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Filseth OM, Kondratiev T, Sieck GC, Tveita T. Functional recovery after accidental deep hypothermic cardiac arrest: Comparison of different cardiopulmonary bypass rewarming strategies. Front Physiol 2022; 13:960652. [PMID: 36134333 PMCID: PMC9483155 DOI: 10.3389/fphys.2022.960652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 08/01/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction: Using a porcine model of accidental immersion hypothermia and hypothermic cardiac arrest (HCA), the aim of the present study was to compare effects of different rewarming strategies on CPB on need for vascular fluid supply, level of cardiac restitution, and cerebral metabolism and pressures. Materials and Methods: Totally sixteen healthy, anesthetized castrated male pigs were immersion cooled to 20°C to induce HCA, maintained for 75 min and then randomized into two groups: 1) animals receiving CPB rewarming to 30°C followed by immersion rewarming to 36°C (CPB30, n = 8), or 2) animals receiving CPB rewarming to 36°C (CPB36, n = 8). Measurements of cerebral metabolism were collected using a microdialysis catheter. After rewarming to 36°C, surviving animals in both groups were further warmed by immersion to 38°C and observed for 2 h. Results: Survival rate at 2 h after rewarming was 5 out of 8 animals in the CPB30 group, and 8 out of 8 in the CPB36 group. All surviving animals displayed significant acute cardiac dysfunction irrespective of rewarming method. Differences between groups in CPB exposure time or rewarming rate created no differences in need for vascular volume supply, in variables of cerebral metabolism, or in cerebral pressures and blood flow. Conclusion: As 3 out of 8 animals did not survive weaning from CPB at 30°C, early weaning gave no advantages over weaning at 36°C. Further, in surviving animals, the results showed no differences between groups in the need for vascular volume replacement, nor any differences in cerebral blood flow or pressures. Most prominent, after weaning from CPB, was the existence of acute cardiac failure which was responsible for the inability to create an adequate perfusion irrespective of rewarming strategy.
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Affiliation(s)
- Ole Magnus Filseth
- Anesthesia and Critical Care Research Group, Faculty of Health Sciences, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
- Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
- Emergency Medical Services, University Hospital of North Norway, Tromsø, Norway
| | - Timofei Kondratiev
- Anesthesia and Critical Care Research Group, Faculty of Health Sciences, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Gary C. Sieck
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, United States
| | - Torkjel Tveita
- Anesthesia and Critical Care Research Group, Faculty of Health Sciences, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
- Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, United States
- *Correspondence: Torkjel Tveita,
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2
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Valkov S, Nilsen JH, Mohyuddin R, Schanche T, Kondratiev T, Sieck GC, Tveita T. Autoregulation of Cerebral Blood Flow During 3-h Continuous Cardiopulmonary Resuscitation at 27°C. Front Physiol 2022; 13:925292. [PMID: 35755426 PMCID: PMC9218627 DOI: 10.3389/fphys.2022.925292] [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: 04/21/2022] [Accepted: 05/20/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction: Victims of accidental hypothermia in hypothermic cardiac arrest (HCA) may survive with favorable neurologic outcome if early and continuous prehospital cardiopulmonary resuscitation (CPR) is started and continued during evacuation and transport. The efficacy of cerebral autoregulation during hypothermic CPR is largely unknown and is aim of the present experiment. Methods: Anesthetized pigs (n = 8) were surface cooled to HCA at 27°C before 3 h continuous CPR. Central hemodynamics, cerebral O2 delivery (DO2) and uptake (VO2), cerebral blood flow (CBF), and cerebral perfusion pressure (CPP) were determined before cooling, at 32°C and at 27°C, then at 15 min after the start of CPR, and hourly thereafter. To estimate cerebral autoregulation, the static autoregulatory index (sARI), and the CBF/VO2 ratio were determined. Results: After the initial 15-min period of CPR at 27°C, cardiac output (CO) and mean arterial pressure (MAP) were reduced significantly when compared to corresponding values during spontaneous circulation at 27°C (-66.7% and -44.4%, respectively), and remained reduced during the subsequent 3-h period of CPR. During the first 2-h period of CPR at 27°C, blood flow in five different brain areas remained unchanged when compared to the level during spontaneous circulation at 27°C, but after 3 h of CPR blood flow in 2 of the 5 areas was significantly reduced. Cooling to 27°C reduced cerebral DO2 by 67.3% and VO2 by 84.4%. Cerebral VO2 was significantly reduced first after 3 h of CPR. Cerebral DO2 remained unaltered compared to corresponding levels measured during spontaneous circulation at 27°C. Cerebral autoregulation was preserved (sARI > 0.4), at least during the first 2 h of CPR. Interestingly, the CBF/VO2 ratio during spontaneous circulation at 27°C indicated the presence of an affluent cerebral DO2, whereas after CPR, the CBF/VO2 ratio returned to the level of spontaneous circulation at 38°C. Conclusion: Despite a reduced CO, continuous CPR for 3 h at 27°C provided sufficient cerebral DO2 to maintain aerobic metabolism and to preserve cerebral autoregulation during the first 2-h period of CPR. This new information supports early start and continued CPR in accidental hypothermia patients during rescue and transportation for in hospital rewarming.
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Affiliation(s)
- Sergei Valkov
- Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway
| | - Jan Harald Nilsen
- Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway.,Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway.,Department of Research and Education, Norwegian Air Ambulance Foundation, Drøbak, Norway
| | - Rizwan Mohyuddin
- Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway
| | - Torstein Schanche
- Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway.,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MI, United States
| | - Timofei Kondratiev
- Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway
| | - Gary C Sieck
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MI, United States
| | - Torkjel Tveita
- Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway.,Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway.,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MI, United States
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3
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Tveita T, Sieck GC. Physiological Impact of Hypothermia: The Good, the Bad and the Ugly. Physiology (Bethesda) 2021; 37:69-87. [PMID: 34632808 DOI: 10.1152/physiol.00025.2021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Hypothermia is defined as a core body temperature of < 35°C, and as body temperature is reduced the impact on physiological processes can be beneficial or detrimental. The beneficial effect of hypothermia enables circulation of cooled experimental animals to be interrupted for 1-2 h without creating harmful effects, while tolerance of circulation arrest in normothermia is between 4 and 5 min. This striking difference has attracted so many investigators, experimental as well as clinical, to this field, and this discovery was fundamental for introducing therapeutic hypothermia in modern clinical medicine in the 1950's. Together with the introduction of cardiopulmonary bypass, therapeutic hypothermia has been the cornerstone in the development of modern cardiac surgery. Therapeutic hypothermia also has an undisputed role as a protective agent in organ transplantation and as a therapeutic adjuvant for cerebral protection in neonatal encephalopathy. However, the introduction of therapeutic hypothermia for organ protection during neurosurgical procedures or as a scavenger after brain and spinal trauma has been less successful. In general, the best neuroprotection seems to be obtained by avoiding hyperthermia in injured patients. Accidental hypothermia occurs when endogenous temperature control mechanisms are incapable of maintaining core body temperature within physiologic limits and core temperature becomes dependent on ambient temperature. During hypothermia spontaneous circulation is considerably reduced and with deep and/or prolonged cooling, circulatory failure may occur, which may limit safe survival of the cooled patient. Challenges that limit safe rewarming of accidental hypothermia patients include cardiac arrhythmias, uncontrolled bleeding, and "rewarming shock".
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Affiliation(s)
- Torkjel Tveita
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.,Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
| | - Gary C Sieck
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, United States
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4
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Bjertnaes LJ, Hauge A, Thoresen M, Walløe L. Prioritized Brain Circulation During Ergometer Cycling with Apnea and Face Immersion in Ice-Cold Water: A Case Report. Int Med Case Rep J 2021; 14:675-681. [PMID: 34602825 PMCID: PMC8478670 DOI: 10.2147/imcrj.s317404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 08/26/2021] [Indexed: 11/23/2022] Open
Abstract
Background Successful cardiopulmonary resuscitation after drowning or avalanche is often attributed to hypothermia-induced decrease in metabolism, which adapts the oxygen demand to the amount supplied under cardiac compression. Four decades ago, we speculated if oxygen-sparing mechanisms like those found in marine mammals, may improve cerebral oxygenation during acute airway blockade in humans. We investigated hemodynamic changes during steady state ergometer cycling with intermittent periods of apnea and face immersion (AFI) in ice-cold water. During AFI, heart rate (HR) dropped by 58% whereas average blood velocity (ABV) determined by means of a Doppler ultrasound velocity meter (UNIDOP University of Oslo, Oslo, Norway) fell by 85% in the radial artery and rose by 67% in the vertebral artery. Similar changes occured in radial artery ABV, albeit more slowly, when the test subject only held his breath while cycling. When he breathed via a snorkel during face immersion, HR remained unchanged while radial artery ABV fell transiently and subsequently returned to its pre-immersion level. These findings later were confirmed by other investigators. Moreover, a recent study revealed that the seal even has a system for selective brain cooling during the dive. Conclusion Our research has confirmed prioritized cerebral circulation during AFI in cold water. We hypothesize that these changes may improve brain oxygenation due both to greater blood flow and possibly also to faster brain cooling, as demonstrated in diving seals.
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Affiliation(s)
- Lars J Bjertnaes
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, N-9037, Norway.,Department of Intensive Care Medicine, University Hospital of North Norway, Tromsø, N- 9017, Norway
| | - Anton Hauge
- Division of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, 0317, Norway
| | - Marianne Thoresen
- Division of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, 0317, Norway.,Translational Health Sciences, University of Bristol, Bristol, UK
| | - Lars Walløe
- Division of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, 0317, Norway
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5
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Nilsen JH, Schanche T, Valkov S, Mohyuddin R, Haaheim B, Kondratiev TV, Næsheim T, Sieck GC, Tveita T. Effects of rewarming with extracorporeal membrane oxygenation to restore oxygen transport and organ blood flow after hypothermic cardiac arrest in a porcine model. Sci Rep 2021; 11:18918. [PMID: 34556695 PMCID: PMC8460815 DOI: 10.1038/s41598-021-98044-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 08/26/2021] [Indexed: 02/08/2023] Open
Abstract
We recently documented that cardiopulmonary resuscitation (CPR) generates the same level of cardiac output (CO) and mean arterial pressure (MAP) during both normothermia (38 °C) and hypothermia (27 °C). Furthermore, continuous CPR at 27 °C provides O2 delivery (ḊO2) to support aerobic metabolism throughout a 3-h period. The aim of the present study was to investigate the effects of extracorporeal membrane oxygenation (ECMO) rewarming to restore ḊO2 and organ blood flow after prolonged hypothermic cardiac arrest. Eight male pigs were anesthetized and immersion cooled to 27 °C. After induction of hypothermic cardiac arrest, CPR was started and continued for a 3-h period. Thereafter, the animals were rewarmed with ECMO. Organ blood flow was measured using microspheres. After cooling with spontaneous circulation to 27 °C, MAP and CO were initially reduced to 66 and 44% of baseline, respectively. By 15 min after the onset of CPR, there was a further reduction in MAP and CO to 42 and 25% of baseline, respectively, which remained unchanged throughout the rest of 3-h CPR. During CPR, ḊO2 and O2 uptake (V̇O2) fell to critical low levels, but the simultaneous small increase in lactate and a modest reduction in pH, indicated the presence of maintained aerobic metabolism. Rewarming with ECMO restored MAP, CO, ḊO2, and blood flow to the heart and to parts of the brain, whereas flow to kidneys, stomach, liver and spleen remained significantly reduced. CPR for 3-h at 27 °C with sustained lower levels of CO and MAP maintained aerobic metabolism sufficient to support ḊO2. Rewarming with ECMO restores blood flow to the heart and brain, and creates a "shockable" cardiac rhythm. Thus, like continuous CPR, ECMO rewarming plays a crucial role in "the chain of survival" when resuscitating victims of hypothermic cardiac arrest.
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Affiliation(s)
- Jan Harald Nilsen
- grid.10919.300000000122595234Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, 9037 Tromsø, Norway ,grid.420120.50000 0004 0481 3017Department of Research and Education, Norwegian Air Ambulance Foundation, 1441 Drøbak, Norway ,grid.412244.50000 0004 4689 5540Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, 9038 Tromsø, Norway
| | - Torstein Schanche
- grid.10919.300000000122595234Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, 9037 Tromsø, Norway ,grid.66875.3a0000 0004 0459 167XDepartment of Physiology & Biomedical Engineering, Mayo Clinic, Rochester, MN USA
| | - Sergei Valkov
- grid.10919.300000000122595234Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, 9037 Tromsø, Norway
| | - Rizwan Mohyuddin
- grid.10919.300000000122595234Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, 9037 Tromsø, Norway
| | - Brage Haaheim
- grid.10919.300000000122595234Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, 9037 Tromsø, Norway
| | - Timofei V. Kondratiev
- grid.10919.300000000122595234Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, 9037 Tromsø, Norway
| | - Torvind Næsheim
- grid.412244.50000 0004 4689 5540Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, 9038 Tromsø, Norway
| | - Gary C. Sieck
- grid.66875.3a0000 0004 0459 167XDepartment of Physiology & Biomedical Engineering, Mayo Clinic, Rochester, MN USA
| | - Torkjel Tveita
- grid.10919.300000000122595234Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, 9037 Tromsø, Norway ,grid.412244.50000 0004 4689 5540Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, 9038 Tromsø, Norway ,grid.66875.3a0000 0004 0459 167XDepartment of Physiology & Biomedical Engineering, Mayo Clinic, Rochester, MN USA
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6
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Darocha T, Hugli O, Kosiński S, Podsiadło P, Caillet-Bois D, Pasquier M. Clinician miscalibration of survival estimate in hypothermic cardiac arrest: HOPE-estimated survival probabilities in extreme cases. Resusc Plus 2021; 7:100139. [PMID: 34223395 PMCID: PMC8244419 DOI: 10.1016/j.resplu.2021.100139] [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: 01/21/2021] [Revised: 05/11/2021] [Accepted: 05/15/2021] [Indexed: 11/25/2022] Open
Abstract
AIM Patients with hypothermic cardiac arrest may survive with an excellent outcome after extracorporeal life support rewarming (ECLSR). The HOPE (Hypothermia Outcome Prediction after ECLS) score is recommended to guide the in-hospital decision on whether or not to initiate ECLSR in patients in cardiac arrest following accidental hypothermia. We aimed to assess the HOPE-estimated survival probabilities for a set of survivors of hypothermic cardiac arrest who had extreme values for the variables included in the HOPE score. METHODS Survivors were identified and selected through a systematic literature review including case reports. We calculated the HOPE score for each patient who presented extraordinary clinical parameters. RESULTS We identified 12 such survivors. The HOPE-estimated survival probability was ≥10% for all (n = 11) patients for whom we were able to calculate the HOPE score. CONCLUSION Our study confirms the robustness of the HOPE score for outliers and thus further confirms its external validity. These cases also confirm that hypothermic cardiac arrest is a fundamentally different entity than normothermic cardiac arrest. Using HOPE for extreme cases may support the proper calibration of a clinician's prognosis and therapeutic decision based on the survival chances of patients with accidental hypothermic cardiac arrest.
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Affiliation(s)
- Tomasz Darocha
- Severe Accidental Hypothermia Center, Department of Anaesthesiology and Intensive Care, Medical University of Silesia, Medykow 14, 40-752 Katowice, Poland
| | - Olivier Hugli
- Emergency Department, Lausanne University Hospital, University of Lausanne, BH 09, CHUV, 1011 Lausanne, Switzerland
| | - Sylweriusz Kosiński
- Faculty of Health Sciences, Jagiellonian University Medical College, Michałowskiego 12, 31-126 Krakow, Poland
| | - Paweł Podsiadło
- Institute of Medical Sciences, Jan Kochanowski University, Al. IX Wieków Kielc 19A, 25-317 Kielce, Poland
| | - David Caillet-Bois
- Department of Emergency Medicine, Lausanne University Hospital, BH 09, 1011 Lausanne, Switzerland
| | - Mathieu Pasquier
- Department of Emergency Medicine, Lausanne University Hospital, BH 09, 1011 Lausanne, Switzerland
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7
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Bjertnæs LJ, Hindberg K, Næsheim TO, Suborov EV, Reierth E, Kirov MY, Lebedinskii KM, Tveita T. Rewarming From Hypothermic Cardiac Arrest Applying Extracorporeal Life Support: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2021; 8:641633. [PMID: 34055829 PMCID: PMC8155640 DOI: 10.3389/fmed.2021.641633] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 03/04/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction: This systematic review and meta-analysis aims at comparing outcomes of rewarming after accidental hypothermic cardiac arrest (HCA) with cardiopulmonary bypass (CPB) or/and extracorporeal membrane oxygenation (ECMO). Material and Methods: Literature searches were limited to references with an abstract in English, French or German. Additionally, we searched reference lists of included papers. Primary outcome was survival to hospital discharge. We assessed neurological outcome, differences in relative risks (RR) of surviving, as related to the applied rewarming technique, sex, asphyxia, and witnessed or unwitnessed HCA. We calculated hypothermia outcome prediction probability score after extracorporeal life support (HOPE) in patients in whom we found individual data. P < 0.05 considered significant. Results: Twenty-three case observation studies comprising 464 patients were included in a meta-analysis comparing outcomes of rewarming with CPB or/and ECMO. One-hundred-and-seventy-two patients (37%) survived to hospital discharge, 76 of 245 (31%) after CPB and 96 of 219 (44 %) after ECMO; 87 and 75%, respectively, had good neurological outcomes. Overall chance of surviving was 41% higher (P = 0.005) with ECMO as compared with CPB. A man and a woman had 46% (P = 0.043) and 31% (P = 0.115) higher chance, respectively, of surviving with ECMO as compared with CPB. Avalanche victims had the lowest chance of surviving, followed by drowning and people losing consciousness in cold environments. Assessed by logistic regression, asphyxia, unwitnessed HCA, male sex, high initial body temperature, low pH and high serum potassium (s-K+) levels were associated with reduced chance of surviving. In patients displaying individual data, overall mean predictive surviving probability (HOPE score; n = 134) was 33.9 ± 33.6% with no significant difference between ECMO and CPB-treated patients. We also surveyed 80 case reports with 96 victims of HCA, who underwent resuscitation with CPB or ECMO, without including them in the meta-analysis. Conclusions: The chance of surviving was significantly higher after rewarming with ECMO, as compared to CPB, and in patients with witnessed compared to unwitnessed HCA. Avalanche victims had the lowest probability of surviving. Male sex, high initial body temperature, low pH, and high s-K+ were factors associated with low surviving chances.
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Affiliation(s)
- Lars J. Bjertnæs
- Anesthesia and Critical Care Research Group, University of Tromsø (UiT), The Arctic University of Norway, Tromsø, Norway
| | - Kristian Hindberg
- K. G. Jebsen Thrombosis Research and Expertise Center, University of Tromsø (UiT), The Arctic University of Norway, Tromsø, Norway
| | - Torvind O. Næsheim
- Cardiovascular Research Group, Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø (UiT), The Arctic University of Norway, Tromsø, Norway
| | - Evgeny V. Suborov
- The Nikiforov Russian Federation Center of Emergency and Radiation Medicine, St. Petersburg, Russia
| | - Eirik Reierth
- Science and Health Library, University of Tromsø, The Arctic University of Norway, Tromsø, Norway
| | - Mikhail Y. Kirov
- Department of Anesthesiology and Intensive Care, Northern State Medical University, Arkhangelsk, Russia
| | - Konstantin M. Lebedinskii
- Department of Anesthesiology and Intensive Care, North-Western State Medical University Named After I. I. Mechnikov, St. Petersburg, Russia
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Torkjel Tveita
- Anesthesia and Critical Care Research Group, University of Tromsø (UiT), The Arctic University of Norway, Tromsø, Norway
- Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
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8
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Nilsen JH, Valkov S, Mohyuddin R, Schanche T, Kondratiev TV, Naesheim T, Sieck GC, Tveita T. Study of the Effects of 3 h of Continuous Cardiopulmonary Resuscitation at 27°C on Global Oxygen Transport and Organ Blood Flow. Front Physiol 2020; 11:213. [PMID: 32372965 PMCID: PMC7177004 DOI: 10.3389/fphys.2020.00213] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 02/24/2020] [Indexed: 12/19/2022] Open
Abstract
Aims Complete restitution of neurologic function after 6 h of pre-hospital resuscitation and in-hospital rewarming has been reported in accidental hypothermia patients with cardiac arrest (CA). However, the level of restitution of circulatory function during long-lasting hypothermic cardiopulmonary resuscitation (CPR) remains largely unknown. We compared the effects of CPR in replacing spontaneous circulation during 3 h at 27°C vs. 45 min at normothermia by determining hemodynamics, global oxygen transport (DO2), oxygen uptake (VO2), and organ blood flow. Methods Anesthetized pigs (n = 7) were immersion cooled to CA at 27°C. Predetermined variables were compared: (1) Before cooling, during cooling to 27°C with spontaneous circulation, after CA and subsequent continuous CPR (n = 7), vs. (2) before CA and during 45 min CPR in normothermic pigs (n = 4). Results When compared to corresponding values during spontaneous circulation at 38°C: (1) After 15 min of CPR at 27°C, cardiac output (CO) was reduced by 74%, mean arterial pressure (MAP) by 63%, DO2 by 47%, but organ blood flow was unaltered. Continuous CPR for 3 h maintained these variables largely unaltered except for significant reduction in blood flow to the heart and brain after 3 h, to the kidneys after 1 h, to the liver after 2 h, and to the stomach and small intestine after 3 h. (2) After normothermic CPR for 15 min, CO was reduced by 71%, MAP by 54%, and DO2 by 63%. After 45 min, hemodynamic function had deteriorated significantly, organ blood flow was undetectable, serum lactate increased by a factor of 12, and mixed venous O2 content was reduced to 18%. Conclusion The level to which CPR can replace CO and MAP during spontaneous circulation at normothermia was not affected by reduction in core temperature in our setting. Compared to spontaneous circulation at normothermia, 3 h of continuous resuscitation at 27°C provided limited but sufficient O2 delivery to maintain aerobic metabolism. This fundamental new knowledge is important in that it encourages early and continuous CPR in accidental hypothermia victims during evacuation and transport.
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Affiliation(s)
- Jan Harald Nilsen
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.,Department of Research and Education, Norwegian Air Ambulance Foundation, Drøbak, Norway
| | - Sergei Valkov
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Rizwan Mohyuddin
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Torstein Schanche
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Timofei V Kondratiev
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Torvind Naesheim
- Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
| | - Gary C Sieck
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, United States
| | - Torkjel Tveita
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.,Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
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9
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Schanche T, Kondratiev T, Tveita T. Extracorporeal rewarming from experimental hypothermia: Effects of hydroxyethyl starch versus saline priming on fluid balance and blood flow distribution. Exp Physiol 2019; 104:1353-1362. [PMID: 31219201 DOI: 10.1113/ep087786] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 06/18/2019] [Indexed: 11/08/2022]
Abstract
NEW FINDINGS What is the central question of this study? Mortality in accidental hypothermia patients rewarmed by extracorporeal circulation remains high. Knowledge concerning optimal fluid additions for extracorporeal rewarming is lacking, with no apparent consensus. Does colloid versus crystalloid priming have different effects on fluid balance and blood flow distribution during extracorporeal rewarming? What is the main finding and its importance? In our rat model of extracorporeal rewarming from hypothermic cardiac arrest, hydroxyethyl starch generates less tissue oedema and increases circulating blood volume and organ blood flow, compared with saline. The composition of fluid additions appears to be important during extracorporeal rewarming from hypothermia. ABSTRACT Rewarming by extracorporeal circulation (ECC) is the recommended treatment for accidental hypothermia patients with cardiac instability. Hypothermia, along with initiation of ECC, introduces major changes in fluid homeostasis and blood flow. Scientific data to recommend best practice use of ECC for rewarming these patients is lacking, and no current guidelines exist concerning the choice of priming fluid for the extracorporeal circuit. The primary aim of this study was to compare the effects of different fluid protocols on fluid balance and blood flow distribution during rewarming from deep hypothermic cardiac arrest. Sixteen anaesthetized rats were cooled to deep hypothermic cardiac arrest and rewarmed by ECC. During cooling, rats were equally randomized into two groups: an extracorporeal circuit primed with saline or primed with hydroxyethyl starch (HES). Calculations of plasma volume (PV), circulating blood volume (CBV), organ blood flow, total tissue water content, global O2 delivery and consumption were made. During and after rewarming, the pump flow rate, mean arterial pressure, PV and CBV were significantly higher in HES-treated compared with saline-treated rats. After rewarming, the HES group had significantly increased global O2 delivery and blood flow to the brain and kidneys compared with the saline group. Rats in the saline group demonstrated a significantly higher total tissue water content in the kidneys, skeletal muscle and lung. Compared with crystalloid priming, the use of an iso-oncotic colloid prime generates less tissue oedema and increases PV, CBV and organ blood flow during ECC rewarming. The composition of fluid additions appears to be an important factor during ECC rewarming from hypothermia.
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Affiliation(s)
- Torstein Schanche
- Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, Tromsø, Norway
| | - Timofei Kondratiev
- Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, Tromsø, Norway
| | - Torkjel Tveita
- Anaesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, Tromsø, Norway.,Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
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10
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Valkov S, Mohyuddin R, Nilsen JH, Schanche T, Kondratiev TV, Sieck GC, Tveita T. Organ blood flow and O 2 transport during hypothermia (27°C) and rewarming in a pig model. Exp Physiol 2018; 104:50-60. [PMID: 30375081 DOI: 10.1113/ep087205] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 10/25/2018] [Indexed: 01/10/2023]
Abstract
NEW FINDINGS What is the central question of this study? Absence of hypothermia-induced cardiac arrest is a strong predictor for a favourable outcome after rewarming. Nevertheless, detailed knowledge of preferences in organ blood flow during rewarming with spontaneous circulation is largely unknown. What is the main finding and its importance? In a porcine model of accidental hypothermia, we find, despite a significantly reduced cardiac output during rewarming, normal blood flow and O2 supply in vital organs owing to patency of adequate physiological compensatory responses. In critical care medicine, active rewarming must aim at supporting the spontaneous circulation and maintaining spontaneous autonomous vascular control. ABSTRACT The absence of hypothermia-induced cardiac arrest is one of the strongest predictors for a favourable outcome after rewarming from accidental hypothermia. We studied temperature-dependent changes in organ blood flow and O2 delivery ( <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML"><mml:msub><mml:mi>D</mml:mi> <mml:msub><mml:mi>O</mml:mi> <mml:mn>2</mml:mn></mml:msub> </mml:msub> </mml:math> ) in a porcine model with spontaneous circulation during 3 h of hypothermia at 27°C followed by rewarming. Anaesthetized pigs (n = 16, weighing 20-29 kg) were randomly assigned to one of two groups: (i) hypothermia/rewarming (n = 10), immersion cooled to 27°C and maintained for 3 h before being rewarmed by pleural lavage; and (ii) time-matched normothermic (38°C) control animals (n = 6), immersed for 6.5 h, the last 2 h with pleural lavage. Regional blood flow was measured using a neutron-labelled microsphere technique. Simultaneous measurements of <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML"><mml:msub><mml:mi>D</mml:mi> <mml:msub><mml:mi>O</mml:mi> <mml:mn>2</mml:mn></mml:msub> </mml:msub> </mml:math> and O2 consumption ( <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML"> <mml:msub><mml:mover><mml:mi>V</mml:mi> <mml:mo>̇</mml:mo></mml:mover> <mml:msub><mml:mi>O</mml:mi> <mml:mn>2</mml:mn></mml:msub> </mml:msub> </mml:math> ) were made. During hypothermia, there was a reduction in organ blood flow, <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML"> <mml:msub><mml:mover><mml:mi>V</mml:mi> <mml:mo>̇</mml:mo></mml:mover> <mml:msub><mml:mi>O</mml:mi> <mml:mn>2</mml:mn></mml:msub> </mml:msub> </mml:math> and <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML"><mml:msub><mml:mi>D</mml:mi> <mml:msub><mml:mi>O</mml:mi> <mml:mn>2</mml:mn></mml:msub> </mml:msub> </mml:math> . After rewarming, there was a 40% reduction in stroke volume and cardiac output, causing a global reduction in <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML"><mml:msub><mml:mi>D</mml:mi> <mml:msub><mml:mi>O</mml:mi> <mml:mn>2</mml:mn></mml:msub> </mml:msub> </mml:math> ; nevertheless, blood flow to the brain, heart, stomach and small intestine returned to prehypothermic values. Blood flow in the liver and kidneys was significantly reduced. Cerebral <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML"><mml:msub><mml:mi>D</mml:mi> <mml:msub><mml:mi>O</mml:mi> <mml:mn>2</mml:mn></mml:msub> </mml:msub> </mml:math> and <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML"> <mml:msub><mml:mover><mml:mi>V</mml:mi> <mml:mo>̇</mml:mo></mml:mover> <mml:msub><mml:mi>O</mml:mi> <mml:mn>2</mml:mn></mml:msub> </mml:msub> </mml:math> returned to control values. After hypothermia and rewarming there is a significant lowering of <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML"><mml:msub><mml:mi>D</mml:mi> <mml:msub><mml:mi>O</mml:mi> <mml:mn>2</mml:mn></mml:msub> </mml:msub> </mml:math> owing to heart failure. However, compensatory mechanisms preserve O2 transport, blood flow and <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML"> <mml:msub><mml:mover><mml:mi>V</mml:mi> <mml:mo>̇</mml:mo></mml:mover> <mml:msub><mml:mi>O</mml:mi> <mml:mn>2</mml:mn></mml:msub> </mml:msub> </mml:math> in most organs. Nevertheless, these results indicate that hypothermia-induced heart failure requires therapeutic intervention.
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Affiliation(s)
- Sergei Valkov
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, 9037, Tromsø, Norway
| | - Rizwan Mohyuddin
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, 9037, Tromsø, Norway
| | - Jan Harald Nilsen
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, 9037, Tromsø, Norway.,Department of Research and Education, Norwegian Air Ambulance Foundation, 1441, Drøbak, Norway.,Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, 9038, Tromsø, Norway
| | - Torstein Schanche
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, 9037, Tromsø, Norway
| | - Timofei V Kondratiev
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, 9037, Tromsø, Norway
| | - Gary C Sieck
- Department of Physiology & Biomedical Engineering, Mayo Clinic Rochester, MN, USA
| | - Torkjel Tveita
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, 9037, Tromsø, Norway.,Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, 9038, Tromsø, Norway
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11
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Dietrichs ES, Håheim B, Kondratiev T, Traasdahl E, Tveita T. Effects of hypothermia and rewarming on cardiovascular autonomic control in vivo. J Appl Physiol (1985) 2017; 124:850-859. [PMID: 29357499 DOI: 10.1152/japplphysiol.00317.2017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Rewarming from accidental hypothermia is associated with cardiovascular dysfunction that complicates rewarming and contributes to a high mortality rate. We investigated autonomic cardiovascular control, as well as the separate effects of cooling, hypothermia, and rewarming on hemodynamic function, aiming to provide knowledge of the pathophysiology causing such complications in these patients. A rat model designed for circulatory studies during cooling, hypothermia (15°C), and rewarming was used. Spectral analysis of diastolic arterial pressure and heart rate allowed assessment of the autonomic nervous system. Hemodynamic variables were monitored using a conductance catheter in the left ventricle and a pressure transducer connected to the left femoral artery. Sympathetic cardiovascular control was reduced after rewarming. Stroke volume increased during cooling but decreased during stable hypothermia and did not normalize during rewarming. Despite autonomic dysfunction, total peripheral resistance increased during cooling and did not normalize after rewarming. The present data show that sympathetic cardiovascular control is reduced by hypothermia and rewarming. A simultaneous systolic dysfunction is seen in rewarmed animals, caused by reduced filling of the left ventricle and impaired contractile function, in the presence of normal diastolic function. These findings show that dysfunction of the efferent sympathetic nervous system could be instrumental in development of rewarming shock. NEW & NOTEWORTHY The present study shows impaired autonomic control of cardiovascular function after rewarming from severe hypothermia. In victims of accidental hypothermia, rewarming shock is a much feared and lethal complication. The pathophysiology causing such cardiovascular collapse appears complex. Our findings indicate that dysfunction of the autonomic nervous system is an important part of the pathophysiology. Thus the present study gives novel information, important for further development of treatment strategies in this patient group.
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Affiliation(s)
- Erik Sveberg Dietrichs
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway , Tromsø , Norway.,Department of Research and Education, Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Clinical Pharmacology, Division of Diagnostic Services, University Hospital of North Norway , Tromsø , Norway
| | - Brage Håheim
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway , Tromsø , Norway
| | - Timofei Kondratiev
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway , Tromsø , Norway
| | - Erik Traasdahl
- PET Imaging Center, Division of Diagnostic Services, University Hospital of North Norway , Tromsø , Norway
| | - Torkjel Tveita
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway , Tromsø , Norway.,Division of Surgical Medicine and Intensive Care, University Hospital of North Norway , Tromsø , Norway
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12
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Brodeur A, Wright A, Cortes Y. Hypothermia and targeted temperature management in cats and dogs. J Vet Emerg Crit Care (San Antonio) 2017; 27:151-163. [PMID: 28122159 DOI: 10.1111/vec.12572] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 03/11/2015] [Accepted: 05/04/2015] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To review current knowledge surrounding the effects, treatment, and prognosis of hypothermia in people, dogs, and cats, as well as the application of therapeutic hypothermia in clinical medicine. ETIOLOGY Hypothermia may be a primary or secondary condition, and may be due to environmental exposure, illness, medications, anesthesia, or trauma. Hypothermia has been applied therapeutically in human medicine for a variety of conditions, including postcardiac arrest. In veterinary medicine, the technique has been applied in cardiac surgeries requiring bypass and in a patient with intractable seizures. DIAGNOSIS Hypothermia can be diagnosed based on presenting temperature or clinical signs, and appropriate diagnosis may require nontraditional thermometers. THERAPY Rewarming is the primary treatment for accidental hypothermia, with intensity ranging from passive surface rewarming to extracorporeal rewarming. The goal is to return the core temperature to a level that restores normal physiologic function of all body processes. Other supportive therapies such as intravenous fluids are typically indicated, and if cardiopulmonary arrest is present, prolonged resuscitation may be required. In cases of secondary hypothermia, reversal of the underlying cause is important. PROGNOSIS There are few prognostic indicators in human and veterinary patients with hypothermia. Even the most severely affected individuals, including those presenting in cardiopulmonary arrest, have potential for complete recovery with appropriate therapy. Therapeutic hypothermia has been shown to improve outcome in people following cardiac arrest. Further studies are needed to examine this application in veterinary medicine, as well as appropriate therapy and prognosis for cases of spontaneous hypothermia.
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Affiliation(s)
| | - Annie Wright
- Maine Veterinary Referral Center, Scarborough, ME, 04074
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13
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Halsøy K, Kondratiev T, Tveita T, Bjertnaes LJ. Effects of Constant Flow vs. Constant Pressure Perfusion on Fluid Filtration in Severe Hypothermic Isolated Blood-Perfused Rat Lungs. Front Med (Lausanne) 2016; 3:70. [PMID: 28066770 PMCID: PMC5179575 DOI: 10.3389/fmed.2016.00070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 12/12/2016] [Indexed: 11/13/2022] Open
Abstract
Background Victims of severe accidental hypothermia are prone to fluid extravasation but rarely develop lung edema. We hypothesize that combined hypothermia-induced increase in pulmonary vascular resistance (PVR) and a concomitant fall in cardiac output protect the lungs against edema development. Our aim was to explore in hypothermic-isolated blood-perfused rat lungs whether perfusion at constant pressure influences fluid filtration differently from perfusion at constant flow. Methods Isolated blood-perfused rat lungs were hanging freely in a weight transducer for measuring weight changes (ΔW). Fluid filtration coefficient (Kfc), was determined by transiently elevating left atrial pressure (Pla) by 5.8 mmHg two times each during normothermia (37°C) and during hypothermia (15°C). The lung preparations were randomized to two groups. One group was perfused with constant flow (Constant flow group) and the other group with constant pulmonary artery pressure (Constant PPA group). Microvascular pressure (Pmv) was determined before and during elevation of Pla (ΔPmv) by means of the double occlusion technique. Kfc was calculated with the formula Kfc = ΔW/ΔPmv/min. All Kfc values were normalized to predicted lung weight (PLW), which was based on body weight (BW) according to the formula: PLW = 0.0053 BW − 0.48 and presented as KfcPLW in mg/min/mmHg/g. At cessation, bronchoalveolar lavage (BAL) fluid/perfusate protein concentration (B/P) ratio was determined photometrically. Data were analyzed with parametric or non-parametric tests as appropriate. p < 0.05 considered as significant. Results Perfusate flow remained constant in the Constant flow group, but was more than halved during hypothermia in the Constant PPA group concomitant with a more fold increase in PVR. In the Constant flow group, KfcPLW and B/P ratio increased significantly by more than 10-fold during hypothermia concerted by visible signs of edema in the trachea. Hemoglobin and hematocrit increased within the Constant flow group and between the groups at cessation of the experiments. Conclusion In hypothermic rat lungs perfused at constant flow, fluid filtration coefficient per gram PLW and B/P ratio increased more than 10-fold concerted by increased hemoconcentration, but the changes were less in hypothermic lungs perfused at constant PPA.
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Affiliation(s)
- Kathrine Halsøy
- Anesthesia and Critical Care Research Group, Faculty of Health Sciences, Department of Clinical Medicine, University of Tromsø, The Arctic University of Norway , Tromsø , Norway
| | - Timofey Kondratiev
- Anesthesia and Critical Care Research Group, Faculty of Health Sciences, Department of Clinical Medicine, University of Tromsø, The Arctic University of Norway , Tromsø , Norway
| | - Torkjel Tveita
- Anesthesia and Critical Care Research Group, Faculty of Health Sciences, Department of Clinical Medicine, University of Tromsø, The Arctic University of Norway , Tromsø , Norway
| | - Lars J Bjertnaes
- Anesthesia and Critical Care Research Group, Faculty of Health Sciences, Department of Clinical Medicine, University of Tromsø, The Arctic University of Norway , Tromsø , Norway
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14
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Outcome After Rewarming From Accidental Hypothermia by Use of Extracorporeal Circulation. Ann Thorac Surg 2016; 103:920-925. [PMID: 27692232 DOI: 10.1016/j.athoracsur.2016.06.093] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 06/20/2016] [Accepted: 06/27/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Accidental hypothermia with arrested circulation remains a condition associated with high mortality. In our institution, extracorporeal circulation (ECC) rewarming has been the cornerstone in treating such patients since 1987. We here explore characteristics and outcomes of this treatment, to identify significant merits and challenges from 3 decades of experience in ECC rewarming. METHODS Sixty-nine patients rewarmed by ECC during the period from December 1987 to December 2015 were analyzed. One patient was excluded from the analyses because of combined traumatic cerebral injury. The analysis was focused on patient characteristics, treatment procedures, and outcomes were focused. Survivors were evaluated according to the cerebral performance categories scale. Simple statistics with nonparametric tests and χ2 tests were used. Median value and range are reported. RESULTS Median age was 30 years (minimum 1.5, maximum 76), and the cause of accidental hypothermia was cold exposure (27.9%), avalanche (5.9%), and immersion/submersion accidents (66.2%). Eighteen patients survived (26.5%). The survival rate did not improve during the years. Survivors had lower serum potassium (p = 0.002), higher pH (p = 0.03), lower core temperature (p = 0.02), and shorter cardiopulmonary resuscitation time (p = 0.001), but ranges were wide. Although suspected primary hypoxia and hypothermia were associated with lower survival, we observed a 10.5% survival of these victims. Sixteen survivors had good outcome (cerebral performance category 1 or 2), whereas 2 patients with suspected primary hypoxia survived with severe cerebral disability (cerebral performance category 3). CONCLUSIONS Despite extended experience with ECC rewarming, improved handling strategies, and intensive care, no overall improvement in survival was observed. Good outcome was observed even among patients with a dismal prognosis.
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15
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Paal P, Gordon L, Strapazzon G, Brodmann Maeder M, Putzer G, Walpoth B, Wanscher M, Brown D, Holzer M, Broessner G, Brugger H. Accidental hypothermia-an update : The content of this review is endorsed by the International Commission for Mountain Emergency Medicine (ICAR MEDCOM). Scand J Trauma Resusc Emerg Med 2016; 24:111. [PMID: 27633781 PMCID: PMC5025630 DOI: 10.1186/s13049-016-0303-7] [Citation(s) in RCA: 163] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 09/07/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND This paper provides an up-to-date review of the management and outcome of accidental hypothermia patients with and without cardiac arrest. METHODS The authors reviewed the relevant literature in their specialist field. Summaries were merged, discussed and approved to produce this narrative review. RESULTS The hospital use of minimally-invasive rewarming for non-arrested, otherwise healthy, patients with primary hypothermia and stable vital signs has the potential to substantially decrease morbidity and mortality for these patients. Extracorporeal life support (ECLS) has revolutionised the management of hypothermic cardiac arrest, with survival rates approaching 100 % in some cases. Hypothermic patients with risk factors for imminent cardiac arrest (temperature <28 °C, ventricular arrhythmia, systolic blood pressure <90 mmHg), and those who have already arrested, should be transferred directly to an ECLS-centre. Cardiac arrest patients should receive continuous cardiopulmonary resuscitation (CPR) during transfer. If prolonged transport is required or terrain is difficult, mechanical CPR can be helpful. Delayed or intermittent CPR may be appropriate in hypothermic arrest when continuous CPR is impossible. Modern post-resuscitation care should be implemented following hypothermic arrest. Structured protocols should be in place to optimise pre-hospital triage, transport and treatment as well as in-hospital management, including detailed criteria and protocols for the use of ECLS and post-resuscitation care. CONCLUSIONS Based on new evidence, additional clinical experience and clearer management guidelines and documentation, the treatment of accidental hypothermia has been refined. ECLS has substantially improved survival and is the treatment of choice in the patient with unstable circulation or cardiac arrest.
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Affiliation(s)
- Peter Paal
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck University Hospital, Anichstr. 35, 6020 Innsbruck, Austria
- Barts Heart Centre, St Bartholomew’s Hospital, West Smithfield, Barts Health NHS Trust, Queen Mary University of London, KGV Building, Office 10, 1st floor, West Smithfield, London, EC1A 7BE UK
- International Commission of Mountain Emergency Medicine (ICAR MEDCOM), Kloten, Switzerland
| | - Les Gordon
- Department of Anaesthesia, University hospitals, Morecambe Bay Trust, Lancaster, UK
- Langdale Ambleside Mountain Rescue Team, Ambleside, UK
| | - Giacomo Strapazzon
- International Commission of Mountain Emergency Medicine (ICAR MEDCOM), Kloten, Switzerland
- Institute of Mountain Emergency Medicine, EURAC research, Drususallee 1, Bozen/Bolzano, Italy
| | - Monika Brodmann Maeder
- International Commission of Mountain Emergency Medicine (ICAR MEDCOM), Kloten, Switzerland
- Institute of Mountain Emergency Medicine, EURAC research, Drususallee 1, Bozen/Bolzano, Italy
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Gabriel Putzer
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck University Hospital, Anichstr. 35, 6020 Innsbruck, Austria
| | - Beat Walpoth
- Department of Surgery, Cardiovascular Research, Service of Cardiovascular Surgery, University Hospital Geneva, Geneva, Switzerland
| | - Michael Wanscher
- Department of Cardiothoracic Anaesthesia and Intensive Care 4142, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Doug Brown
- International Commission of Mountain Emergency Medicine (ICAR MEDCOM), Kloten, Switzerland
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
| | - Michael Holzer
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Gregor Broessner
- Department of Neurology, Neurologic Intensive Care Unit, Medical University of Innsbruck, Innsbruck, Austria
| | - Hermann Brugger
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck University Hospital, Anichstr. 35, 6020 Innsbruck, Austria
- Institute of Mountain Emergency Medicine, EURAC research, Drususallee 1, Bozen/Bolzano, Italy
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16
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Kornhall DK, Martens-Nielsen J. The prehospital management of avalanche victims. J ROY ARMY MED CORPS 2015; 162:406-412. [PMID: 26092971 DOI: 10.1136/jramc-2015-000441] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 05/31/2015] [Accepted: 06/01/2015] [Indexed: 12/26/2022]
Abstract
Avalanche accidents are frequently lethal events with an overall mortality of 23%. Mortality increases dramatically to 50% in instances of complete burial. With modern day dense networks of ambulance services and rescue helicopters, health workers often become involved during the early stages of avalanche rescue. Historically, some of the most devastating avalanche accidents have involved military personnel. Armed forces are frequently deployed to mountain regions in order to train for mountain warfare or as part of ongoing conflicts. Furthermore, military units are frequently called to assist civilian organised rescue in avalanche rescue operations. It is therefore important that clinicians associated with units operating in mountain regions have an understanding of, the medical management of avalanche victims, and of the preceding rescue phase. The ensuing review of the available literature aims to describe the pathophysiology particular to avalanche victims and to outline a structured approach to the search, rescue and prehospital medical management.
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Affiliation(s)
- Daniel K Kornhall
- Anesthesia and Critical Care Research Group, UIT-The Arctic University of Norway, Tromsø, Norway.,Department of Internal Medicine, Helgeland Hospital Trust, Sandnessjoen, Norway.,East Anglian Air Ambulance, Marshall Airfield, Cambridge, UK.,Department of Anaesthesiology, University Hospital of North Norway, Tromsoe, Norway.,Svolvaer Alpine Rescue Group, Svolvaer, Norway
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17
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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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18
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Negative inotropic effects of epinephrine in the presence of increased β-adrenoceptor sensitivity during hypothermia in a rat model. Cryobiology 2014; 70:9-16. [PMID: 25445571 DOI: 10.1016/j.cryobiol.2014.10.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 10/21/2014] [Accepted: 10/29/2014] [Indexed: 11/22/2022]
Abstract
BACKGROUND Animal studies show reduced inotropic effects of cardiac β-adrenoceptor agonists like epinephrine (Epi) during hypothermia and rewarming, while drugs targeting other pharmacological mechanisms have positive effects. This study therefore aimed to determine β-adrenoceptor sensitivity in isolated cardiomyocytes and investigate hemodynamic effects of Epi and its ability to stimulate cardiac β-adrenoceptors at different temperatures in vivo. METHODS Isolated rat myocardial cells were incubated with the radioactive β-adrenoceptor ligand [(3)H]-CGP12177 and propranolol, used as a displacer. Cells were subjected to normothermia (37 °C) or hypothermia (15 °C). After incubation, radioactivity was measured to estimate β-adrenoceptor affinity for propranolol (IC50), as a measure of β-adrenoceptor sensitivity. In separate in vivo experiments, Epi (1.25 μg/min) was administered the last 5min of experiments in normothermic (37 °C, 5h), hypothermic (4h at 15 °C) and rewarmed rats (4h at 15 °C, and subsequently rewarmed to 37 °C). Hemodynamic parameters were monitored during infusion. Hearts were thereafter freeze-clamped and tissue cAMP was measured. RESULTS In vitro measurements of IC50 for propranolol showed a hypothermia-induced increase in β-adrenoceptor sensitivity at 15 °C. Corresponding in vivo experiments at 15 °C showed decreased cardiac output and stroke volume, whereas total peripheral resistance (TPR) increased during Epi infusion, simultaneous with a 4-fold cAMP increase. CONCLUSIONS This experiment shows a hypothermia-induced in vivo and in vitro increase of cardiac β-adrenoceptor sensitivity, and simultaneous lack of inotropic effects of Epi in the presence of increased TPR. Our findings therefore indicate that hypothermia-induced reduction in inotropic effects of Epi is due to substantial elevation of TPR, rather than β-adrenoceptor dysfunction.
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Dietrichs ES, Håheim B, Kondratiev T, Sieck GC, Tveita T. Cardiovascular effects of levosimendan during rewarming from hypothermia in rat. Cryobiology 2014; 69:402-10. [PMID: 25280932 DOI: 10.1016/j.cryobiol.2014.09.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 09/18/2014] [Accepted: 09/22/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Previous research aimed at ameliorating hypothermia-induced cardiac dysfunction has shown that inotropic drugs, that stimulate the cAMP, - PKA pathway via the sarcolemmal β-receptor, have a decreased inotropic effect during hypothermia. We therefore wanted to test whether levosimendan, a calcium sensitizer and dose-dependent phosphodiesterase 3 (PDE3) inhibitor, is able to elevate stroke volume during rewarming from experimental hypothermia. METHODS A rat model designed for circulatory studies during experimental hypothermia (4h at 15°C) and rewarming was used. The following three groups were included: (1) A normothermic group receiving levosimendan, (2) a hypothermic group receiving levosimendan the last hour of stable hypothermia and during rewarming, and (3) a hypothermic placebo control group. Hemodynamic variables were monitored using a Millar conductance catheter in the left ventricle (LV), and a pressure transducer connected to the left femoral artery. In order to investigate the level of PKA stimulation by PDE3 inhibition, myocardial Ser23/24-cTnI phosphorylation was measured using Western-blot. RESULTS After rewarming, stroke volume (SV), cardiac output (CO) and preload recruitable stroke work (PRSW) were restored to within pre-hypothermic values in the levosimendan-treated animals. Compared to the placebo group after rewarming, SV, CO, PRSW, as well as levels of Ser23/24-cTnI phosphorylation, were significantly higher in the levosimendan-treated animals. CONCLUSION The present data shows that levosimendan ameliorates hypothermia-induced systolic dysfunction by elevating SV during rewarming from 15°C. Inotropic treatment during rewarming from hypothermia in the present rat model is therefore better achieved through calcium sensitizing and PDE3 inhibition, than β-receptor stimulation.
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Affiliation(s)
- Erik Sveberg Dietrichs
- Dept. of Research and Education, Norwegian Air Ambulance Foundation, 1441 Drøbak, Norway; Anesthesia and Critical Care Research Group, Institute of Clinical Medicine, UiT, The Arctic University of Norway, 9037 Tromsø, Norway.
| | - Brage Håheim
- Anesthesia and Critical Care Research Group, Institute of Clinical Medicine, UiT, The Arctic University of Norway, 9037 Tromsø, Norway; Dept. of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
| | - Timofei Kondratiev
- Anesthesia and Critical Care Research Group, Institute of Clinical Medicine, UiT, The Arctic University of Norway, 9037 Tromsø, Norway.
| | - Gary C Sieck
- Dept. of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine, Rochester, MN 55905, USA; Anesthesia and Critical Care Research Group, Institute of Clinical Medicine, UiT, The Arctic University of Norway, 9037 Tromsø, Norway.
| | - Torkjel Tveita
- Anesthesia and Critical Care Research Group, Institute of Clinical Medicine, UiT, The Arctic University of Norway, 9037 Tromsø, Norway; Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, 9038 Tromsø, Norway.
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Dietrichs ES, Kondratiev T, Tveita T. Milrinone ameliorates cardiac mechanical dysfunction after hypothermia in an intact rat model. Cryobiology 2014; 69:361-6. [PMID: 25224046 DOI: 10.1016/j.cryobiol.2014.09.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 08/21/2014] [Accepted: 09/02/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Rewarming from hypothermia is often complicated by cardiac dysfunction, characterized by substantial reduction in stroke volume. Previously we have reported that inotropic agents, working via cardiac β-receptor agonism may exert serious side effects when applied to treat cardiac contractile dysfunction during rewarming. In this study we tested whether Milrinone, a phosphodiesterase III inhibitor, is able to ameliorate such dysfunction when given during rewarming. METHODS A rat model designed for circulatory studies during experimental hypothermia with cooling to a core temperature of 15°C, stable hypothermia at this temperature for 3h and subsequent rewarming was used, with a total of 3 groups: (1) a normothermic group receiving Milrinone, (2) a hypothermic group receiving Milrinone the last hour of hypothermia and during rewarming, and (3) a hypothermic saline control group. Hemodynamic function was monitored using a conductance catheter introduced to the left ventricle. RESULTS After rewarming from 15°C, stroke volume and cardiac output returned to within baseline values in Milrinone treated animals, while these variables were significantly reduced in saline controls. CONCLUSIONS Milrinone ameliorated cardiac dysfunction during rewarming from 15°C. The present results suggest that at low core temperatures and during rewarming from such temperatures, pharmacologic efforts to support cardiovascular function is better achieved by substances preventing cyclic AMP breakdown rather than increasing its formation via β-receptor stimulation.
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Affiliation(s)
- Erik Sveberg Dietrichs
- Department of Research and Education, Norwegian Air Ambulance Foundation, 1441 Drøbak, Norway; Anesthesia and Critical Care Research Group, Institute of Clinical Medicine, UiT, The Arctic University of Norway, 9037 Tromsø, Norway.
| | - Timofei Kondratiev
- Anesthesia and Critical Care Research Group, Institute of Clinical Medicine, UiT, The Arctic University of Norway, 9037 Tromsø, Norway.
| | - Torkjel Tveita
- Anesthesia and Critical Care Research Group, Institute of Clinical Medicine, UiT, The Arctic University of Norway, 9037 Tromsø, Norway; Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, 9019 Tromsø, Norway.
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Hilmo J, Naesheim T, Gilbert M. “Nobody is dead until warm and dead”: Prolonged resuscitation is warranted in arrested hypothermic victims also in remote areas – A retrospective study from northern Norway. Resuscitation 2014; 85:1204-11. [DOI: 10.1016/j.resuscitation.2014.04.029] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Revised: 03/04/2014] [Accepted: 04/01/2014] [Indexed: 10/25/2022]
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Neurologic recovery from profound accidental hypothermia after 5 hours of cardiopulmonary resuscitation. Crit Care Med 2014; 42:e167-70. [PMID: 24158171 DOI: 10.1097/ccm.0b013e3182a643bc] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To describe the successful neurologic recovery from profound accidental hypothermia with cardiac arrest despite the longest reported duration of cardiopulmonary resuscitation. DESIGN Case report. SETTING Mountain. PATIENT A 57-year-old woman experienced profound accidental hypothermia (16.9°C) in a mountainous region of Grenoble. She was unconscious and had extreme bradycardia (6 beats/min) at presentation. A cardiac arrest occurred at the mobilization that was not responsive to electrical shocks or epinephrine. INTERVENTION Cardiopulmonary resuscitation was continued for 307 minutes after rescue until venoarterial extracorporeal membrane oxygenation blood flow had been established at the emergency department. MEASUREMENTS AND MAIN RESULTS At a 3-month follow-up, the patient showed good physical and mental recovery. CONCLUSION With no evidence of trauma or asphyxia, profound accidental hypothermia with cardiac arrest represents a specific condition for which successful neurologic recovery is feasible despite prolonged cardiopulmonary resuscitation.
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Meyer M, Pelurson N, Khabiri E, Siegenthaler N, Walpoth BH. Sequela-free long-term survival of a 65-year-old woman after 8 hours and 40 minutes of cardiac arrest from deep accidental hypothermia. J Thorac Cardiovasc Surg 2013; 147:e1-2. [PMID: 24176273 DOI: 10.1016/j.jtcvs.2013.08.085] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 08/01/2013] [Accepted: 08/16/2013] [Indexed: 12/21/2022]
Affiliation(s)
- Marie Meyer
- Service of Anesthesiology, University Hospital of Geneva, Geneva, Switzerland.
| | | | - Ebrahim Khabiri
- Service of Cardiovascular Surgery, University Hospital of Geneva, Geneva, Switzerland
| | - Nils Siegenthaler
- Service of Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | - Beat H Walpoth
- Service of Cardiovascular Surgery, University Hospital of Geneva, Geneva, Switzerland
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