cardiol 2012; 59:197-210. [DOI: 10.1016/j.jacc.2011.06.077] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Revised: 06/20/2011] [Accepted: 06/27/2011] [Indexed: 10/14/2022]
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Survival does not improve when therapeutic hypothermia is added to post-cardiac arrest care. Resuscitation 2011; 82:1168-73. [DOI: 10.1016/j.resuscitation.2011.05.024] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Revised: 05/18/2011] [Accepted: 05/22/2011] [Indexed: 11/17/2022]
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Laish-Farkash A, Matetzky S, Oieru D, Sandach A, Levi N, Or J, Rieck J, Barsheshet A, Hod H. Usefulness of mild therapeutic hypothermia for hospitalized comatose patients having out-of-hospital cardiac arrest. Am J Cardiol 2011; 108:173-8. [PMID: 21545984 DOI: 10.1016/j.amjcard.2011.03.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Revised: 03/11/2011] [Accepted: 03/11/2011] [Indexed: 11/28/2022]
Abstract
Mild therapeutic hypothermia has proved beneficial after out-of-hospital cardiac arrest in the adult population, when the initial rhythm is ventricular fibrillation (VF). In this study, data from 110 consecutive patients with out-of-hospital cardiac arrest due to VF (n = 86) or to non-VF rhythm (n = 24), admitted to an intensive cardiac care unit with restoration of spontaneous circulation and who remained unconscious on admission, were analyzed. Patients were cooled using an external cooling system. Of the patients with VF, 66% had favorable outcomes (Glasgow-Pittsburgh Cerebral Performance Category 1 or 2), and 30% died. Of the patients with non-VF, 8% had favorable outcomes (p <0.001 vs VF), and 63% died (p = 0.004 vs VF). In patients with VF, those with poor outcomes were older than those with favorable outcomes (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.03 to 2.7, p = 0.001) and had previous ejection fractions <35% (OR 7.72, 95% CI 1.8 to 33, p = 0.002). Outcomes were also worse when patients presented to the emergency room with seizures (OR 20.96, 95% CI 2.48 to 177.42, p = 0.003) or hemodynamic instability (OR 14.4, 95% CI 3.47 to 60, p <0.0001). In the non-VF group, the 2 patients with good outcomes were younger than those with unfavorable outcomes (39 ± 16 vs 65 ± 12 years, respectively, p = 0.04), with good left ventricular function on presentation (100% vs 4.5%, p = 0.0001) and with short asystole and/or short time from collapse to restoration of spontaneous circulation. In conclusion, mild therapeutic hypothermia in the adult population is more effective in patients with VF compared to those with non-VF. Good prognostic factors for patients with non-VF could be young age, good left ventricular function, and short anoxic time.
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Improved survival with therapeutic hypothermia after cardiac arrest with cold saline and surfacing cooling: keep it simple. Emerg Med Int 2011; 2011:395813. [PMID: 22046539 PMCID: PMC3200081 DOI: 10.1155/2011/395813] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Accepted: 02/17/2011] [Indexed: 11/17/2022] Open
Abstract
Aim. To evaluate whether the introduction of a therapeutic hypothermia (TH) protocol consisting of cold saline infusion and surface cooling would be effective in targeting mild therapeutic hypothermia (32–34°C). Additionally, to evaluate if TH would improve survival after cardiac arrest.
Design. Before-after design.
Setting. General Intensive Care Unit (ICU) at an urban general hospital with 470 beds.
Patients and Methods. Patients admitted in the ICU after cardiac arrest between 2004 and 2009 were included. Effectiveness of the TH protocol to achieve the targeted temperature was evaluated. Hospital mortality was compared before (October 2004–March 2006) and after (April 2006–September 2009) the protocol implementation.
Results. Hundred and thirty patients were included, 75 patients were not submitted to TH (before TH group), and 55 were submitted to TH (TH group). There were no significant differences concerning baseline, ICU, and cardiac arrest characteristics between both groups. There was a significant reduction in hospital mortality from 61% (n = 46) in the before TH group to 40% (n = 22) in the TH group.
Conclusion. Our protocol consisting of cold saline infusion and surface cooling might be effective in inducing and maintaining mild therapeutic hypothermia. TH achieved with this protocol was associated with a significant reduction in hospital mortality.
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