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Falat C. Environmental Hypothermia. Emerg Med Clin North Am 2024; 42:493-511. [PMID: 38925770 DOI: 10.1016/j.emc.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
Although a rare diagnosis in the Emergency Department, hypothermia affects patients in all environments, from urban to mountainous settings. Classic signs of death cannot be interpreted in the hypothermic patient, thus resulting in the mantra, "No one is dead until they're warm and dead." This comprehensive review of environmental hypothermia covers the clinical significance and pathophysiology of hypothermia, pearls and pitfalls in the prehospital management of hypothermia (including temperature measurement techniques and advanced cardiac life support deviations), necessary Emergency Department diagnostics, available rewarming modalities including extracorporeal life support, and criteria for termination of resuscitation.
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Affiliation(s)
- Cheyenne Falat
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
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2
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Schanche T, Han YS, Jensen CW, Arteaga GM, Tveita T, Sieck GC. β-adrenergic stimulation after rewarming does not mitigate hypothermia-induced contractile dysfunction in rat cardiomyocytes. Cryobiology 2024; 116:104927. [PMID: 38857777 DOI: 10.1016/j.cryobiol.2024.104927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 06/06/2024] [Accepted: 06/06/2024] [Indexed: 06/12/2024]
Abstract
Victims of severe accidental hypothermia are frequently treated with catecholamines to counteract the hemodynamic instability associated with hypothermia-induced cardiac contractile dysfunction. However, we previously reported that the inotropic effects of epinephrine are diminished after hypothermia and rewarming (H/R) in an intact animal model. Thus, the goal of this study was to investigate the effects of Epi treatment on excitation-contraction coupling in isolated rat cardiomyocytes after H/R. In adult male rats, cardiomyocytes isolated from the left ventricle were electrically stimulated at 0.5 Hz and evoked cytosolic [Ca2+] and contractile responses (sarcomere length shortening) were measured. In initial experiments, the effects of varying concentrations of epinephrine on evoked cytosolic [Ca2+] and contractile responses at 37 °C were measured. In a second series of experiments, cardiomyocytes were cooled from 37 °C to 15 °C, maintained at 15 °C for 2 h, then rewarmed to 37 °C (H/R protocol). Immediately after rewarming, the effects of epinephrine treatment on evoked cytosolic [Ca2+] and contractile responses of cardiomyocytes were determined. At 37 °C, epinephrine treatment increased both cytosolic [Ca2+] and contractile responses of cardiomyocytes in a concentration-dependent manner peaking at 25-50 nM. The evoked contractile response of cardiomyocytes after H/R was reduced while the cytosolic [Ca2+] response was slightly elevated. The diminished contractile response of cardiomyocytes after H/R was not mitigated by epinephrine (25 nM) and epinephrine treatment reduced the exponential time decay constant (Tau), but did not increase the cytosolic [Ca2+] response. We conclude that epinephrine treatment does not mitigate H/R-induced contractile dysfunction in cardiomyocytes.
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Affiliation(s)
- Torstein Schanche
- Department of Physiology & Biomedical Engineering, Mayo Clinic Rochester, MN, USA; Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, 9037, Tromsø, Norway
| | - Young Soo Han
- Department of Physiology & Biomedical Engineering, Mayo Clinic Rochester, MN, USA
| | - Cole W Jensen
- Department of Physiology & Biomedical Engineering, Mayo Clinic Rochester, MN, USA
| | - Grace M Arteaga
- Department of Physiology & Biomedical Engineering, Mayo Clinic Rochester, MN, USA
| | - Torkjel Tveita
- Department of Physiology & Biomedical Engineering, Mayo Clinic Rochester, MN, USA; 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
| | - Gary C Sieck
- Department of Physiology & Biomedical Engineering, Mayo Clinic Rochester, MN, USA.
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Sugiyama K, Nomura O, Irie J, Ishizawa Y, Takauji S, Hayakawa M, Tamada Y, Hanada H. Effects of rewarming therapies on outcomes in accidental hypothermia: A secondary analysis of a multicenter prospective study. Am J Emerg Med 2024; 79:91-96. [PMID: 38412669 DOI: 10.1016/j.ajem.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 01/22/2024] [Accepted: 02/12/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND Rewarming therapies for accidental hypothermia (AH) include extracorporeal membrane oxygenation (ECMO) and non-ECMO related (conventional) therapies. However, there are limited data available to inform the selection of conventional rewarming therapy. The aim of the present study was to explore what patients' factors and which rewarming therapy predicted favorable prognosis. METHODS This study is a secondary analysis of the Intensive Care with Extra Corporeal membrane oxygenation Rewarming in Accidentally Severe Hypothermia (ICE-CRASH) study, a multicenter prospective, observational study conducted in Japan. Enrolled in the ICE-CRASH study were patients aged ≥18 years with a core temperature of ≤32 °C who were transported to the emergency departments of 36 tertiary care hospitals in Japan between 1 December 2019 and 31 March 2022, among whom those who were rewarmed with conventional rewarming therapy were included in the present study. Logistic regression analysis was performed with 28-day survival as the objective variable; and seven factors including age, activities of daily living (ADL) independence, sequential organ failure assessment (SOFA) score, and each rewarming technique as explanatory variables. We performed linear regression analysis to identify whether each rewarming technique was associated with rewarming rate. RESULTS Of the 499 patients enrolled in the ICE-CRASH study, 371 were eligible for this secondary analysis. The median age was 81 years, 50.9% were male, and the median initial body temperature was 28.8 °C. Age (odds ratio [OR]: 0.97, 95% confidence interval [CI]: 0.94-1.00) and SOFA score (OR: 0.73, 95% CI: 0.67-0.81) were associated with lower survival, whereas ADL independence (OR: 2.31, 95% CI: 1.15-4.63) was associated with higher survival. No conventional rewarming therapy was associated with 28-day survival. Hot bath was associated with a high rewarming rate (regression coefficient: 1.14, 95% CI: 0.75-1.53). CONCLUSION No conventional rewarming therapy was associated with improved 28-day survival, which suggests that background factors such as age, ADL, and severity of condition contribute more to prognosis than does the selection of rewarming technique.
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Affiliation(s)
- Kana Sugiyama
- Department of Emergency and Disaster Medicine, Hirosaki University, 5, Zaifu-cho, Hirosaki 036-8562, Japan.
| | - Osamu Nomura
- Department of Health Sciences Education, Hirosaki University, 5, Zaifu-cho, Hirosaki 036-8562, Japan
| | - Jin Irie
- Department of Emergency Medicine, Hirosaki General Medical Center, 1, Tomino-cho, Hirosaki 036-8545, Japan
| | - Yoshiya Ishizawa
- Department of Emergency and Critical Care Center, Aomori Prefectural Central, Hospital, 2-1-1, Higashitsukurimichi, Aomori 030-8553, Japan
| | - Shuhei Takauji
- Emergency and Critical Care Center, Hokkaido University Hospital, N15W7, Kita-ku, Sapporo 060-8648, Japan
| | - Mineji Hayakawa
- Emergency and Critical Care Center, Hokkaido University Hospital, N15W7, Kita-ku, Sapporo 060-8648, Japan
| | - Yoshinori Tamada
- Department of Medical Data Intelligence, Hirosaki University, 5, Zaifu-cho, Hirosaki 036-8562, Japan
| | - Hiroyuki Hanada
- Department of Emergency and Disaster Medicine, Hirosaki University, 5, Zaifu-cho, Hirosaki 036-8562, Japan
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Podsiadło P, Smoleń A, Brožek T, Kosiński S, Balik M, Hymczak H, Cools E, Walpoth B, Nowak E, Dąbrowski W, Miazgowski B, Witt-Majchrzak A, Jędrzejczak T, Reszka K, Segond N, Debaty G, Dudek M, Górski S, Darocha T. Extracorporeal Rewarming Is Associated With Increased Survival Rate in Severely Hypothermic Patients With Preserved Spontaneous Circulation. ASAIO J 2023; 69:749-755. [PMID: 37039862 DOI: 10.1097/mat.0000000000001935] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023] Open
Abstract
Treatment recommendations for rewarming patients in severe accidental hypothermia with preserved spontaneous circulation have a weak evidence due to the absence of randomized clinical trials. We aimed to compare the outcomes of extracorporeal versus less-invasive rewarming of severely hypothermic patients with preserved spontaneous circulation. We conducted a multicenter retrospective study. The patient population was compiled based on data from the HELP Registry, the International Hypothermia Registry, and a literature review. Adult patients with a core temperature <28°C and preserved spontaneous circulation were included. Patients who underwent extracorporeal rewarming were compared with patients rewarmed with less-invasive methods, using a matched-pair analysis. The study population consisted of 50 patients rewarmed extracorporeally and 85 patients rewarmed with other, less-invasive methods. Variables significantly associated with survival included: lower age; outdoor cooling circumstances; higher blood pressure; higher PaCO 2 ; higher BE; higher HCO 3 ; and the absence of comorbidities. The survival rate was higher in patients rewarmed extracorporeally ( p = 0.049). The relative risk of death was twice as high in patients rewarmed less invasively. Based on our data, we conclude that patients in severe accidental hypothermia with circulatory instability can benefit from extracorporeal rewarming without an increased risk of complications.
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Affiliation(s)
- Paweł Podsiadło
- From the Department of Emergency Medicine, Jan Kochanowski University, Kielce, Poland
| | - Agata Smoleń
- Department of Epidemiology and Clinical Research Methodology, Medical University of Lublin, Poland
| | - Tomáš Brožek
- Department of Anaesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Sylweriusz Kosiński
- Faculty of Health Sciences, Jagiellonian University Medical College, Kraków, Poland
| | - Martin Balik
- Department of Anaesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Hubert Hymczak
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Kraków University, Kraków, Poland
| | - Evelien Cools
- Department of Acute Medicine, Division of Anaesthesiology, University Hospitals, Geneva, Switzerland
| | - Beat Walpoth
- Emeritus. Department of Cardiovascular Surgery, University Hospitals of Geneva, Switzerland
| | - Ewelina Nowak
- Institute of Health Sciences, Jan Kochanowski University, Kielce, Poland
| | - Wojciech Dąbrowski
- Department of Anaesthesiology and Intensive Care, Medical University of Lublin, Poland
| | - Bartosz Miazgowski
- Emergency Department, University Hospital, Pomeranian Medical University, Szczecin, Poland
| | - Anna Witt-Majchrzak
- Department of Cardiac Surgery Provincial Specialist Hospital, Olsztyn, Poland
| | - Tomasz Jędrzejczak
- Department of Cardiosurgery, Pomeranian Medical University in Szczecin, Poland
| | - Kacper Reszka
- Department of Anaesthesiology and Intensive Care, University Hospital, Łódź, Poland
| | - Nicolas Segond
- Univ. Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, CHU Grenoble Alpes, TIMC, Grenoble, France
| | - Guillaume Debaty
- Univ. Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, CHU Grenoble Alpes, TIMC, Grenoble, France
| | - Michał Dudek
- Department of Emergency Medicine, Faculty of Health Sciences, University of Bielsko-Biała, Poland
| | - Stanisław Górski
- Department of Medical Education, Jagiellonian University Medical College, Kraków, Poland
| | - Tomasz Darocha
- Department of Anaesthesiology and Intensive Care, Medical University of Silesia, Katowice, Poland
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Ushimoto T, Murasaka K, Wato Y, Inaba H. Associations between prehospital defibrillation and outcomes of out-of-hospital cardiac arrests presumed to be caused by hypothermia: A nationwide observational study with epidemiological analysis. Medicine (Baltimore) 2023; 102:e33618. [PMID: 37115090 PMCID: PMC10146074 DOI: 10.1097/md.0000000000033618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/03/2023] [Accepted: 04/04/2023] [Indexed: 04/29/2023] Open
Abstract
This study aimed to clarify the epidemiology of out of-hospital cardiac arrest (OHCA) cases caused by hypothermia. The associations between the presence/absence of shockable initial electrocardiography rhythm, prehospital defibrillation and the outcomes of OHCA were also investigated. This study involved the retrospective analysis of prospectively collected, nationwide, population-based data for OHCA cases caused by hypothermia. One thousand five hundred seventy-five emergency medical service (EMS)-confirmed OHCA cases with hypothermia, recorded between 2013 and 2019, were extracted from the Japanese nationwide database. The primary outcome was neurologically favorable 1-month survival, defined as cerebral performance category 1 or 2. The secondary outcome was 1-month survival. OHCA cases with hypothermia occurred more frequently in the winter. In approximately half (837) of the hypothermic OHCA cases, EMS was activated in the morning (6:00 am to 11:59 am). Shockable initial electrocardiogram rhythms were recorded in 30.8% (483/1570) of cases. prehospital defibrillation was attempted in 96.1% (464/483) of cases with shockable rhythms and 25.8% (280/1087) of cases with non-shockable initial rhythms. EMS-witnessed cases, prolonged transportation time intervals and prehospital epinephrine administration were associated with rhythm conversion in cases with non-shockable initial rhythms. Binominal logit test followed by multivariable logistic regression revealed that shockable initial rhythms were associated with better outcomes. prehospital defibrillation was not significantly associated with better outcomes, regardless of the type of initial rhythm (shockable or non-shockable). Transportation to high-level emergency hospitals was associated with better outcomes (adjusted odds ratio: 2.94, 95% confidence interval: 1.66-5.21). In hypothermic OHCA, shockable initial rhythm but not prehospital defibrillation is likely to be associated with better neurologically favorable outcomes. In addition, transport to a high-level acute care hospital may be appropriately considered despite prolonged transport. Further investigation, including core temperature data in analyses, is necessary to determine the benefit of prehospital defibrillation in hypothermic OHCA.
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Affiliation(s)
- Tomoyuki Ushimoto
- Department of Emergency Medicine, Kanazawa Medical University, Uchinada, Japan
| | - Kenshi Murasaka
- Department of Emergency Medicine, Kanazawa Medical University, Uchinada, Japan
| | - Yukihiro Wato
- Department of Emergency Medicine, Kanazawa Medical University, Uchinada, Japan
| | - Hideo Inaba
- Department of Emergency Medicine, Kanazawa Medical University, Uchinada, Japan
- Kanazawa University, Kanazawa, Japan
- Department of Emergency Medical Sciences, Niigata University of Health and Welfare, Niigata, Japan
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Yamamoto R, Yoshizawa J, Takauji S, Hayakawa M, Sasaki J. Hyperoxia for accidental hypothermia and increased mortality: a post-hoc analysis of a multicenter prospective observational study. Crit Care 2023; 27:131. [PMID: 37005646 PMCID: PMC10067299 DOI: 10.1186/s13054-023-04407-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/16/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND Supraphysiologic oxygen administration causes unfavorable clinical outcomes in various diseases, including traumatic brain injury, post-cardiac arrest syndrome, and acute lung injury. Accidental hypothermia is a critical illness that reduces oxygen demands, and excessive oxygen is likely to emerge. This study aimed to determine whether hyperoxia would be associated with increased mortality in patients with accidental hypothermia. METHODS A post-hoc analysis of a nationwide multicenter prospective observational study (ICE-CRASH study) on patients with accidental hypothermia admitted in 2019-2022 was conducted. Adult patients without cardiac arrest whose core body temperature was < 32 °C and whose arterial partial pressure of oxygen (PaO2) was measured at the emergency department were included. Hyperoxia was defined as a PaO2 level of 300 mmHg or higher, and 28-day mortality was compared between patients with and without hyperoxia before rewarming. Inverse probability weighting (IPW) analyses with propensity scores were performed to adjust patient demographics, comorbidities, etiology and severity of hypothermia, hemodynamic status and laboratories on arrival, and institution characteristics. Subgroup analyses were conducted according to age, chronic cardiopulmonary diseases, hemodynamic instability, and severity of hypothermia. RESULTS Of the 338 patients who were eligible for the study, 65 had hyperoxia before rewarming. Patients with hyperoxia had a higher 28-day mortality rate than those without (25 (39.1%) vs. 51 (19.5%); odds ratio (OR) 2.65 (95% confidence interval 1.47-4.78); p < 0.001). IPW analyses with propensity scores revealed similar results (adjusted OR 1.65 (1.14-2.38); p = 0.008). Subgroup analyses showed that hyperoxia was harmful in the elderly and those with cardiopulmonary diseases and severe hypothermia below 28 °C, whereas hyperoxia exposure had no effect on mortality in patients with hemodynamic instability on hospital arrival. CONCLUSIONS Hyperoxia with PaO2 levels of 300 mmHg or higher before initiating rewarming was associated with increased 28-day mortality in patients with accidental hypothermia. The amount of oxygen to administer to patients with accidental hypothermia should be carefully determined. TRIAL REGISTRATION The ICE-CRASH study was registered at the University Hospital Medical Information Network Clinical Trial Registry on April 1, 2019 (UMIN-CTR ID, UMIN000036132).
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Affiliation(s)
- Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan.
| | - Jo Yoshizawa
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Shuhei Takauji
- Department of Emergency Medicine, Asahikawa Medical University Hospital, Asahikawa, Japan
| | - Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
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Takauji S, Hayakawa M, Yamada D, Tian T, Minowa K, Inoue A, Fujimoto Y, Isokawa S, Miura N, Endo T, Irie J, Otomo G, Sato H, Bando K, Suzuki T, Toyohara T, Tomita A, Iwahara M, Murata S, Shimazaki J, Matsuyoshi T, Yoshizawa J, Nitta K, Sato Y. Outcome of extracorporeal membrane oxygenation use in severe accidental hypothermia with cardiac arrest and circulatory instability: A multicentre, prospective, observational study in Japan (ICE-CRASH study). Resuscitation 2023; 182:109663. [PMID: 36509361 DOI: 10.1016/j.resuscitation.2022.12.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/30/2022] [Accepted: 12/03/2022] [Indexed: 12/14/2022]
Abstract
AIM To elucidate the effectiveness of extracorporeal membrane oxygenation (ECMO) in accidental hypothermia (AH) patients with and without cardiac arrest (CA), including details of complications. METHODS This study was a multicentre, prospective, observational study of AH in Japan. All adult (aged ≥18 years) AH patients with body temperature ≤32 °C who presented to the emergency department between December 2019 and March 2022 were included. Among the patients, those with CA or circulatory instability, defined as severe AH, were selected and divided into the ECMO and non-ECMO groups. We compared 28-day survival and favourable neurological outcomes at discharge between the ECMO and non-ECMO groups by adjusting for the patients' background characteristics using multivariable logistic regression analysis. RESULTS Among the 499 patients in this study, 242 patients with severe AH were included in the analysis: 41 in the ECMO group and 201 in the non-ECMO group. Multivariable analysis showed that the ECMO group was significantly associated with better 28-day survival and favourable neurological outcomes at discharge in patients with CA compared to the non-ECMO group (odds ratio [OR] 0.17, 95% confidence interval [CI]: 0.05-0.58, and OR 0.22, 95%CI: 0.06-0.81). However, in patients without CA, ECMO not only did not improve 28-day survival and neurological outcomes, but also decreased the number of event-free days (ICU-, ventilator-, and catecholamine administration-free days) and increased the frequency of bleeding complications. CONCLUSIONS ECMO improved survival and neurological outcomes in AH patients with CA, but not in AH patients without CA.
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Affiliation(s)
- Shuhei Takauji
- Department of Emergency Medicine, Asahikawa Medical University Hospital, Asahikawa, Japan.
| | - Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Daisuke Yamada
- Senri Critical Care Medical Center, Saiseikai Senri Hospital, Suita, Japan
| | - Tian Tian
- Emergency and Critical Care Medical Center, Kishiwada Tokushukai Hospital, Osaka, Japan
| | - Keita Minowa
- Department of Emergency and Critical Care Medicine, Hachinohe City Hospital, Hachinohe, Japan
| | - Akihiko Inoue
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Japan
| | - Yoshihiro Fujimoto
- Department of Emergency Medicine, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Shutaro Isokawa
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Naoya Miura
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Tokai, Japan
| | - Tomoyuki Endo
- Department of Emergency and Disaster Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Jin Irie
- Department of Emergency and Disaster Medicine, Hirosaki University, Hirosaki, Japan
| | - Gen Otomo
- Emergency and Critical Care Medicine, Asahikawa Red Cross Hospital, Asahikawa, Japan
| | - Hiroki Sato
- Critical Care and Emergency Center National Hospital Organization Hokkaido Medical Center, Sapporo, Japan
| | - Keisuke Bando
- Department of Emergency Medicine and Critical Care, Sapporo City General Hospital, Sapporo, Japan
| | - Tsuyoshi Suzuki
- Department of Emergency and Critical Care Medicine, Fukushima Medical University, Fukushima City, Fukushima, Japan
| | - Takashi Toyohara
- Department of Emergency Medicine, Kushiro City General Hospital, Kushiro, Japan
| | - Akiko Tomita
- Department of Emergency Medicine, Sunagawa City Medical Center, Sunagawa, Japan
| | - Motoko Iwahara
- Department of Emergency Medicine, Nayoro City General Hospital, Nayoro, Japan
| | - Satoru Murata
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Junya Shimazaki
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takeo Matsuyoshi
- Emergency and Critical Care Center, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Jo Yoshizawa
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kenichi Nitta
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yuta Sato
- Emergency and Critical Care Center, Aomori Prefectural Central Hospital, Aomori, Japan
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Selli AL, Kuzmiszyn AK, Smaglyukova N, Kondratiev T, Fuskevåg OM, Sager G, Dietrichs ES. Pharmacodynamic properties for inhibition of cAMP- and cGMP elimination by pentoxifylline remain unaltered in vitro during hypothermia. Scand J Trauma Resusc Emerg Med 2022; 30:73. [PMID: 36522632 PMCID: PMC9756503 DOI: 10.1186/s13049-022-01060-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 11/30/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Rewarming from hypothermia is associated with severe complications, one of which is hypothermia-induced cardiac dysfunction. This condition is characterized by decreased cardiac output accompanied by increased total peripheral resistance. This contributes to mortality rate approaching 40%. Despite this, no pharmacological interventions are recommended for these patients below 30 °C. Raising the intracellular levels of cAMP and/or cGMP, through PDE3- and PDE5-inhibitors respectively, have showed the ability to alleviate hypothermia-induced cardiac dysfunction in vivo. Drugs that raise levels of both cAMP and cGMP could therefore prove beneficial in patients suffering from hypothermia-induced cardiac dysfunction. METHODS The unselective PDE-inhibitor pentoxifylline was investigated to determine its ability to reach the intracellular space, inhibit PDE3 and PDE5 and inhibit cellular efflux of cAMP and cGMP at temperatures 37, 34, 30, 28, 24 and 20 °C. Recombinant human PDE-enzymes and human erythrocytes were used in the experiments. IC50-values were calculated at all temperatures to determine temperature-dependent changes. RESULTS At 20 °C, the IC50-value for PDE5-mediated enzymatic breakdown of cGMP was significantly increased compared to normothermia (IC50: 39.4 µM ± 10.9 µM vs. 7.70 µM ± 0.265 µM, p-value = 0.011). No other significant changes in IC50-values were observed during hypothermia. CONCLUSIONS This study shows that pentoxifylline has minimal temperature-dependent pharmacodynamic changes, and that it can inhibit elimination of both cAMP and cGMP at low temperatures. This can potentially be effective treatment of hypothermia-induced cardiac dysfunction. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Anders Lund Selli
- grid.10919.300000000122595234Department of Medical Biology, Experimental and Clinical Pharmacology, UiT – The Arctic University of Norway, Tromsø, Norway
| | - Adrina Kalasho Kuzmiszyn
- grid.10919.300000000122595234Department of Medical Biology, Experimental and Clinical Pharmacology, UiT – The Arctic University of Norway, Tromsø, Norway ,grid.420120.50000 0004 0481 3017Research and Development Department, Norwegian Air Ambulance Foundation, Oslo, Norway ,grid.412244.50000 0004 4689 5540Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
| | - Natalia Smaglyukova
- grid.10919.300000000122595234Department of Medical Biology, Experimental and Clinical Pharmacology, UiT – The Arctic University of Norway, Tromsø, Norway
| | - Timofey Kondratiev
- grid.10919.300000000122595234Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Ole-Martin Fuskevåg
- grid.412244.50000 0004 4689 5540Division of Diagnostic Services, Department of Laboratory Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Georg Sager
- grid.10919.300000000122595234Department of Medical Biology, Experimental and Clinical Pharmacology, UiT – The Arctic University of Norway, Tromsø, Norway
| | - Erik Sveberg Dietrichs
- grid.10919.300000000122595234Department of Medical Biology, Experimental and Clinical Pharmacology, UiT – The Arctic University of Norway, Tromsø, Norway ,grid.413684.c0000 0004 0512 8628Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
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9
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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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10
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Kuzmiszyn AK, Selli AL, Smaglyukova N, Kondratiev T, Fuskevåg OM, Lyså RA, Ravna AW, Tveita T, Sager G, Dietrichs ES. Treatment of Cardiovascular Dysfunction with PDE3-Inhibitors in Moderate and Severe Hypothermia—Effects on Cellular Elimination of Cyclic Adenosine Monophosphate and Cyclic Guanosine Monophosphate. Front Physiol 2022; 13:923091. [PMID: 35910566 PMCID: PMC9326216 DOI: 10.3389/fphys.2022.923091] [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: 04/18/2022] [Accepted: 06/24/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction: Rewarming from accidental hypothermia is often complicated by hypothermia-induced cardiovascular dysfunction, which could lead to shock. Current guidelines do not recommend any pharmacological treatment at core temperatures below 30°C, due to lack of knowledge. However, previous in vivo studies have shown promising results when using phosphodiesterase 3 (PDE3) inhibitors, which possess the combined effects of supporting cardiac function and alleviating the peripheral vascular resistance through changes in cyclic nucleotide levels. This study therefore aims to investigate whether PDE3 inhibitors milrinone, amrinone, and levosimendan are able to modulate cyclic nucleotide regulation in hypothermic settings. Materials and methods: The effect of PDE3 inhibitors were studied by using recombinant phosphodiesterase enzymes and inverted erythrocyte membranes at six different temperatures—37°C, 34°C, 32°C, 28°C, 24°C, and 20°C- in order to evaluate the degree of enzymatic degradation, as well as measuring cellular efflux of both cAMP and cGMP. The resulting dose-response curves at every temperature were used to calculate IC50 and Ki values. Results: Milrinone IC50 and Ki values for cGMP efflux were significantly lower at 24°C (IC50: 8.62 ± 2.69 µM) and 20°C (IC50: 7.35 ± 3.51 µM), compared to 37°C (IC50: 22.84 ± 1.52 µM). There were no significant changes in IC50 and Ki values for enzymatic breakdown of cAMP and cGMP. Conclusion: Milrinone, amrinone and levosimendan, were all able to suppress enzymatic degradation and inhibit extrusion of cGMP and cAMP below 30°C. Our results show that these drugs have preserved effect on their target molecules during hypothermia, indicating that they could provide an important treatment option for hypothermia-induced cardiac dysfunction.
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Affiliation(s)
- Adrina Kalasho Kuzmiszyn
- Norwegian Air Ambulance Foundation, Research and Development Department, Oslo, Norway
- Experimental and Clinical Pharmacology, Department of Medical Biology, UiT The Arctic University of Norway, Tromsø, Norway
- Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
| | - Anders Lund Selli
- Experimental and Clinical Pharmacology, Department of Medical Biology, UiT The Arctic University of Norway, Tromsø, Norway
| | - Natalia Smaglyukova
- Experimental and Clinical Pharmacology, Department of Medical Biology, 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
| | - Ole-Martin Fuskevåg
- Department of Laboratory Medicine, Division of Diagnostic Services, University Hospital of North Norway, Tromsø, Norway
| | - Roy Andre Lyså
- Experimental and Clinical Pharmacology, Department of Medical Biology, UiT The Arctic University of Norway, Tromsø, Norway
| | - Aina Westrheim Ravna
- Experimental and Clinical Pharmacology, Department of Medical Biology, UiT The Arctic University of Norway, Tromsø, Norway
| | - Torkjel Tveita
- Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Georg Sager
- Experimental and Clinical Pharmacology, Department of Medical Biology, UiT The Arctic University of Norway, Tromsø, Norway
| | - Erik Sveberg Dietrichs
- Experimental and Clinical Pharmacology, Department of Medical Biology, UiT The Arctic University of Norway, Tromsø, Norway
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
- *Correspondence: Erik Sveberg Dietrichs,
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11
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Filseth OM, Hermansen SE, Kondratiev T, Sieck GC, Tveita T. Cooling to Hypothermic Circulatory Arrest by Immersion vs. Cardiopulmonary Bypass (CPB): Worse Outcome After Rewarming in Immersion Cooled Pigs. Front Physiol 2022; 13:862729. [PMID: 35431978 PMCID: PMC9008231 DOI: 10.3389/fphys.2022.862729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 02/25/2022] [Indexed: 12/04/2022] Open
Abstract
Introduction Cooling by cardiopulmonary bypass (CPB) to deep hypothermic cardiac arrest (HCA) for cardiac surgical interventions, followed by CPB-rewarming is performed on a routine basis with relatively low mortality. In contrast, victims of deep accidental hypothermia rewarmed with CPB generally have a much worse prognosis. Thus, we have developed an intact pig model to compare effects on perfusion pressures and global oxygen delivery (DO2) during immersion cooling versus cooling by CPB. Further, we compared the effects of CPB-rewarming between groups, to restitute cardiovascular function, brain blood flow, and brain metabolism. Materials and Methods Total sixteen healthy, anesthetized juvenile (2–3 months) castrated male pigs were randomized in a prospective, open placebo-controlled experimental study to immersion cooling (IMMc, n = 8), or cooling by CPB (CPBc, n = 8). After 75 minutes of deep HCA in both groups, pigs were rewarmed by CPB. After weaning from CPB surviving animals were observed for 2 h before euthanasia. Results Survival rates at 2 h after completed rewarming were 4 out of 8 in the IMMc group, and 8 out of 8 in the CPBc group. Compared with the CPBc-group, IMMc animals showed significant reduction in DO2, mean arterial pressure (MAP), cerebral perfusion pressure, and blood flow during cooling below 25°C as well as after weaning from CPB after rewarming. After rewarming, brain blood flow returned to control in CPBc animals only, and brain micro dialysate-data showed a significantly increase in the lactate/pyruvate ratio in IMMc vs. CPBc animals. Conclusion Our data indicate that, although global O2 consumption was independent of DO2, regional ischemic damage may have taken place during cooling in the brain of IMMc animals below 25°C. The need for prolonged extracorporeal membrane oxygenation (ECMO) should be considered in all victims of accidental hypothermic arrest that cannot be weaned from CPB immediately after rewarming.
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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
| | - Stig Eggen Hermansen
- Cardiothoracic Research Group, Faculty of Health Sciences, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
- Cardiothoracic and Respiratory Medicine, 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 College of Medicine & Science, 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 College of Medicine & Science, Rochester, MN, United States
- *Correspondence: Torkjel Tveita,
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12
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Paal P, Pasquier M, Darocha T, Lechner R, Kosinski S, Wallner B, Zafren K, Brugger H. Accidental Hypothermia: 2021 Update. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:501. [PMID: 35010760 PMCID: PMC8744717 DOI: 10.3390/ijerph19010501] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 12/08/2021] [Accepted: 12/09/2021] [Indexed: 12/13/2022]
Abstract
Accidental hypothermia is an unintentional drop of core temperature below 35 °C. Annually, thousands die of primary hypothermia and an unknown number die of secondary hypothermia worldwide. Hypothermia can be expected in emergency patients in the prehospital phase. Injured and intoxicated patients cool quickly even in subtropical regions. Preventive measures are important to avoid hypothermia or cooling in ill or injured patients. Diagnosis and assessment of the risk of cardiac arrest are based on clinical signs and core temperature measurement when available. Hypothermic patients with risk factors for imminent cardiac arrest (temperature < 30 °C in young and healthy patients and <32 °C in elderly persons, or patients with multiple comorbidities), ventricular dysrhythmias, or systolic blood pressure < 90 mmHg) and hypothermic patients who are already in cardiac arrest, should be transferred directly to an extracorporeal life support (ECLS) centre. If a hypothermic patient arrests, continuous cardiopulmonary resuscitation (CPR) should be performed. In hypothermic patients, the chances of survival and good neurological outcome are higher than for normothermic patients for witnessed, unwitnessed and asystolic cardiac arrest. Mechanical CPR devices should be used for prolonged rescue, if available. In severely hypothermic patients in cardiac arrest, if continuous or mechanical CPR is not possible, intermittent CPR should be used. Rewarming can be accomplished by passive and active techniques. Most often, passive and active external techniques are used. Only in patients with refractory hypothermia or cardiac arrest are internal rewarming techniques required. ECLS rewarming should be performed with extracorporeal membrane oxygenation (ECMO). A post-resuscitation care bundle should complement treatment.
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Affiliation(s)
- Peter Paal
- Department of Anesthesiology and Intensive Care Medicine, St. John of God Hospital, Paracelsus Medical University, 5020 Salzburg, Austria
- International Commission for Mountain Emergency Medicine (ICAR MedCom), 8302 Kloten, Switzerland; (M.P.); (K.Z.); (H.B.)
| | - Mathieu Pasquier
- International Commission for Mountain Emergency Medicine (ICAR MedCom), 8302 Kloten, Switzerland; (M.P.); (K.Z.); (H.B.)
- Department of Emergency Medicine, Lausanne University Hospital, 1011 Lausanne, Switzerland
| | - Tomasz Darocha
- Department of Anesthesiology and Intensive Care, Medical University of Silesia, 40-001 Katowice, Poland;
| | - Raimund Lechner
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Military Hospital, 89081 Ulm, Germany;
| | - Sylweriusz Kosinski
- Faculty of Health Sciences, Jagiellonian University Medical College, 34-500 Krakow, Poland;
| | - Bernd Wallner
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria;
| | - Ken Zafren
- International Commission for Mountain Emergency Medicine (ICAR MedCom), 8302 Kloten, Switzerland; (M.P.); (K.Z.); (H.B.)
- Department of Emergency Medicine, Alaska Native Medical Center, Anchorage, AK 99508, USA
- Department of Emergency Medicine, Stanford University Medical Center, Stanford University, Palo Alto, CA 94304, USA
| | - Hermann Brugger
- International Commission for Mountain Emergency Medicine (ICAR MedCom), 8302 Kloten, Switzerland; (M.P.); (K.Z.); (H.B.)
- Institute of Mountain Emergency Medicine, Eurac Research, 39100 Bolzano, Italy
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria
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13
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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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14
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Takauji S, Hifumi T, Saijo Y, Yokobori S, Kanda J, Kondo Y, Hayashida K, Shimazaki J, Moriya T, Yagi M, Yamaguchi J, Okada Y, Okano Y, Kaneko H, Kobayashi T, Fujita M, Shimizu K, Yokota H. Accidental hypothermia: characteristics, outcomes, and prognostic factors-A nationwide observational study in Japan (Hypothermia study 2018 and 2019). Acute Med Surg 2021; 8:e694. [PMID: 34567577 PMCID: PMC8448583 DOI: 10.1002/ams2.694] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/06/2021] [Accepted: 08/28/2021] [Indexed: 12/25/2022] Open
Abstract
Aim This study describes the clinical characteristics and outcomes as well as the prognostic factors of patients with accidental hypothermia (AH) using Japan’s nationwide registry data. Methods The Hypothermia study 2018 and 2019, which included patients aged 18 years or older with a body temperature of 35°C or less, was a multicenter registry conducted at 87 and 89 institutions throughout Japan, with data collected from December 2018 to February 2019 and December 2019 to February 2020, respectively. Results In total, 1363 patients were enrolled in the registry, of which 1194 were analyzed in this study. The median (interquartile range) age was 79 (68–87) years, and the median (interquartile range) body temperature at the emergency department was 30.8°C (28.4–33.6°C). Forty‐three percent of patients with AH had a mild condition, 35.2% moderate, and 21.9% severe. AH occurred in an indoor setting in 73.4% and was caused by acute medical illness in 49.3% of patients. A total of 101 (8.5%) patients suffered from cardiopulmonary arrest on arrival at the hospital. The overall 30‐day mortality rate was 24.5%, the median (interquartile range) intensive care unit stay was 4 (2–7) days, and the median (interquartile range) hospital stay was 13 (4–27) days. In the multivariable logistic analysis, the prognostic factors were age (≥75 years old), male, activities of daily living (needing total assistance), cause of AH (trauma, alcohol), Glasgow Coma Scale score, and potassium level (>5.5 mEq/L). Conclusion The mortality rate of AH was 24.5% in Japan. The prognostic factors developed in this study may be useful for the early prediction, prevention, and awareness of severe AH.
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Affiliation(s)
- Shuhei Takauji
- Department of Emergency Medicine Asahikawa Medical University Hospital Asahikawa Japan.,Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan
| | - Toru Hifumi
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan.,Department of Emergency and Critical Care Medicine St. Luke's International Hospital Tokyo Japan
| | - Yasuaki Saijo
- Department of Social Medicine Asahikawa Medical University Asahikawa Japan
| | - Shoji Yokobori
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan.,Department of Emergency and Critical Care Medicine Nippon Medical School Tokyo Japan
| | - Jun Kanda
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan.,Department of Emergency Medicine Teikyo University Hospital Tokyo Japan
| | - Yutaka Kondo
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan.,Department of Emergency and Critical Care Medicine Juntendo University Urayasu Hospital Urayasu Japan
| | - Kei Hayashida
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan.,Department of Emergency Medicine North Shore University Hospital Northwell Health System Manhasset NY USA
| | - Junya Shimazaki
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan.,Department of Traumatology and Acute Critical Medicine Osaka University Graduate School Osaka Japan
| | - Takashi Moriya
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan.,Department of Emergency and Critical Care Medicine Jichi Medical University Saitama Medical Center Omiya Japan
| | - Masaharu Yagi
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan.,Department of Emergency, Disaster and Critical Care Medicine Showa University School of Medicine Tokyo Japan
| | - Junko Yamaguchi
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan.,Department of Acute Medicine Nihon University School of Medicine Tokyo Japan
| | - Yohei Okada
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan.,Department of Primary Care and Emergency Medicine Graduate School of Medicine Kyoto University Kyoto Japan
| | - Yuichi Okano
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan.,Department of Emergency Medicine Japanese Red Cross Kumamoto Hospital Kumamoto Japan
| | - Hitoshi Kaneko
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan.,Emergency and Critical Care Center Tokyo Metropolitan Tama Medical Center Tokyo Japan
| | - Tatsuho Kobayashi
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan.,Department of Emergency and Critical Care Medicine Aizu Chuo Hospital Aizu Wakamatsu Japan
| | - Motoki Fujita
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan.,Advanced Medical Emergency and Critical Care Center Yamaguchi University Hospital Ube Japan
| | - Keiki Shimizu
- Emergency and Critical Care Center Tokyo Metropolitan Tama Medical Center Tokyo Japan
| | - Hiroyuki Yokota
- Japan Association of Acute Medicine Heatstroke and Hypothermia Surveillance Committee Tokyo Japan.,Department of Emergency and Critical Care Medicine Nippon Medical School Tokyo Japan
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15
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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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16
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Walpoth BH, Maeder MB, Courvoisier DS, Meyer M, Cools E, Darocha T, Blancher M, Champly F, Mantovani L, Lovis C, Mair P. Hypothermic Cardiac Arrest - Retrospective cohort study from the International Hypothermia Registry. Resuscitation 2021; 167:58-65. [PMID: 34416307 DOI: 10.1016/j.resuscitation.2021.08.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 08/01/2021] [Accepted: 08/12/2021] [Indexed: 11/25/2022]
Abstract
AIM The International Hypothermia Registry (IHR) was created to increase knowledge of accidental hypothermia, particularly to develop evidence-based guidelines and find reliable outcome predictors. The present study compares hypothermic patients with and without cardiac arrest included in the IHR. METHODS Demographic, pre-hospital and in-hospital data, method of rewarming and outcome data were collected anonymously in the IHR between 2010 and 2020. RESULTS Two hundred and one non-consecutive cases were included. The major causeof hypothermia was mountain accidents, predominantly in young men. Hypothermic Cardiac Arrest (HCA) occurred in 73 of 201 patients. Core temperature was significantly lower in the patients in cardiac arrest (25.0 vs. 30.0 °C, p < 0.001). One hundred and fifteen patients were rewarmed externally (93% with ROSC), 53 by extra-corporeal life support (ECLS) (40% with ROSC) and 21 with invasive internal techniques (71% with ROSC). The overall survival rate was 95% for patients with preserved circulation and 36% for those in cardiac arrest. Witnessed cardiac arrest and ROSC before rewarming were positive outcome predictors, asphyxia, coagulopathy, high potassium and lactate negative outcome predictors. CONCLUSIONS This first analysis of 201 IHR patients with moderate to severe accidental hypothermia shows an excellent 95% survival rate for patients with preserved circulation and 36% for HCA patients. Witnessed cardiac arrest, restoration of spontaneous circulation, low potassium and lactate and absence of asphyxia were positive survival predictors despite hypothermia in young, healthy adults after mountaineering accidents. However, accidental hypothermia is a heterogenous entity that should be considered in both treatment strategies and prognostication.
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Affiliation(s)
- Beat H Walpoth
- Dept. of Cardiovascular Surgery, University Hospitals, Geneva, Switzerland (Emeritus).
| | - Monika Brodmann Maeder
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Switzerland; Institute of Mountain Emergency Medicine, EURAC Research, Bolzano, Italy
| | | | - Marie Meyer
- Dept. of Anesthesia, University Hospital, Lausanne, Switzerland
| | - Evelien Cools
- Division of Anesthesia, University Hospitals, Geneva, Switzerland
| | - Tomasz Darocha
- Dept. Anesthesiology & Intensive Care, Medical University of Silesia, Katowice, Poland
| | | | | | | | - Christian Lovis
- Division of Medical Information Sciences, University Hospitals, Geneva, Switzerland
| | - Peter Mair
- Dept. of Anesthesia, University Hospitals, Innsbruck, Austria
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17
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Selli AL, Kuzmiszyn AK, Smaglyukova N, Kondratiev TV, Fuskevåg OM, Lyså RA, Ravna AW, Tveita T, Sager G, Dietrichs ES. Treatment of Cardiovascular Dysfunction With PDE5-Inhibitors - Temperature Dependent Effects on Transport and Metabolism of cAMP and cGMP. Front Physiol 2021; 12:695779. [PMID: 34393818 PMCID: PMC8361756 DOI: 10.3389/fphys.2021.695779] [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: 04/15/2021] [Accepted: 07/09/2021] [Indexed: 01/24/2023] Open
Abstract
Introduction Cardiovascular dysfunction is a potentially lethal complication of hypothermia. Due to a knowledge gap, pharmacological interventions are not recommended at core temperatures below 30°C. Yet, further cooling is induced in surgical procedures and survival of accidental hypothermia is reported after rewarming from below 15°C, advocating a need for evidence-based treatment guidelines. In vivo studies have proposed vasodilation and afterload reduction through arteriole smooth muscle cGMP-elevation as a favorable strategy to prevent cardiovascular dysfunction in hypothermia. Further development of treatment guidelines demand information about temperature-dependent changes in pharmacological effects of clinically relevant vasodilators. Materials and Methods Human phosphodiesterase-enzymes and inverted erythrocytes were utilized to evaluate how vasodilators sildenafil and vardenafil affected cellular efflux and enzymatic breakdown of cAMP and cGMP, at 37°C, 34°C, 32°C, 28°C, 24°C, and 20°C. The ability of both drugs to reach their cytosolic site of action was assessed at the same temperatures. IC50- and Ki-values were calculated from dose–response curves at all temperatures, to evaluate temperature-dependent effects of both drugs. Results Both drugs were able to reach the intracellular space at all hypothermic temperatures, with no reduction compared to normothermia. Sildenafil IC50 and Ki-values increased during hypothermia for enzymatic breakdown of both cAMP (IC50: 122 ± 18.9 μM at 37°C vs. 269 ± 14.7 μM at 20°C, p < 0.05) and cGMP (IC50: 0.009 ± 0.000 μM at 37°C vs. 0.024 ± 0.004 μM at 32°C, p < 0.05), while no significant changes were detected for vardenafil. Neither of the drugs showed significant hypothermia-induced changes in IC50 and Ki–values for inhibition of cellular cAMP and cGMP efflux. Conclusion Sildenafil and particularly vardenafil were ableto inhibit elimination of cGMP down to 20°C. As the cellular effects of these drugs can cause afterload reduction, they show potential in treating cardiovascular dysfunction during hypothermia. As in normothermia, both drugs showed higher selectivity for inhibition of cGMP-elimination than cAMP-elimination at low core temperatures, indicating that risk for cardiotoxic side effects is not increased by hypothermia.
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Affiliation(s)
- Anders L Selli
- Experimental and Clinical Pharmacology, Department of Medical Biology, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Adrina K Kuzmiszyn
- Experimental and Clinical Pharmacology, Department of Medical Biology, UiT - The Arctic University of Norway, Tromsø, Norway.,Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
| | - Natalia Smaglyukova
- Experimental and Clinical Pharmacology, Department of Medical Biology, 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
| | - Ole-Martin Fuskevåg
- Department of Laboratory Medicine, Division of Diagnostic Services, University Hospital of North Norway, Tromsø, Norway
| | - Roy A Lyså
- Experimental and Clinical Pharmacology, Department of Medical Biology, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Aina W Ravna
- Experimental and Clinical Pharmacology, Department of Medical Biology, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Torkjel Tveita
- Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway.,Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Georg Sager
- Experimental and Clinical Pharmacology, Department of Medical Biology, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Erik S Dietrichs
- Experimental and Clinical Pharmacology, Department of Medical Biology, UiT - The Arctic University of Norway, Tromsø, Norway.,Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
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18
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Piktel JS, Suen Y, Kouk S, Maleski D, Pawlowski G, Laurita KR, Wilson LD. Effect of Amiodarone and Hypothermia on Arrhythmia Substrates During Resuscitation. J Am Heart Assoc 2021; 10:e016676. [PMID: 33938226 PMCID: PMC8200710 DOI: 10.1161/jaha.120.016676] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Amiodarone is administered during resuscitation, but its antiarrhythmic effects during targeted temperature management are unknown. The purpose of this study was to determine the effect of both therapeutic hypothermia and amiodarone on arrhythmia substrates during resuscitation from cardiac arrest. Methods and Results We utilized 2 complementary models: (1) In vitro no‐flow global ischemia canine left ventricular transmural wedge preparation. Wedges at different temperatures (36°C or 32°C) were given 5 µmol/L amiodarone (36‐Amio or 32‐Amio, each n=8) and subsequently underwent ischemia and reperfusion. Results were compared with previous controls. Optical mapping was used to measure action potential duration, dispersion of repolarization (DOR), and conduction velocity (CV). (2) In vivo pig model of resuscitation. Pigs (control or targeted temperature management, 32–34°C) underwent ischemic cardiac arrest and were administered amiodarone (or not) after 8 minutes of ventricular fibrillation. In vitro: therapeutic hypothermia but not amiodarone prolonged action potential duration. During ischemia, DOR increased in the 32‐Amio group versus 32‐Alone (84±7 ms versus 40±7 ms, P<0.05) while CV slowed in the 32‐Amio group. Amiodarone did not affect CV, DOR, or action potential duration during ischemia at 36°C. Conduction block was only observed at 36°C (5/8 36‐Amio versus 6/7 36‐Alone, 0/8 32‐Amio, versus 0/7 32‐Alone). In vivo: QTc decreased upon reperfusion from ischemia that was ameliorated by targeted temperature management. Amiodarone did not worsen DOR or CV. Amiodarone suppressed rearrest caused by ventricular fibrillation (7/8 without amiodarone, 2/7 with amiodarone, P=0.041), but not pulseless electrical activity (2/8 without amiodarone, 5/7 with amiodarone, P=0.13). Conclusions Although amiodarone abolishes a beneficial effect of therapeutic hypothermia on ischemia‐induced DOR and CV, it did not worsen susceptibility to ventricular tachycardia/ventricular fibrillation during resuscitation.
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Affiliation(s)
- Joseph S Piktel
- Department of Emergency Medicine and The Heart and Vascular Research Center MetroHealth Campus Case Western Reserve University Cleveland OH
| | - Yi Suen
- Department of Emergency Medicine and The Heart and Vascular Research Center MetroHealth Campus Case Western Reserve University Cleveland OH
| | - Shalen Kouk
- Department of Emergency Medicine and The Heart and Vascular Research Center MetroHealth Campus Case Western Reserve University Cleveland OH
| | - Danielle Maleski
- Department of Emergency Medicine and The Heart and Vascular Research Center MetroHealth Campus Case Western Reserve University Cleveland OH
| | - Gary Pawlowski
- Department of Emergency Medicine and The Heart and Vascular Research Center MetroHealth Campus Case Western Reserve University Cleveland OH
| | - Kenneth R Laurita
- Department of Emergency Medicine and The Heart and Vascular Research Center MetroHealth Campus Case Western Reserve University Cleveland OH
| | - Lance D Wilson
- Department of Emergency Medicine and The Heart and Vascular Research Center MetroHealth Campus Case Western Reserve University Cleveland OH
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19
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Okada Y, Matsuyama T, Morita S, Ehara N, Miyamae N, Jo T, Sumida Y, Okada N, Watanabe M, Nozawa M, Tsuruoka A, Fujimoto Y, Okumura Y, Kitamura T, Iiduka R, Ohtsuru S. Machine learning-based prediction models for accidental hypothermia patients. J Intensive Care 2021; 9:6. [PMID: 33422146 PMCID: PMC7797142 DOI: 10.1186/s40560-021-00525-z] [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: 10/30/2020] [Accepted: 01/02/2021] [Indexed: 12/23/2022] Open
Abstract
Background Accidental hypothermia is a critical condition with high risks of fatal arrhythmia, multiple organ failure, and mortality; however, there is no established model to predict the mortality. The present study aimed to develop and validate machine learning-based models for predicting in-hospital mortality using easily available data at hospital admission among the patients with accidental hypothermia. Method This study was secondary analysis of multi-center retrospective cohort study (J-point registry) including patients with accidental hypothermia. Adult patients with body temperature 35.0 °C or less at emergency department were included. Prediction models for in-hospital mortality using machine learning (lasso, random forest, and gradient boosting tree) were made in development cohort from six hospitals, and the predictive performance were assessed in validation cohort from other six hospitals. As a reference, we compared the SOFA score and 5A score. Results We included total 532 patients in the development cohort [N = 288, six hospitals, in-hospital mortality: 22.0% (64/288)], and the validation cohort [N = 244, six hospitals, in-hospital mortality 27.0% (66/244)]. The C-statistics [95% CI] of the models in validation cohorts were as follows: lasso 0.784 [0.717–0.851] , random forest 0.794[0.735–0.853], gradient boosting tree 0.780 [0.714–0.847], SOFA 0.787 [0.722–0.851], and 5A score 0.750[0.681–0.820]. The calibration plot showed that these models were well calibrated to observed in-hospital mortality. Decision curve analysis indicated that these models obtained clinical net-benefit. Conclusion This multi-center retrospective cohort study indicated that machine learning-based prediction models could accurately predict in-hospital mortality in validation cohort among the accidental hypothermia patients. These models might be able to support physicians and patient’s decision-making. However, the applicability to clinical settings, and the actual clinical utility is still unclear; thus, further prospective study is warranted to evaluate the clinical usefulness. Supplementary Information The online version contains supplementary material available at 10.1186/s40560-021-00525-z.
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Affiliation(s)
- Yohei Okada
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, ShogoinKawaramachi54, Sakyo, Kyoto, 606-8507, Japan. .,Preventive Services, School of Public Health, Kyoto University, Kyoto, Japan. .,Department of Emergency and Critical Care Medicine, Japanese Red Cross Society, Kyoto Daini Hospital, Kyoto, Japan.
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Sachiko Morita
- Senri Critical Care Medical Center, Saiseikai Senri Hospital, Suita, Japan
| | - Naoki Ehara
- Department of Emergency, Japanese Red Cross Society, Kyoto Daiichi Red Cross Hospital, Kyoto, Japan
| | - Nobuhiro Miyamae
- Department of Emergency Medicine, Rakuwa-kai Otowa Hospital, Kyoto, Japan
| | - Takaaki Jo
- Department of Emergency Medicine, Uji-Tokushukai Medical Center, Uji, Japan
| | - Yasuyuki Sumida
- Department of Emergency Medicine, North Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nobunaga Okada
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan.,Department of Emergency and Critical Care Medicine, National Hospital Organization, Kyoto Medical Center, Kyoto, Japan
| | - Makoto Watanabe
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masahiro Nozawa
- Department of Emergency and Critical Care Medicine, Saiseikai Shiga Hospital, Ritto, Japan
| | - Ayumu Tsuruoka
- Department of Emergency and Critical Care Medicine, Kyoto Min-Iren Chuo Hospital, Kyoto, Japan
| | - Yoshihiro Fujimoto
- Department of Emergency Medicine, Yodogawa Christian Hospital, Osaka, Japan
| | - Yoshiki Okumura
- Department of Emergency Medicine, Fukuchiyama City Hospital, Fukuchiyama, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Ryoji Iiduka
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Society, Kyoto Daini Hospital, Kyoto, Japan
| | - Shigeru Ohtsuru
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, ShogoinKawaramachi54, Sakyo, Kyoto, 606-8507, Japan
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20
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Fujimoto Y, Matsuyama T, Morita S, Ehara N, Miyamae N, Okada Y, Jo T, Sumida Y, Okada N, Watanabe M, Nozawa M, Tsuruoka A, Okumura Y, Kitamura T, Takegami T. Care at critical care medical centers is associated with improved outcomes in patients with accidental hypothermia: a historical cohort study from the J-Point registry. Acute Med Surg 2020; 7:e578. [PMID: 33133614 PMCID: PMC7590663 DOI: 10.1002/ams2.578] [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: 05/15/2020] [Revised: 08/23/2020] [Accepted: 09/14/2020] [Indexed: 11/24/2022] Open
Abstract
Aim The recommendation that patients with accidental hypothermia should be transported to specialized centers that can provide extracorporeal life support has not been validated, and the efficacy remains unclear. Methods This was a multicenter retrospective cohort study of patients with a body temperature of ≤35°C presenting at the emergency department of 12 hospitals in Japan between April 2011 and March 2016. We divided the patients into two groups based on the point of care delivery: critical care medical center (CCMC) or non‐CCMC. The primary outcome of this study was in‐hospital death. In‐hospital death was compared using a multivariable logistic regression analysis. Subgroup analyses were carried out according to patients with severe hypothermia (<28°C) or systolic blood pressure (sBP) of <90 mmHg. Results A total of 537 patients were included, 413 patients (76.9%) in the CCMC group and 124 patients (23.1%) in the non‐CCMC group. The in‐hospital death rate was lower in the CCMC group than in the non‐CCMC group (22.3% versus 31.5%, P < 0.001). The multivariable logistic regression analysis showed that the adjusted odds ratio (AOR) of the CCMC group was 0.54 (95% confidence interval, 0.32–0.90). In subgroup analyses, patients with systolic blood pressure <90 mmHg in the CCMC group were less likely to experience in‐hospital death (AOR 0.36; 95% CI, 0.23–0.56). However, no such association was observed among patients with severe hypothermia (AOR 1.08; 95% CI, 0.63–1.85). Conclusions Our multicenter study indicated that care at a CCMC was associated with improved outcomes in patients with accidental hypothermia.
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Affiliation(s)
- Yoshihiro Fujimoto
- Department of Emergency Medicine Japanese Red Cross Kyoto Daiichi Hospital Kyoto Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine Kyoto Prefectural University of Medicine Kyoto Japan
| | - Sachiko Morita
- Senri Critical Care Medical Center Saiseikai Senri Hospital Suita Japan
| | - Naoki Ehara
- Department of Emergency Medicine Japanese Red Cross Kyoto Daiichi Hospital Kyoto Japan
| | - Nobuhiro Miyamae
- Department of Emergency Medicine Rakuwa-kai Otowa Hospital Kyoto Japan
| | - Yohei Okada
- Department of Emergency and Critical Care Medicine Japanese Red Cross Society Kyoto Daini Red Cross Hospital Kyoto Japan
| | - Takaaki Jo
- Department of Emergency Medicine Uji-Tokushukai Medical Center Uji Japan
| | - Yasuyuki Sumida
- Department of Emergency Medicine North Medical Center Kyoto Prefectural University of Medicine Yosa-gun Japan
| | - Nobunaga Okada
- Department of Emergency Medicine Kyoto Prefectural University of Medicine Kyoto Japan.,Department of Emergency and Critical Care Medicine National Hospital Organization, Kyoto Medical Center Kyoto Japan
| | - Makoto Watanabe
- Department of Emergency Medicine North Medical Center Kyoto Prefectural University of Medicine Yosa-gun Japan
| | - Masahiro Nozawa
- Department of Emergency and Critical Care Medicine Saiseikai Shiga Hospital Ritto Japan
| | - Ayumu Tsuruoka
- Department of Emergency and Critical Care Medicine, Kidney and Cardiovascular Center Kyoto Min-iren Chuo Hospital Kyoto Japan.,Emergency and Critical Care Medical Center Osaka City General Hospital Osaka Japan
| | - Yoshiki Okumura
- Department of Emergency Medicine Fukuchiyama City Hospital Fukuchiyama Japan
| | - Tetsuhisa Kitamura
- Department of Social and Environmental Medicine Division of Environmental Medicine and Population Sciences Graduate School of Medicine Osaka University Suita Japan
| | - Tetsuro Takegami
- Department of Emergency Medicine Japanese Red Cross Kyoto Daiichi Hospital Kyoto Japan
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21
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Fujimoto Y, Matsuyama T, Morita S, Ehara N, Miyamae N, Okada Y, Jo T, Sumida Y, Okada N, Watanabe M, Nozawa M, Tsuruoka A, Okumura Y, Kitamura T, Takegami T. Indoor Versus Outdoor Occurrence in Mortality of Accidental Hypothermia in Japan: The J-Point Registry. Ther Hypothermia Temp Manag 2020; 10:159-164. [DOI: 10.1089/ther.2019.0017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Yoshihiro Fujimoto
- Department of Emergency Medicine, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Sachiko Morita
- Senri Critical Care Medical Center, Saiseikai Senri Hospital, Suita, Japan
| | - Naoki Ehara
- Department of Emergency Medicine, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Nobuhiro Miyamae
- Department of Emergency Medicine, Rakuwa-kai Otowa Hospital, Kyoto, Japan
| | - Yohei Okada
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Society Kyoto Daini Red Cross Hospital, Kyoto, Japan
| | - Takaaki Jo
- Department of Emergency Medicine, Uji-Tokushukai Medical Center, Uji, Japan
| | - Yasuyuki Sumida
- Department of Emergency Medicine, North Medical Center, Kyoto Prefectural University of Medicine, Yosa-gun, Japan
| | - Nobunaga Okada
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Department of Emergency and Critical Care Medicine, National Hospital Organization, Kyoto Medical Center, Kyoto, Japan
| | - Makoto Watanabe
- Department of Emergency Medicine, North Medical Center, Kyoto Prefectural University of Medicine, Yosa-gun, Japan
| | - Masahiro Nozawa
- Department of Emergency and Critical Care Medicine, Saiseikai Shiga Hospital, Ritto, Japan
| | - Ayumu Tsuruoka
- Department of Emergency and Critical Care Medicine, Kidney and Cardiovascular Center, Kyoto Min-iren Chuo Hospital, Kyoto, Japan
- Emergency and Critical Care Medical Center, Osaka City General Hospital, Osaka, Japan
| | - Yoshiki Okumura
- Department of Emergency Medicine, Fukuchiyama City Hospital, Fukuchiyama, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Tetsurou Takegami
- Department of Emergency Medicine, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
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22
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Ishimaru N, Kinami S, Shimokawa T, Seto H, Kanzawa Y. Hypothermia in a Japanese subtropical climate: Retrospective validation study of severity score and mortality prediction. J Gen Fam Med 2020; 21:134-139. [PMID: 32742902 PMCID: PMC7388666 DOI: 10.1002/jgf2.323] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 03/31/2020] [Accepted: 04/01/2020] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION This study aimed to clarify the accuracy of an in-hospital mortality prediction score for patients with hypothermia. The score consists of five variables (age ≥70 years, mean arterial pressure <90 mm Hg, pH < 7.35, creatinine >1.5 mg/dL, and confusion). In contrast to the previously reported population in southern Israel, a desert climate, we apply the score system to a Japanese humid subtropical climate. METHODS The study included patients with a principal diagnosis of hypothermia who were admitted to our community hospital between January 2008 and January 2019. Using the medical records from initial visits, we retrospectively calculated in-hospital mortality prediction scores along with sensitivity and specificity. RESULTS We recruited 69 patients, 67 of which had analyzable data. Among them, the in-hospital mortality rate was 25.4%. Hypothermia was defined as mild (32-35°C) in 34 cases (50.7%), moderate (28-32°C) in 23 cases (34.3%), and severe (<28°C) in 10 cases (14.9%). The C-statistics of the in-hospital mortality prediction score was 0.703 (95% confidence interval, 0.55-0.84) for thirty-day survival prediction. After adjustment of the cutoff point of each item with ROC analysis and selection of the variants, the C-statistics of the in-hospital mortality prediction score rose to 0.81 (95% confidence interval, 0.69-0.92). CONCLUSION The in-hospital mortality prediction scores showed slightly less predictive value than those in the previous report. With some modification, however, the score system could still be applied efficiently in the humid Japanese subtropical climate. An appropriate management strategy could be established based on the predicted mortality risk.
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Affiliation(s)
- Naoto Ishimaru
- Department of General Internal MedicineAkashi Medical CenterAkashiJapan
| | - Saori Kinami
- Department of General Internal MedicineAkashi Medical CenterAkashiJapan
| | - Toshio Shimokawa
- Clinical Study Support CentreWakayama Medical UniversityWakayamaJapan
| | - Hiroyuki Seto
- Department of General Internal MedicineAkashi Medical CenterAkashiJapan
| | - Yohei Kanzawa
- Department of General Internal MedicineAkashi Medical CenterAkashiJapan
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23
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Epinephrine at 25°C Core Body Temperature and During Rewarming: Case Report of Successful Infant Resuscitation After Cold Water Submersion. Pediatr Emerg Care 2020; 36:e346-e348. [PMID: 30829844 DOI: 10.1097/pec.0000000000001766] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Epinephrine plays a controversial role in accidental hypothermia (<30°C). We report its use in the advanced life support of a 13-month-old white girl with pulseless electrical activity and 25°C core body temperature after 32 minutes of submersion in a fast-running Swiss mountain stream at 8°C. Two doses of epinephrine (10 μg/kg) were given in the field, followed by 12 doses (10 μg/kg) and an infusion of 0.1 μg/kg per minute during rewarming. Spontaneous circulation returned at 29.5°C after 2.5 hours of cardiopulmonary resuscitation. Neurologic long-term outcome was excellent. We conclude that in the presence of nonshockable rhythm the benefits of epinephrine may outweigh the risks of side effects when used in pediatric advanced life support for accidental hypothermia.
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24
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Shida A, Ikeda T, Tani N, Morioka F, Aoki Y, Ikeda K, Watanabe M, Ishikawa T. Cortisol levels after cold exposure are independent of adrenocorticotropic hormone stimulation. PLoS One 2020; 15:e0218910. [PMID: 32069307 PMCID: PMC7028257 DOI: 10.1371/journal.pone.0218910] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 01/27/2020] [Indexed: 02/08/2023] Open
Abstract
We previously showed that postmortem serum levels of adrenocorticotropic hormone (ACTH) were significantly higher in cases of hypothermia (cold exposure) than other causes of death. This study examined how the human hypothalamic-pituitary-adrenal axis, and specifically cortisol, responds to hypothermia. Human samples: Autopsies on 205 subjects (147 men and 58 women; age 15-98 years, median 60 years) were performed within 3 days of death. Cause of death was classified as either hypothermia (cold exposure, n = 14) or non-cold exposure (controls; n = 191). Cortisol levels were determined in blood samples obtained from the left and right cardiac chambers and common iliac veins using a chemiluminescent enzyme immunoassay. Adrenal gland tissues samples were stained for cortisol using a rabbit anti-human polyclonal antibody. Cell culture: AtT20, a mouse ACTH secretory cell line, and Y-1, a corticosterone secretory cell line derived from a mouse adrenal tumor, were analyzed in mono-and co-culture, and times courses of ACTH (in AtT20) and corticosterone (in Y-1) secretion were assessed after low temperature exposure mimicking hypothermia and compared with data for samples collected postmortem for other cases of death. However, no correlation between ACTH concentration and cortisol levels was observed in hypothermia cases. Immunohistologic analyses of samples from hypothermia cases showed that cortisol staining was localized primarily to the nucleus rather than the cytoplasm of cells in the zona fasciculata of the adrenal gland. During both mono-culture and co-culture, AtT20 cells secreted high levels of ACTH after 10-15 minutes of cold exposure, whereas corticosterone secretion by Y-1 cells increased slowly during the first 15-20 minutes of cold exposure. Similar to autopsy results, no correlation was detected between ACTH levels and corticosterone secretion, either in mono-culture or co-culture experiments. These results suggested that ACTH-independent cortisol secretion may function as a stress response during cold exposure.
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Affiliation(s)
- Alissa Shida
- Department of Legal Medicine, Osaka City University Medical School, Osaka, Japan
- * E-mail:
| | - Tomoya Ikeda
- Department of Legal Medicine, Osaka City University Medical School, Osaka, Japan
- Forensic Autopsy Section, Medico-legal Consultation and Postmortem Investigation Support Center (MLCPI-SC), Osaka, Japan
| | - Naoto Tani
- Department of Legal Medicine, Osaka City University Medical School, Osaka, Japan
- Forensic Autopsy Section, Medico-legal Consultation and Postmortem Investigation Support Center (MLCPI-SC), Osaka, Japan
| | - Fumiya Morioka
- Department of Legal Medicine, Osaka City University Medical School, Osaka, Japan
| | - Yayoi Aoki
- Department of Legal Medicine, Osaka City University Medical School, Osaka, Japan
| | - Kei Ikeda
- Department of Legal Medicine, Osaka City University Medical School, Osaka, Japan
| | - Miho Watanabe
- Department of Legal Medicine, Osaka City University Medical School, Osaka, Japan
- Laboratory of Clinical Regenerative Medicine Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Health and Medical Science Innovation laboratory, Tsukuba City, Ibaraki, Japan
| | - Takaki Ishikawa
- Department of Legal Medicine, Osaka City University Medical School, Osaka, Japan
- Forensic Autopsy Section, Medico-legal Consultation and Postmortem Investigation Support Center (MLCPI-SC), Osaka, Japan
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25
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Okada N, Matsuyama T, Morita S, Ehara N, Miyamae N, Okada Y, Jo T, Sumida Y, Watanabe M, Nozawa M, Tsuruoka A, Fujimoto Y, Okumura Y, Hamanaka K, Kitamura T, Nishiyama K, Ohta B. Osborn Wave Is Related to Ventricular Fibrillation and Tachycardia in Hypothermic Patients. Circ J 2020; 84:445-455. [PMID: 31996488 DOI: 10.1253/circj.cj-19-0856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The Osborn wave (OW) is often observed in hypothermic patients; however, whether OW in hypothermic patients is related to the development of fatal ventricular arrhythmia, including ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT), remains undetermined. This study aimed to estimate the association between OW and the incidence of fatal ventricular arrhythmias.Methods and Results: This retrospective study used the Japanese Accidental Hypothermia Network registry database and included 572 hypothermic patients. Patients were divided into the OW group (those with OW) and non-OW group (those without OW). The relationship between the development of fatal arrhythmias and presence of OW was assessed using the chi-squared test. All patients who developed VF/VT (n=10) had OW on electrocardiogram upon hospital arrival. The presence of OW had a sensitivity of 100%, specificity of 47.8%, positive predictive value of 4.0%, and negative predictive value of 100% for VF/VT development. The in-hospital mortality rate was 22.3% in the OW group and 21.2% in the non-OW group (P=0.781). CONCLUSIONS OW was observed in all hypothermic patients with VF/VT. The occurrence of ventricular arrhythmias is highly unlikely in the absence of OW on the electrocardiogram. Although the presence of OW might be used to predict these fatal arrhythmias in hypothermic patients, there was no association between the presence of OW and in-hospital mortality.
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Affiliation(s)
- Nobunaga Okada
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine
| | - Sachiko Morita
- Senri Critical Care Medical Center, Saiseikai Senri Hospital
| | - Naoki Ehara
- Department of Emergency, Japanese Red Cross Society Kyoto Daiichi Red Cross Hospital
| | | | - Yohei Okada
- Department of Primary Care and Emergency Medicine, Kyoto University
| | - Takaaki Jo
- Department of Emergency Medicine, Uji-Tokushukai Medical Center
| | - Yasuyuki Sumida
- Department of Emergency Medicine, North Medical Center, Kyoto Prefectural University of Medicine
| | - Makoto Watanabe
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine
| | - Masahiro Nozawa
- Department of Emergency and Critical Care Medicine, Saiseikai Shiga Hospital
| | - Ayumu Tsuruoka
- Emergency and Critical Care Medical Center, Osaka City General Hospital
| | - Yoshihiro Fujimoto
- Department of Emergency, Japanese Red Cross Society Kyoto Daiichi Red Cross Hospital
| | | | - Kunio Hamanaka
- Department of Emergency and Critical Care Medicine, National Hospital Organization Kyoto Medical Center
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine
| | - Kei Nishiyama
- Department of Emergency and Critical Care Medicine, National Hospital Organization Kyoto Medical Center
| | - Bon Ohta
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine
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26
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Willmore R. Cardiac Arrest Secondary to Accidental Hypothermia: Rewarming Strategies in the Field. Air Med J 2020; 39:64-67. [PMID: 32044073 DOI: 10.1016/j.amj.2019.09.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 09/03/2019] [Indexed: 06/10/2023]
Abstract
Hypothermic cardiac arrest is rare and poses a challenge to prehospital responders. Standard cardiac arrest protocols advise treating reversible causes of arrest; however, rewarming the cold casualty is not easily achieved in the field. This article aimed to review the literature on hypothermia in order to produce evidence-based recommendations on rewarming that could realistically be applied to hypothermic cardiac arrest patients.
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Affiliation(s)
- Robert Willmore
- Institute of Pre-Hospital Care at London's Air Ambulance, The Royal London Hospital, London, United Kingdom.
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27
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Uemura T, Kimura A, Matsuda W, Sasaki R, Kobayashi K. Derivation of a model to predict mortality in urban patients with accidental hypothermia: a retrospective observational study. Acute Med Surg 2019; 7:e478. [PMID: 31988790 PMCID: PMC6971436 DOI: 10.1002/ams2.478] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/11/2019] [Accepted: 11/24/2019] [Indexed: 11/08/2022] Open
Abstract
Aim Accidental hypothermia in urban settings is associated with high mortality rates. However, the predictors of mortality remain under discussion. The purpose of this study was to evaluate prognostic factors and develop a prediction model in patients with accidental hypothermia in urban settings. Methods We retrospectively reviewed medical records in patients with hypothermia brought to our hospital by ambulance in a 7-year study period. Patients' records of survival discharge or in-hospital death and clinical data were collected from medical records. We analyzed factors to predict in-hospital death using multiple logistic regression analysis. Recursive partitioning analysis was used to construct a prediction model using predictors from multiple logistic regression analysis. Results In the study period, 192 patients were included in this study. Of them, 154 patients were discharged alive and 38 patients died. Multiple logistic regression analysis revealed that in-hospital death was related to Glasgow Coma Scale (GCS) score, prothrombin time - international normalized ratio (PT-INR) value, and fibrin degradation product (FDP). Recursive partitioning analysis revealed that patients with accidental hypothermia could be divided into four groups: very high risk (FDP ≥ 14 µg/mL, PT-INR ≥ 1.4), high risk (FDP ≥ 14 µg/mL, PT-INR < 1.4), moderate risk (FDP < 14 µg/mL, GCS < 10), and low risk (FDP < 14 µg/mL, GCS ≥ 10). Conclusion High FDP and PT-INR values and low GCS score on arrival at the emergency department were associated with in-hospital mortality in urban patients with hypothermia. A simple prediction model for grouping risk was developed using these predictors.
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Affiliation(s)
- Tatsuki Uemura
- Department of Emergency Medicine and Critical Care Center Hospital of the National Center for Global Health and Medicine Tokyo Japan
| | - Akio Kimura
- Department of Emergency Medicine and Critical Care Center Hospital of the National Center for Global Health and Medicine Tokyo Japan
| | - Wataru Matsuda
- Department of Emergency Medicine and Critical Care Center Hospital of the National Center for Global Health and Medicine Tokyo Japan
| | - Ryo Sasaki
- Department of Emergency Medicine and Critical Care Center Hospital of the National Center for Global Health and Medicine Tokyo Japan
| | - Kentaro Kobayashi
- Department of Emergency Medicine and Critical Care Center Hospital of the National Center for Global Health and Medicine Tokyo Japan
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28
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Kandori K, Okada Y, Matsuyama T, Morita S, Ehara N, Miyamae N, Jo T, Sumida Y, Okada N, Watanabe M, Nozawa M, Tsuruoka A, Fujimoto Y, Okumura Y, Kitamura T, Iiduka R. Prognostic ability of the sequential organ failure assessment score in accidental hypothermia: a multi-institutional retrospective cohort study. Scand J Trauma Resusc Emerg Med 2019; 27:103. [PMID: 31718708 PMCID: PMC6849316 DOI: 10.1186/s13049-019-0681-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 10/31/2019] [Indexed: 12/05/2022] Open
Abstract
Background Severe accidental hypothermia (AH) is life threatening. Thus, prognostic prediction in AH is essential to rapidly initiate intensive care. Several studies on prognostic factors for AH are known, but none have been established. We clarified the prognostic ability of the Sequential Organ Failure Assessment (SOFA) score in comparison with previously reported prognostic factors among patients with AH. Methods The J-point registry database is a multi-institutional retrospective cohort study for AH in 12 Japanese emergency departments. From this registry, we enrolled patients who were treated at the intensive care unit (ICU) in various critical care medical centers. In-hospital mortality was the primary outcome. We investigated the discrimination ability of each candidate prognostic factor and the in-hospital mortality by applying the logistic regression models with areas under the receiver operating characteristic curve (AUROC) with 95% confidence interval (CI). Results Of the 572 patients with AH registered in the J-point registry, 220 were eligible for the analyses. The in-hospital mortality was 23.2%. The AUROC of the SOFA score (0.80; 95% CI: 0.72–0.86) was the highest among all factors. The other factors were serum potassium (0.65; 95% CI: 0.55–0.73), lactate (0.67; 95% CI: 0.57–0.75), quick SOFA (qSOFA) (0.55; 95% CI: 0.46–0.65), systemic inflammatory response syndrome (SIRS) (0.60; 95% CI: 0.50–0.69), and 5A severity scale (0.77; 95% CI: 0.68–0.84). Discussion Although serum potassium and lactate had relatively good discrimination ability as mortality predictors, the SOFA score had slightly better discrimination ability. The reason is that lactate and serum potassium were mainly reflected by the hemodynamic state; conversely, the SOFA score is a comprehensive score of organ failure, basing on six different scores from the respiratory, cardiovascular, hepatic, coagulation, renal, and neurological systems. Meanwhile, the qSOFA and SIRS scores underestimated the severity, with low discrimination abilities for mortality. Conclusions The SOFA score demonstrated better discrimination ability as a mortality predictor among all known prognostic factors in patients with AH.
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Affiliation(s)
- Kenji Kandori
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Society, Kyoto Daini Hospital, Kyoto, Japan
| | - Yohei Okada
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Society, Kyoto Daini Hospital, Kyoto, Japan. .,Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Sachiko Morita
- Senri Critical Care Medical Center, Saiseikai Senri Hospital, Suita, Japan
| | - Naoki Ehara
- Department of Emergency, Japanese Red Cross Society, Kyoto Daiichi Red Cross Hospital, Kyoto, Japan
| | - Nobuhiro Miyamae
- Department of Emergency Medicine, Rakuwa-kai Otowa Hospital, Kyoto, Japan
| | - Takaaki Jo
- Department of Emergency Medicine, Uji-Tokushukai Medical Center, Uji, Japan
| | - Yasuyuki Sumida
- Department of Emergency Medicine, North Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nobunaga Okada
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan.,Department of Emergency and Critical Care Medicine, National Hospital Organization, Kyoto Medical Center, Kyoto, Japan
| | - Makoto Watanabe
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masahiro Nozawa
- Department of Emergency and Critical Care Medicine, Saiseikai Shiga Hospital, Ritto, Japan
| | - Ayumu Tsuruoka
- Department of Emergency and Critical Care Medicine, Kyoto Min-Iren Chuo Hospital, Kyoto, Japan
| | - Yoshihiro Fujimoto
- Department of Emergency Medicine, Yodogawa Christian Hospital, Osaka, Japan
| | - Yoshiki Okumura
- Department of Emergency Medicine, Fukuchiyama City Hospital, Fukuchiyama, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Ryoji Iiduka
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Society, Kyoto Daini Hospital, Kyoto, Japan
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29
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Hypothermia-rewarming: A Double-edged sword? Med Hypotheses 2019; 133:109387. [PMID: 31541781 DOI: 10.1016/j.mehy.2019.109387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 08/27/2019] [Accepted: 08/29/2019] [Indexed: 01/05/2023]
Abstract
Hypothermia is a condition in which the body's core temperature drops below 35.0 °C. Hypothermia is the opposite of hyperthermia, which the metabolism and body functions are abnormal. Severe hypothermia is a life-threatening problem that may cause atrial and ventricular dysrhythmias, coagulopathy, cardiac, and central nervous system depression. What is worse, it is fatal when untreated or treated improperly. Accidental deaths due to hypothermia resulting from immersion in cold water, especially involving naval fighters and maritime victims have occurred continually in the past years. Currently, the treatment of hypothermia has become a research focus. Rewarming is the only approach that should be considered for hypothermia treatment. However, the treatment is of low efficiency, and few active rewarming cases have been reported. It is well known that timely reperfusion is the best way to save the lives of patients with ischemia. Similarly, reoxygenation is effective for hypoxia. However, several studies have identified that improper reperfusion of ischemic tissues and reoxygenation of hypoxic tissues give rise to further injury. Analogically, this study attempts to propose the hypothesis that hypothermia-rewarming injury may also exist. When suffered from hypothermia, both the blood circulation and the oxygen supply in the body will be affected in a deficient state, an injury may also appear in the improper rewarming process. In a word, hypothermia-rewarming may be a double-edged sword.
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30
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Murakami T, Yoshida T, Kurokochi A, Takamatsu K, Teranishi Y, Shigeta K, Tamaki S, Morita S, Mizuno R, Oya M. Accidental Hypothermia Treated by Hemodialysis in the Acute Phase: Three Case Reports and a Review of the Literature. Intern Med 2019; 58:2743-2748. [PMID: 31178478 PMCID: PMC6794177 DOI: 10.2169/internalmedicine.1945-18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Accidental hypothermia is defined as a core body temperature <35°C. Even with the use of multiple active rewarming methods, it has a high mortality rate. No standard treatment strategy for moderate or severe hypothermia in the absence of cardiac arrest has yet been established. We herein report three patients with severe or moderate accidental hypothermia who were treated by hemodialysis in the acute phase. This case report with a literature review describes the usefulness of hemodialysis for the treatment of moderate and severe accidental hypothermia without cardiac arrest.
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Affiliation(s)
| | - Tadashi Yoshida
- Apheresis and Dialysis Center, Keio University School of Medicine, Japan
| | - Arata Kurokochi
- Department of Internal Medicine, Keio University School of Medicine, Japan
| | | | - Yu Teranishi
- Department of Urology, Keio University School of Medicine, Japan
| | - Keisuke Shigeta
- Department of Urology, Keio University School of Medicine, Japan
| | - Satoshi Tamaki
- Department of Urology, Keio University School of Medicine, Japan
- Apheresis and Dialysis Center, Keio University School of Medicine, Japan
| | - Shinya Morita
- Department of Urology, Keio University School of Medicine, Japan
- Apheresis and Dialysis Center, Keio University School of Medicine, Japan
| | - Ryuichi Mizuno
- Department of Urology, Keio University School of Medicine, Japan
| | - Mototsugu Oya
- Department of Urology, Keio University School of Medicine, Japan
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31
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Tveita T, Arteaga GM, Han YS, Sieck GC. Cardiac troponin-I phosphorylation underlies myocardial contractile dysfunction induced by hypothermia rewarming. Am J Physiol Heart Circ Physiol 2019; 317:H726-H731. [PMID: 31373512 DOI: 10.1152/ajpheart.00101.2019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Rewarming the intact heart after a period of hypothermia is associated with reduced myocardial contractility, decreased Ca2+ sensitivity, and increased cardiac troponin-I (cTnI) phosphorylation. We hypothesized that hypothermia/rewarming (H/R) induces left ventricular (LV) contractile dysfunction due to phosphorylation of cTnI at Ser23/24. To test this hypothesis, the response of wild-type mice (n = 7) to H/R was compared with transgenic (TG) mice expressing slow skeletal TnI (TG-ssTnI; n = 7) that lacks the Ser23/24 phosphorylation sites. Hypothermia was induced by surface cooling and maintained at 23-25°C for 3 h. Subsequently, the animals were rewarmed to 37°C. LV systolic and diastolic function was assessed using a 1.4 F pressure-volume Millar catheter introduced via the right carotid artery. At baseline conditions, there were no significant differences in LV systolic function between wild-type and TG-ssTnI mice, whereas measurements of diastolic function [isovolumic relaxation constant (τ) and end-diastolic pressure-volume relationship (EDPVR)] were significantly (P < 0.05) reduced in TG-ssTnI animals. Immediately after rewarming, significant differences between groups were found in cardiac output (CO; wild-type 6.6 ± 0.7 vs. TG-ssTnI 8.8 ± 0.7 mL/min), stroke work (SW; wild-type 796 ± 112 vs. TG-ssTnI 1208 ± 67 mmHg/μL), and the preload recruited stroke work (PRSW; wild-type 38.3 ± 4.9 vs. TG-ssTnI 68.8 ± 8.2 mmHg). However, EDPVR and τ returned to control levels within 1 h in both groups. We conclude that H/R-induced LV systolic dysfunction results from phosphorylation of cTnI at Ser23/24.NEW & NOTEWORTHY Rewarming following a period of accidental hypothermia leads to a form of acute cardiac failure (rewarming shock), which is in part due to reduced sensitivity to Ca2+ activation of myocardial contraction. The results of the present study support the hypothesis that rewarming shock is due to phosphorylation of cardiac troponin I.
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Affiliation(s)
- Torkjel Tveita
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine, Rochester, Minnesota.,Anesthesia and Critical Care Research Group, Institute of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway
| | - Grace M Arteaga
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Young-Soo Han
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Gary C Sieck
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine, Rochester, Minnesota
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32
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Rousseau G, Reynier P, Jousset N, Rougé-Maillart C, Palmiere C. Updated review of postmortem biochemical exploration of hypothermia with a presentation of standard strategy of sampling and analyses. Clin Chem Lab Med 2019; 56:1819-1827. [PMID: 29715177 DOI: 10.1515/cclm-2018-0153] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 04/03/2018] [Indexed: 11/15/2022]
Abstract
Hypothermia is defined as a core body temperature below 35°C and can be caused by environmental exposure, drug intoxication, metabolic or nervous system dysfunction. This lethal pathology with medico-legal implications is complex to diagnose because macroscopic and microscopic lesions observed at the autopsy and the histological analysis are suggestive but not pathognomonic. Postmortem biochemical explorations have been progressively developed through the study of several biomarkers to improve the diagnosis decision cluster. Here, we present an updated review with novel biomarkers (such as catecholamines O-methylated metabolites, thrombomodulin and the cardiac oxyhemoglobin ratio) as well as some propositional interpretative postmortem thresholds and, to the best of our knowledge, for the first time, we present the most adapted strategy of sampling and analyses to identify biomarkers of hypothermia. For our consideration, the most relevant identified biomarkers are urinary catecholamines and their O-methylated metabolites, urinary free cortisol, blood cortisol, as well as blood, vitreous humor and pericardial fluid for ketone bodies and blood free fatty acids. These biomarkers are increased in response either to cold-mediated stress or to bioenergetics ketogenesis crisis and significantly contribute to the diagnosis by exclusion of death by hypothermia.
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Affiliation(s)
- Guillaume Rousseau
- Département de Biochimie et Génétique, Centre Hospitalier Universitaire d'Angers, Angers, France
- Service de Médecine Légale et Pénitentiaire, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Pascal Reynier
- Département de Biochimie et Génétique, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Nathalie Jousset
- Service de Médecine Légale et Pénitentiaire, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Clotilde Rougé-Maillart
- GEROM-LHEA, IRIS-IBS Institut de Biologie en Santé, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Cristian Palmiere
- CURML, Centre Universitaire Romand de Médecine Légale, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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33
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Braams NJ, Hendriks ML, van Halm VP. Mode of death in Shapiro syndrome: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2019; 3:5491553. [PMID: 31449626 PMCID: PMC6601220 DOI: 10.1093/ehjcr/ytz074] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 10/24/2018] [Accepted: 04/29/2019] [Indexed: 11/13/2022]
Abstract
BACKGROUND Shapiro syndrome is extremely rare and is characterized by the triad of spontaneous periodic hypothermia, hyperhidrosis and agenesis of the corpus callosum, resulting in neurological and psychological disorders. The exact mechanism of this syndrome is unknown and treatment consists of controlling the periodic attacks. This case report describes a case of Shapiro syndrome presenting with ventricular fibrillation (VF) who was treated with dual chamber implantable cardioverter defibrillator (ICD) therapy. CASE SUMMARY A 45-year-old man, suffering from Shapiro syndrome with frequent hypothermic attacks, was admitted to the emergency department with an out of hospital cardiac arrest caused by VF due to hypothermia. To prevent cardiac death during future hypothermic attacks with VF, the patient was treated with a dual chamber ICD. Within 1 month after ICD implantation the patient had two events of ventricular tachycardia/VF during hypothermia, which were both successfully terminated by an ICD shock. One year after ICD implantation the patient suffered from an uncontrolled urinary tract infection and the patient passed away. Post-mortem interrogation of the ICD did not reveal further episodes of VF and showed a higher supraventricular heartrate in the last days before his death, probably due to a sinus tachycardia driven by the infection. It was concluded that the most likely cause of death was an uncontrolled sepsis. DISCUSSION The current case showed that ICD therapy can be successful in treating VF episodes in patients with unexpected periods of hypothermia.
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Affiliation(s)
- Natalia Joanna Braams
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Matthijs L Hendriks
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Vokko P van Halm
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
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34
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Okada Y, Matsuyama T, Morita S, Ehara N, Miyamae N, Jo T, Sumida Y, Okada N, Watanabe M, Nozawa M, Tsuruoka A, Fujimoto Y, Okumura Y, Kitamura T, Yamamoto S, Iiduka R, Koike K. The development and validation of a "5A" severity scale for predicting in-hospital mortality after accidental hypothermia from J-point registry data. J Intensive Care 2019; 7:27. [PMID: 31073406 PMCID: PMC6499959 DOI: 10.1186/s40560-019-0384-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 04/23/2019] [Indexed: 12/23/2022] Open
Abstract
Background Accidental hypothermia is a serious condition that requires immediate and accurate assessment to determine severity and treatment. Currently, accidental hypothermia is evaluated using the Swiss grading system which uses core body temperature and clinical findings; however, research has shown that core body temperature is not associated with in-hospital mortality in urban settings. Therefore, we developed and validated a severity scale for predicting in-hospital mortality among urban Japanese patients with accidental hypothermia. Methods Data for this multi-center retrospective cohort study were obtained from the J-point registry. We included patients with accidental hypothermia who were admitted to an emergency department. The total cohort was divided into a development cohort and validation cohort, based on the location of each institution. We developed a logistic regression model for predicting in-hospital mortality using the development cohort and assessed its internal validity using bootstrapping. The model was then subjected to external validation using the validation cohorts. Results Among the 572 patients in the J-point registry, 532 were ultimately included and divided into the development cohort (N = 288, six hospitals, in-hospital mortality 22.0%) and the validation cohort (N = 244, six hospitals, in-hospital mortality 27.0%). The 5 “A” scoring system based on age, activities-of-daily-living status, near arrest, acidemia, and serum albumin level was developed based on the variables’ coefficients in the development cohort. In the validation cohort, the prediction performance was validated. Conclusion Our “5A” severity scoring system could accurately predict the risk of in-hospital mortality among patients with accidental hypothermia. Electronic supplementary material The online version of this article (10.1186/s40560-019-0384-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yohei Okada
- 1Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, 606-8501, Yoshidakonoe-cho, Sakyo, Kyoto, Japan.,2Department of Emergency and Critical Care Medicine, Japanese Red Cross Society, Kyoto Daini Hospital, Kyoto, Japan
| | - Tasuku Matsuyama
- 3Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Sachiko Morita
- Senri Critical Care Medical Center, Saiseikai Senri Hospital, Suita, Japan
| | - Naoki Ehara
- Department of Emergency, Japanese Red Cross Society, Kyoto Daiichi Red Cross Hospital, Kyoto, Japan
| | - Nobuhiro Miyamae
- 6Department of Emergency Medicine, Rakuwa-kai Otowa Hospital, Kyoto, Japan
| | - Takaaki Jo
- Department of Emergency Medicine, Uji-Tokushukai Medical Center, Uji, Japan
| | - Yasuyuki Sumida
- 8Department of Emergency Medicine, North Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nobunaga Okada
- 3Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan.,9Department of Emergency and Critical Care Medicine, National Hospital Organization, Kyoto Medical Center, Kyoto, Japan
| | - Makoto Watanabe
- 3Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masahiro Nozawa
- 10Department of Emergency and Critical Care Medicine, Saiseikai Shiga Hospital, Ritto, Japan
| | - Ayumu Tsuruoka
- Department of Emergency and Critical Care Medicine, Kyoto Min-Iren Chuo Hospital, Kyoto, Japan
| | - Yoshihiro Fujimoto
- 12Department of Emergency Medicine, Yodogawa Christian Hospital, Osaka, Japan
| | - Yoshiki Okumura
- Department of Emergency Medicine, Fukuchiyama City Hospital, Fukuchiyama, Japan
| | - Tetsuhisa Kitamura
- 14Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Shungo Yamamoto
- 15Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ryoji Iiduka
- 2Department of Emergency and Critical Care Medicine, Japanese Red Cross Society, Kyoto Daini Hospital, Kyoto, Japan
| | - Kaoru Koike
- 1Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, 606-8501, Yoshidakonoe-cho, Sakyo, Kyoto, Japan
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35
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Mair P, Gasteiger L, Mair B, Stroehle M, Walpoth B. Successful Defibrillation of Four Hypothermic Patients with Witnessed Cardiac Arrest. High Alt Med Biol 2019; 20:71-77. [DOI: 10.1089/ham.2018.0084] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Peter Mair
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Lukas Gasteiger
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Birgit Mair
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Mathias Stroehle
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Beat Walpoth
- Emeritus, Department of Cardiovascular Surgery, Geneva University, Geneva, Switzerland
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36
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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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Misleading symptoms and successful noninvasive rewarming of a patient with severe hypothermia (23.1 °C). Anaesthesist 2018; 67:931-935. [DOI: 10.1007/s00101-018-0508-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 10/11/2018] [Accepted: 10/12/2018] [Indexed: 10/28/2022]
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Morita S, Matsuyama T, Ehara N, Miyamae N, Okada Y, Jo T, Sumida Y, Okada N, Watanabe M, Nozawa M, Tsuruoka A, Fujimoto Y, Okumura Y, Kitamura T, Hayashi Y. Prevalence and outcomes of accidental hypothermia among elderly patients in Japan: Data from the J-Point registry. Geriatr Gerontol Int 2018; 18:1427-1432. [PMID: 30094918 DOI: 10.1111/ggi.13502] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 06/11/2018] [Accepted: 07/02/2018] [Indexed: 12/01/2022]
Abstract
AIM We aimed to evaluate the prevalence and outcomes of accidental hypothermia (AH) among elderly patients in Japan. METHODS This was a multicenter chart review study of patients with AH (Japanese accidental hypothermia network registry; J-Point registry) that included patients with a body temperature ≤35 °C and those aged ≥18 years who visited the emergency department of 12 institutions in Japan from 1 April 2011 to 31 March 2016. The patients were classified into three groups: adult (aged 18-64 years), young-old (aged 65-79 years) and old-old (aged ≥80 years). The association between each age category and in-hospital mortality from AH was examined through a multivariable logistic regression analysis. RESULTS In total, 572 patients were registered in the J-Point registry database, of which 537 were included. The proportion of individuals who developed AH in an indoor setting was higher in the old-old group than in the adult group (86.9% [226/260] vs 61.1% [87/113]). The in-hospital mortality rates of the adult, young-old and old-old groups were 15.0% (17/113), 21.3% (35/164) and 30.4% (79/260), respectively. In the multivariable analysis, the in-hospital mortality rate was higher in the young-old and old-old groups than in the adult group (young-old vs adult, adjusted odds ratio: 2.31 and 95% confidence interval 1.16-4.64; old-old vs adult, adjusted odds ratio: 2.91 and 95% confidence interval 1.41-6.02). CONCLUSIONS Approximately 80% of patients with AH were aged ≥65 years. The in-hospital mortality rate of patients aged ≥65 years was significantly higher than that of those aged <65 years. Geriatr Gerontol Int 2018; 18: 1427-1432.
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Affiliation(s)
- Sachiko Morita
- Senri Critical Care Medical Center, Saiseikai Senri Hospital, Suita, Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Naoki Ehara
- Department of Emergency, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Nobuhiro Miyamae
- Department of Emergency Medicine, Rakuwa-kai Otowa Hospital, Kyoto, Japan
| | - Yohei Okada
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Society Kyoto Daini Red Cross Hospital, Kyoto, Japan
| | - Takaaki Jo
- Department of Emergency Medicine, Uji-Tokushukai Medical Center, Uji, Japan
| | - Yasuyuki Sumida
- Department of Emergency Medicine, North Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nobunaga Okada
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan.,Department of Emergency and Critical Care Medicine, National Hospital Organization, Kyoto Medical Center, Kyoto, Japan
| | - Makoto Watanabe
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masahiro Nozawa
- Department of Emergency and Critical Care Medicine, Saiseikai Shiga 23 Hospital, Ritto, Japan
| | - Ayumu Tsuruoka
- Department of Emergency and Critical Care Medicine, Kidney and Cardiovascular Center, Kyoto Min-iren Chuo Hospital, Kyoto, Japan.,Emergency and Critical Care Medical Center, Osaka City General Hospital, Osaka, Japan
| | - Yoshihiro Fujimoto
- Department of Emergency Medicine, Yodogawa Christian Hospital, Osaka, Japan
| | - Yoshiki Okumura
- Department of Emergency Medicine, Fukuchiyama City Hospital, Fukuchiyama, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Yasuyuki Hayashi
- Senri Critical Care Medical Center, Saiseikai Senri Hospital, Suita, Japan
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Okada Y, Matsuyama T, Morita S, Ehara N, Miyamae N, Jo T, Sumida Y, Okada N, Kitamura T, Iiduka R. Prognostic factors for patients with accidental hypothermia: A multi-institutional retrospective cohort study. Am J Emerg Med 2018; 37:565-570. [PMID: 29950275 DOI: 10.1016/j.ajem.2018.06.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 06/11/2018] [Accepted: 06/11/2018] [Indexed: 10/28/2022] Open
Abstract
INTRODUCTION In cases of severe accidental hypothermia (AH) in urban areas, the prognostic factors are unknown. We identified factors associated with in-hospital mortality in patients with moderate-to-severe AH in urban areas of Japan. METHOD The J-Point registry database is a multi-institutional retrospective cohort study for AH in 12 Japanese emergency departments. From this registry, we enrolled patients whose core body temperature was 32 °C or less on admission. In-hospital death was the primary outcome of this study. We investigated the association between each candidate prognostic factor and in-hospital death by applying the multivariate logistic regression analyses with adjusted odds ratios (AORs) and their 95% confidence interval [CI] as the effect variables. RESULTS Of 572 patients registered in the J-point registry, 358 hypothermic patients were eligible for analyses. Median body temperature was 29.2 °C (interquartile range, 27.0 °C-30.8 °C). In-hospital deaths comprised 26.3% (94/358) of all study patients. Factors associated with in-hospital death were age ≥ 75 years (AOR, 3.09; 95% CI, 1.31-7.27), need for assistance with activities of daily living (ADL; AOR, 3.06; 95% CI, 1.68-5.59), hemodynamic instability (AOR, 2.49; 95% CI, 1.32-4.68), and hyperkalemia (≥5.6 mEq/L; AOR, 2.65; 95% CI, 1.13-6.21). CONCLUSION The independent prognostic factors associated with in-hospital mortality of patients with moderate-to-severe AH in urban areas of Japan were age ≥ 75 years, need for assistance with ADL, hemodynamic instability, and hyperkalemia.
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Affiliation(s)
- Yohei Okada
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Society Kyoto Daini Red Cross Hospital, Japan.
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Sachiko Morita
- Senri Critical Care Medical Center, SaiseikaiSenri Hospital, Suita, Japan
| | - Naoki Ehara
- Department of Emergency, Japanese Red Cross Society Kyoto Daiichi Red Cross Hospital, Kyoto, Japan
| | - Nobuhiro Miyamae
- Department of Emergency Medicine, Rakuwa-kai Otowa Hospital, Kyoto, Japan
| | - Takaaki Jo
- Department of Emergency Medicine, Uji-Tokushukai Medical Center, Uji, Japan
| | - Yasuyuki Sumida
- Department of Emergency Medicine, North Medical Center, Kyoto Prefectural University of Medicine, Japan
| | - Nobunaga Okada
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan; Department of Emergency and Critical Care Medicine, National Hospital Organization, Kyoto Medical Center, Kyoto, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Japan
| | - Ryoji Iiduka
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Society Kyoto Daini Red Cross Hospital, Japan
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Matsuyama T, Morita S, Ehara N, Miyamae N, Okada Y, Jo T, Sumida Y, Okada N, Watanabe M, Nozawa M, Tsuruoka A, Fujimoto Y, Okumura Y, Kitamura T, Ohta B. Characteristics and outcomes of accidental hypothermia in Japan: the J-Point registry. Emerg Med J 2018; 35:659-666. [PMID: 29886414 DOI: 10.1136/emermed-2017-207238] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 05/12/2018] [Accepted: 05/18/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Accidental hypothermia (AH) has higher incidence and mortality in geriatric populations. Japan has a rapidly ageing population, and little is known about the epidemiology of hypothermia in this country. METHODS We created an AH registry based on retrospective review of patients visiting the ED of 12 institutions with temperature ≤35°C between April 2011 and March 2016. The severity of AH was classified as mild (≤35, ≥32°C), moderate (<32, ≥28°C) or severe (<28°C). The relationship between in-hospital mortality and severity of AH was assessed using a multivariable logistic regression analysis. RESULTS A total of 572 patients were registered in this registry and 537 patients were eligible for our analysis. The median age was 79 (IQR 66-87) years and the proportion of men was 51.2% (273/537). AH was more likely to occur in elderly patients aged ≥65 years (424/537, 80.0%) and in indoor settings (418/537, 77.8%). The condition most frequently associated with AH, irrespective of severity, was acute medical illness. A lower mean outside temperature was associated with a higher prevalence of AH, and particularly severe AH (p for trend <0.001). The overall proportion of cases resulting in in-hospital death was 24.4% (131/537), with no significant difference between severity levels observed in a multivariable logistic regression analysis (severe group (37/118, 31.4%) vs mild group (42/192, 21.9%), adjusted OR (AOR) 1.01, 95% CI 0.61 to 1.68; and moderate group (52/227, 22.9%) vs mild group, AOR 1.11, 95% CI 0.58 to 2.14). CONCLUSION Active prevention and intervention should occur for this important public health issue.
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Affiliation(s)
- Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Sachiko Morita
- Department of Emergency and Critical Care Medicine, Senri Critical Care Medical Center, Saiseikai Senri Hospital, Suita, Japan
| | - Naoki Ehara
- Department of Emergency Medicine, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Nobuhiro Miyamae
- Department of Emergency Medicine, Rakuwa-kai Otowa Hospital, Kyoto, Japan
| | - Yohei Okada
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Society Kyoto Daini Red Cross Hospital, Kyoto, Japan
| | - Takaaki Jo
- Department of Emergency Medicine, Uji-Tokushukai Medical Center, Uji, Japan
| | - Yasuyuki Sumida
- Department of Emergency Medicine, North Medical Center, Kyoto Prefectural University of Medicine, Yosa-gun, Japan
| | - Nobunaga Okada
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan.,Department of Emergency and Critical Care Medicine, National Hospital Organization, Kyoto Medical Center, Kyoto, Japan
| | - Makoto Watanabe
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masahiro Nozawa
- Department of Emergency and Critical Care Medicine, Saiseikai Shiga Hospital, Ritto, Japan
| | - Ayumu Tsuruoka
- Department of Emergency and Critical Care Medicine, Kidney and Cardiovascular Center, Kyoto Min-iren Chuo Hospital, Kyoto, Japan.,Department of Emergency and Critical Care Medicine, Emergency and Critical Care Medical Center, Osaka City General Hospital, Osaka, Japan
| | - Yoshihiro Fujimoto
- Department of Emergency Medicine, Yodogawa Christian Hospital, Osaka, Japan
| | - Yoshiki Okumura
- Department of Emergency Medicine, Fukuchiyama City Hospital, Fukuchiyama, Japan
| | - Tetsuhisa Kitamura
- Department of Social and Environmental Medicine, Division of Environmental Medicine and Population Sciences, Graduate School of Medicine, Osaka University, Suita City, Japan
| | - Bon Ohta
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Abstract
Accidental hypothermia causes profound changes to the body's physiology. After an initial burst of agitation (e.g., 36-37°C), vital functions will slow down with further cooling, until they vanish (e.g. <20-25°C). Thus, a deeply hypothermic person may appear dead, but may still be able to be resuscitated if treated correctly. The hospital use of minimally invasive rewarming for nonarrested, 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 revolutionized the management of hypothermic cardiac arrest, with survival rates approaching 100%. Hypothermic patients with risk factors for imminent cardiac arrest (i.e., temperature <28°C, ventricular arrhythmia, systolic blood pressure <90 mmHg), and those who have already arrested, should be transferred directly to an ECLS center. Cardiac arrest patients should receive continuous cardiopulmonary resuscitation (CPR) during transfer. If prolonged transport is required or terrain is difficult, mechanic CPR can be helpful. Intermittent CPR may be appropriate in hypothermic arrest when continuous CPR is impossible. Modern postresuscitation care should be implemented following hypothermic arrest. Structured protocols should be in place to optimize prehospital triage, transport, and treatment as well as in-hospital management, including detailed criteria and protocols for the use of ECLS and postresuscitation care.
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Affiliation(s)
- Peter Paal
- Department of Anaesthesia and Intensive Care Medicine, Hospitallers Brothers Hospital, Salzburg, Austria.
| | - Hermann Brugger
- Institute of Mountain Emergency Medicine, EURAC Research, Bolzano, Italy
| | - Giacomo Strapazzon
- Institute of Mountain Emergency Medicine, EURAC Research, Bolzano, Italy
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Fukaya H, Piktel JS, Wan X, Plummer BN, Laurita KR, Wilson LD. Arrhythmogenic Delayed Afterdepolarizations Are Promoted by Severe Hypothermia But Not Therapeutic Hypothermia. Circ J 2018; 82:62-70. [DOI: 10.1253/circj.cj-17-0145] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Hidehira Fukaya
- The Heart and Vascular Research Center, MetroHealth Campus, Case Western Reserve University
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | - Joseph S. Piktel
- The Heart and Vascular Research Center, MetroHealth Campus, Case Western Reserve University
- Department of Emergency Medicine, MetroHealth Campus, Case Western Reserve University
| | - Xiaoping Wan
- The Heart and Vascular Research Center, MetroHealth Campus, Case Western Reserve University
| | - Bradley N. Plummer
- The Heart and Vascular Research Center, MetroHealth Campus, Case Western Reserve University
| | - Kenneth R. Laurita
- The Heart and Vascular Research Center, MetroHealth Campus, Case Western Reserve University
| | - Lance D. Wilson
- The Heart and Vascular Research Center, MetroHealth Campus, Case Western Reserve University
- Department of Emergency Medicine, MetroHealth Campus, Case Western Reserve University
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Endovascular rewarming in the emergency department for moderate to severe accidental hypothermia. Am J Emerg Med 2017; 35:1624-1629. [PMID: 28506506 DOI: 10.1016/j.ajem.2017.05.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 04/09/2017] [Accepted: 05/08/2017] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Endovascular temperature control catheters can be utilized for emergent rewarming in accidental hypothermia. The purpose of this study was to compare patients with moderate to severe hypothermia rewarmed with an endovascular temperature control catheter versus usual care at our institution. METHODS We conducted a retrospective, observational cohort study of patients with moderate to severe accidental hypothermia (core body temperature less than 32°C) in the Emergency Department of an urban, tertiary care medical center. We identified the rewarming techniques utilized for each patient, including those who had an endovascular temperature control catheter placed (Quattro© or Icy© catheter, CoolGuard© 3000 regulation system, Zoll Medical). Rewarming rates and outcomes were compared for patients with and without the endovascular temperature control catheter. We systematically screened for procedural complications. RESULTS There were 106 patients identified with an initial core temperature less than or equal to 32°C; 52 (49%) patients rewarmed with an endovascular temperature control catheter. Other methods of rewarming included external forced-air rewarming (85, 80%), bladder lavage (17, 16%), gastric lavage (10, 9%), closed pleural lavage (6, 6%), and peritoneal lavage (3, 3%). Rate of rewarming did not differ between the groups with and without catheter-based rewarming (1.3°C/h versus 1.0°C/h, difference 0.3°C, 95% confidence interval [CI] of the difference 0-0.6°C) and neither did survival (70% versus 71%, difference 1%, 95% CI -17 to 20%). We did not identify any significant vascular injuries resulting from endovascular catheter use. CONCLUSION The endovascular temperature control system was not associated with an increased rate of rewarming in this cohort with moderate to severe hypothermia; however, this technique appears to be safe and feasible.
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Clinical course and prognostic factors of patients in severe accidental hypothermia with circulatory instability rewarmed with veno-arterial ECMO - an observational case series study. Scand J Trauma Resusc Emerg Med 2017; 25:46. [PMID: 28464863 PMCID: PMC5414327 DOI: 10.1186/s13049-017-0388-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 04/25/2017] [Indexed: 11/10/2022] Open
Abstract
Background Recently, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has become the rewarming treatment of choice in hypothermic cardiac arrest. The detailed indications for extracorporeal rewarming in non-arrested, severely hypothermic patients with circulatory instability have not been established yet. The primary purpose of the study was a preliminary analysis of all aspects of the treatment process, as well as initial identification of mortality risk factors within the group of severely hypothermic patients, treated with arteriovenous extracorporeal membrane oxygenation (VA-ECMO). The secondary aim of the study was to evaluate efficacy of VA-ECMO in initial 6-h period of treatment Methods From July 2013 to June 2016, thirty one hypothermic patients were accepted for extracorporeal rewarming at Severe Accidental Hypothermia Center, Cracow. Thirteen patients were identified with circulatory instability and were enrolled in the study. The evaluation took into account patients’ condition on admission, the course of therapy, and changes in laboratory and hemodynamic parameters. Results Nine out of 13 analyzed patients survived (69%). Patients who died were older, had lower both systolic and diastolic pressure, and had increased creatinine an potassium levels on admission. In surviving patients, arterial blood gases parameters (pH, BE, HCO3) and lactates would normalize more quickly. Their potassium level was lower on admission as well. The values of the core temperature on admission were comparable. Although normothermia was achieved in 92% of patients, none of them had been weaned-off VA-ECMO in the first 6 h of treatment. Discussion and Conclusions In our preliminary study more pronounced markers of cardiocirculatory instability and organ hypoperfusion were observed in non-survivors. Future studies on indications to extracorporeal rewarming in severely hypothermic, non-arrested patients should focus on the extent of hemodynamic disturbances. Short term (<6 h) treatment in severe hypothermic, non-arrested patients seems to be not clinically appropriate.
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Dietrichs ES, Sager G, Tveita T. Altered pharmacological effects of adrenergic agonists during hypothermia. Scand J Trauma Resusc Emerg Med 2016; 24:143. [PMID: 27919274 PMCID: PMC5139099 DOI: 10.1186/s13049-016-0339-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 11/29/2016] [Indexed: 01/02/2023] Open
Abstract
Rewarming from accidental hypothermia is often complicated by hypothermia-induced cardiac dysfunction, calling for immediate pharmacologic intervention. Studies show that although cardiac pharmacologic support is applied when rewarming these patients, a lack of updated treatment recommendations exist. Mainly due to lack of clinical and experimental data, neither of the international guidelines includes information about pharmacologic cardiac support at temperatures below 30 °C. However, core temperature of accidental hypothermia patients is often reduced below 30 °C. Few human studies exploring effects of adrenergic drugs during hypothermia have been published, and therefore prevailing information is collected from pre-clinical studies. The most prominent finding in these studies is an apparent depressive effect of adrenaline on cardiac function when used in doses which elevate cardiac output during normothermia. Also noradrenaline and isoprenaline largely lacked positive cardiac effects during hypothermia, while dopamine is a more promising drug for supporting cardiac function during rewarming. Data and information from these studies are in support of the prevailing notion; not to use adrenergic drugs at core temperatures below 30 °C.
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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, 9037, Tromsø, Norway. .,Department of Research and Education, Norwegian Air Ambulance Foundation, 1441, Drøbak, Norway.
| | - Georg Sager
- Experimental and Clinical Pharmacology, Department of medical biology, UiT, The Arctic University of Norway, 9037, Tromsø, Norway
| | - 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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Omar HR, El-Khabiry E, Tripathi N, Mangar D, Camporesi EM. Hypothermic Osborn waves without shivering artifacts: causes and implications. Ther Adv Endocrinol Metab 2016; 7:229-232. [PMID: 28203359 PMCID: PMC5298361 DOI: 10.1177/2042018816680588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
| | - Ehab El-Khabiry
- Department of Internal Medicine, OSF Saint Anthony Medical Center, Rockford, IL, USA
| | - Nishant Tripathi
- Internal Medicine Department, Ottumwa Regional Health Center, IA, USA
| | - Devanand Mangar
- Chief of Anesthesia, Tampa General Hospital; CEO, FGTBA and Regional Medical Director, TEAMHealth, Tampa, FL, USA
| | - Enrico M. Camporesi
- Emeritus Professor, University of South Florida, FGTBA and TEAMHealth, Tampa, FL, USA
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Lee WS, Nam GB, Kim SH, Choi JH, Jo U, Kim WY, Oh YS, Park KN, Seo GW, Kim KH, Jin ES, Rhee KS, Jung L, Hwang KW, Kim YR, Kwon CH, Kim J, Choi KJ, Kim YH. ECG features and proarrhythmic potentials of therapeutic hypothermia. Heart 2016; 102:1558-65. [DOI: 10.1136/heartjnl-2015-308821] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 04/21/2016] [Indexed: 11/03/2022] Open
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Di Girolamo N, Toth G, Selleri P. Prognostic value of rectal temperature at hospital admission in client-owned rabbits. J Am Vet Med Assoc 2016; 248:288-97. [DOI: 10.2460/javma.248.3.288] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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The Osborn wave: what have we learned? Herz 2015; 41:48-56. [DOI: 10.1007/s00059-015-4338-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 06/22/2015] [Accepted: 06/29/2015] [Indexed: 11/28/2022]
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