Differential Effect of Targeted Temperature Management Between 32 °C and 36 °C Following Cardiac Arrest According to Initial Severity of Illness: Insights From Two International Data Sets

BACKGROUND

Recent guidelines have emphasized actively avoiding fever to improve outcomes in patients who are comatose following resuscitation from cardiac arrest (ie, out-of-hospital cardiac arrest). However, whether targeted temperature management between 32 °C and 36 °C (TTM32-36) can improve neurologic outcome in some patients remains debated.

RESEARCH QUESTION

Is there an association between the use of TTM32-36 and outcome according to severity assessed at ICU admission using a previously derived risk score?

STUDY DESIGN AND METHODS

Data prospectively collected in the Sudden Death Expertise Center (SDEC) registry (France) between May 2011 and December 2017 and in the Resuscitation Outcomes Consortium Continuous Chest Compressions (ROC-CCC) trial (United States and Canada) between June 2011 and May 2015 were used for this study. Severity at ICU admission was assessed through a modified version of the Cardiac Arrest Hospital Prognosis (mCAHP) score, divided into tertiles of severity. The study explored associations between TTM32-36 and favorable neurologic status at hospital discharge by using multiple logistic regression as well as in tertiles of severity for each data set.

RESULTS

A total of 2,723 patients were analyzed in the SDEC data set and 4,202 patients in the ROC-CCC data set. A favorable neurologic status at hospital discharge occurred in 728 (27%) patients in the French data set and in 1,239 (29%) patients in the North American data set. Among the French data set, TTM32-36 was independently associated with better neurologic outcome in the tertile of patients with low (adjusted OR, 1.63; 95% CI, 1.15-2.30; P = .006) and high (adjusted OR, 1.94; 95% CI, 1.06-3.54; P = .030) severity according to mCAHP at ICU admission. Similar results were observed in the North American data set (adjusted ORs of 1.36 [95% CI, 1.05-1.75; P = .020] and 2.42 [95% CI, 1.38-4.24; P = .002], respectively). No association was observed between TTM32-36 and outcome in the moderate groups of the two data sets.

INTERPRETATION

TTM32-36 was significantly associated with a better outcome in patients with low and high severity at ICU admission assessed according to the mCAHP score. Further studies are needed to evaluate individualized temperature control following out-of-hospital cardiac arrest.

Association between Vitamin D Deficiency and Prognosis after Hip Fracture Surgery in Older Patients in a Dedicated Orthogeriatric Care Pathway

OBJECTIVES

Vitamin D deficiency is common in patients undergoing hip fracture surgery (HFS) and has been found to be associated with poor post-operative outcome in other settings. This study aimed to analyze the association between vitamin D status and prognosis after HFS.

DESIGN

Observational, prospective, single-center study.

SETTING AND PARTICIPANTS

All patients admitted in a peri-operative geriatric unit between 2009 and 2020 for HFS were included.

MEASUREMENTS

A moderate vitamin D deficiency was defined by a vitamin D level between 25 and 75 nmol/l and a severe deficiency by a vitamin D level <25 nmol/l. Primary endpoint was mortality 6 months after surgery. Secondary endpoints were bacterial infections and delirium during hospitalization. Odds ratio (OR) and 95% confidence interval (95%CI) were computed using logistic regression models with adjustment for confounders.

RESULTS

1197 patients were included (median age 87 years, IQR [82-91]). Median vitamin D level was 55 nmol/l (IQR [30-75 nmol/l]). Moderate and severe vitamin D deficiencies were reported in 53% and 21% of patients, respectively. There was no significant association between moderate or severe vitamin D deficiencies and 6-month mortality (OR 0.91, 95%CI [0.59-1.39], and OR 1.31, 95%CI [0.77-2.22], respectively), bacterial infection (OR 0.89, 95%CI [0.60-1.31] and OR 1.55, 95%CI [0.99-2.41], respectively), nor delirium (OR 1.03, 95%CI [0.75-1.40], and OR 1.05, 95%CI [0.70-1.57], respectively).

CONCLUSION

Vitamin D deficiency was not associated with mortality, bacterial infection or delirium after HFS. Our results suggest that comorbidities, functional status and post-operative complications are the main determinants of post-operative outcome after HFS.

Retour d’expérience sur la direction médicale de crise à l’Assistance publique–Hôpitaux de Paris pendant la crise Covid-19

Un retour d’expérience sur la direction médicale de crise (DMC) pendant la première phase de l’épidémie de Covid-19 a été effectué à l’Assistance publique–Hôpitaux de Paris (AP–HP), le plus important centre hospitalier universitaire européen. L’AP–HP s’est dotée d’un directeur médical de crise (DMC) AP–HP, de six DMC de groupes hospitaliers (GH) et d’un DMC pour chacun des 39 sites hospitaliers. Le pilotage s’est appuyé sur des réunions quotidiennes de crise AP–HP et de GH, des groupes de travail disciplinaires et des tableaux de bord quotidiens fiabilisés qui ont permis d’optimiser les actions. Des actions innovantes ont été mises en place : cellules de régulation des entrées et des sorties de réanimation, suivi des patients infectés à domicile, traçage des contacts, transferts interrégionaux de patients de réanimation. Les éléments clés de la réussite ont été les relations entre direction générale et DMC, l’articulation entre l’échelon central (AP–HP) et celui des GH, la mobilisation de tous les acteurs vers un objectif unique identifié et la mobilisation de l’ensemble des soignants, y compris les étudiants. Parmi les pistes d’amélioration soulignées, il convient de citer la généralisation des DMC hors AP–HP, conformément à la réglementation, le développement de la connaissance du mode de fonctionnement de crise, l’anticipation de la formation à la gestion de crise, la réalisation d’une information quotidienne de l’ensemble des acteurs des actions menées dans une crise de longue durée et la participation des représentants des usagers. La gestion de la recherche en temps de crise reste à inventer au niveau national, voire européen.

Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a registry study

Aims

Out-of-hospital cardiac arrest (OHCA) without return of spontaneous circulation (ROSC) despite conventional resuscitation is common and has poor outcomes. Adding extracorporeal membrane oxygenation (ECMO) to cardiopulmonary resuscitation (extracorporeal-CPR) is increasingly used in an attempt to improve outcomes.

Methods and results

We analysed a prospective registry of 13 191 OHCAs in the Paris region from May 2011 to January 2018. We compared survival at hospital discharge with and without extracorporeal-CPR and identified factors associated with survival in patients given extracorporeal-CPR. Survival was 8% in 525 patients given extracorporeal-CPR and 9% in 12 666 patients given conventional-CPR (P = 0.91). By adjusted multivariate analysis, extracorporeal-CPR was not associated with hospital survival [odds ratio (OR), 1.3; 95% confidence interval (95% CI), 0.8–2.1; P = 0.24]. By conditional logistic regression with matching on a propensity score (including age, sex, occurrence at home, bystander CPR, initial rhythm, collapse-to-CPR time, duration of resuscitation, and ROSC), similar results were found (OR, 0.8; 95% CI, 0.5–1.3; P = 0.41). In the extracorporeal-CPR group, factors associated with hospital survival were initial shockable rhythm (OR, 3.9; 95% CI, 1.5–10.3; P = 0.005), transient ROSC before ECMO (OR, 2.3; 95% CI, 1.1–4.7; P = 0.03), and prehospital ECMO implantation (OR, 2.9; 95% CI, 1.5–5.9; P = 0.002).

Conclusions

In a population-based registry, 4% of OHCAs were treated with extracorporeal-CPR, which was not associated with increased hospital survival. Early ECMO implantation may improve outcomes. The initial rhythm and ROSC may help select patients for extracorporeal-CPR.

Comparison of different techniques of central venous pressure measurement in mechanically ventilated critically ill patients

BACKGROUND

Several techniques exist for measuring central venous pressure (CVP) but little information is available about the accuracy of each method. The aim of this study was to compare different methods of CVP measurements in mechanically ventilated patients.

METHODS

CVP was measured in mechanically ventilated patients without spontaneous breathing using four different techniques: 1) end expiratory CVP measurement at the base of the" c" wave (CVP_MEASURED), chosen as the reference method; 2) CVP measurement from the monitor averaging CVP over the cardiac and respiratory cycles (CVP_MONITOR); 3) CVP measurement after a transient withdrawing of mechanical ventilation (CVP_NADIR); 4) CVP measurement corrected for the transmitted respiratory pressure induced by intrinsic PEEP (calculated CVP: CVP_CALCULATED). Bias, precision, limits of agreement, and proportions of outliers (difference > 2 mm Hg) were determined.

RESULTS

Among 61 included patients, 103 CVP assessments were performed. CVP_MONITOR bias [-0.87  (1.06) mm Hg] was significantly different from those of CVP_CALCULATED [1.42  (1.07), P < 0.001 and CVP_NADIR (1.04  (1.29), P < 0.001]. The limits of agreement of CVP_MONITOR [-2.96 to 1.21 mm Hg] were not significantly different to those of CVP_NADIR (-1.49 to 3.57 mm Hg, P = 0.39) and CVP_CALCULATED (-0.68 to 3.53 mm Hg, P = 0.31). The proportion of outliers was not significantly different between CVP_MONITOR (n = 5, 5%) and CVP_NADIR (n = 9, 9%, P = 0.27) but was greater with CVP_CALCULATED (n = 16, 15%, P = 0.01).

CONCLUSIONS

In mechanically ventilated patients, CVP_MONITOR is a reliable method for assessing CVP_MEASURED Taking into account transmitted respiratory pressures, CVP_CALCULATED had a higher proportion of outliers and precision than CVP_NADIR.

Reduced mortality by meeting guideline criteria before using recombinant activated factor VII in severe trauma patients with massive bleeding

BACKGROUND

Management of trauma patients with severe bleeding has led to criteria before considering use of recombinant activated factor VII (rFVIIa), including haemoglobin >8 g dl^-1, serum fibrinogen ≥1.0 g l^-1, platelets >50,000 x 10⁹ l^-1, arterial pH ≥ 7.20, and body temperature ≥34 °C. We hypothesized that meeting these criteria is associated with improved outcomes.

METHODS

In this prospective cohort study of 26 French trauma centres, subjects were included if they received rFVIIa for persistent massive bleeding despite appropriate care after severe blunt and/or penetrating trauma.

RESULTS

After surgery and/or embolization as haemostatic interventions, 112 subjects received a first dose of 103 μg kg^-1 rFVIIa (82-200) (median, 25^th-75^th percentile) at 420 min (285-647) post-trauma. Of these, 71 (63%) "responders" were still alive at 24h post-trauma and had their transfusion requirements reduced by > 2 packed red blood cell units after rFVIIa treatment. Mortality was 54% on day 30 post-trauma. There were 21%, 44% and 35% subjects who fulfilled 0-1, 2-3 or 4-5, respectively, of the guidelines before receiving rFVIIa. Survival at day 30 was 13%, 49% and 64% and the proportion of responders was 39%, 64% and 82%, when subjects fulfilled 0-1, 2-3 or 4-5 conditions, respectively (both P <0.01).

CONCLUSIONS

In actively bleeding trauma patients, meeting guideline criteria before considering rFVIIa was associated with lower mortality and a higher proportion of responders to the rFVIIa.

Descriptif de l'activité des structures des urgences en Île-de-France à l'aide du questionnaire « National Emergency Department Inventory » (NEDI) appliqué au système français

Introduction : La base de données NEDI (National Emergency Department Inventory) repose sur un descriptif de l'activité des structures des urgences (SU). Elle rend compte de la diversité de ces structures au niveau national et international. L'objectif de cette étude NEDI-Paris était de décrire l'organisation des SU en Île-de-France et les moyens à disposition, selon le statut public ou privé.

Méthode : Les SU ouvertes 24 heures/24 et 7 jours/7 ont été inclus. Un questionnaire comprenant 29 items a permis de recueillir les caractéristiques de ces services et les données relatives à l'activité de l'année 2015. Un taux de participation de 80 % était souhaité dans le cadre des enquêtes NEDI pour assurer une exhaustivité des résultats.

Résultats : Sur 117 services éligibles, 97 ont participé à l'étude, soit un taux de réponse de 83 %. L'ensemble de ces services était localisé dans des établissements hospitaliers. Le service était sur un seul site géographique dans 86 % des cas. Le nombre annuel médian de visites était de 34 000 (interquartile : 23 000–56 000). Soixante-six centres (68 %) appartenaient au système public, dont 22 centres universitaires et 31 centres (32 %) étaient des services privés. Les urgences adultes, pédiatriques et mixtes représentaient respectivement 54, 26 et 20 % de l'offre de soins. Un temps d'attente inférieur à une heure était rapporté par 25 % des services : 42 % pour les services privés versus 17 % dans le public (p = 0,01). Un taux d'hospitalisation inférieur à 20 % était rapporté par 54 % des centres, similaire entre public et privé (60 vs 50 % ; p = 0,40). Parmi les services interrogés, 22 % ont déclaré fonctionner en surcharge, plus fréquemment dans le public comparativement aux services privés (27 vs 10 %). La gestion 24 heures/24 et 7 jours/7 de certaines pathologies de même que la disponibilité de certains spécialistes étaient le plus souvent observées dans les hôpitaux publics, notamment universitaires.

Conclusion : L'enquête NEDI en Île-de-France a montré une hétérogénéité dans les caractéristiques et les moyens à disposition des SU. Un déterminant majeur de ces disparités repose sur le statut public versus privé. Une réflexion peut être menée à partir de ces résultats.

Fundus autofluorescence in retinal artery occlusion: A more precise diagnosis

IMPORTANCE

Retinal artery occlusion (RAO) is a medical emergency associated with a high risk of cerebral vascular accident and other cardiovascular events. Among patients with non-arteritic RAO, a retinal embolus is observed in approximately 40% of cases. Fundus examination and retinography are not reliable to predict the nature of the emboli.

OBSERVATIONS

We report three consecutive cases of central and branch RAO that were investigated with fundus autofluorescence, fluorescein angiography and color retinal photographs. All patients underwent complete neurological and cardiovascular workups, with brain imaging, cardiac Doppler ultrasound, carotid Dopplers and Holter ECG's, to determine the underlying mechanism of retinal embolism. In the three cases, aged 77.7±4 years (2 women and 1 man), fundus autofluorescence demonstrated hyperautofluorescent emboli. In two cases, it allowed visualization of emboli that were not detected with fundus examination or retinography. The cardiovascular work-up demonstrated atheromatous carotid or aortic plaques in all patients. In one case, it permitted the diagnosis of RAO. Two of the three cases were considered to be of atherosclerotic origin and one of undefined origin.

CONCLUSION AND RELEVANCE

Fundus autofluorescence may help to detect and characterize retinal emboli. Since lipofuscin, which is present in large quantity in atherosclerotic plaques, is the main fluorophore detected with fundus autofluorescence, this non-invasive and simple examination may give information about the underlying mechanism of retinal embolism, and thus impact the etiologic assessment of RAO. Additional studies are necessary to confirm this potential role of autofluorescence.

[Elderly patients and intensive care: Systematic review and geriatrician's point of view]

The global population is aging and intensive care unit admission rate of elderly patients is dramatically increasing. The objective of this review is to provide an overview of the literature about the management of elderly patients in intensive care unit and more specifically about epidemiology, admission criteria, mortality, functional prognosis and ethical aspects. We also discuss the data on cardiorespiratory arrest, shock, acute respiratory failure and delirium. The mortality rate of patients over 80 years old in intensive care unit can reach up to 70% at 1year, but is dependent on many factors, such as comorbidities or frailty. Above all, more than half of elderly patients recover their long-term autonomy. Their quality of life is comparable to that of the same age population. Considering that the first 3months after an intensive care unit stay are the most decisive in terms of vital and functional prognosis, we will discuss strategies to improve care through the creation of dedicated intensive care-geriatrics networks.

Procalcitonin for clinical decisions on influenza-like illness in emergency department during influenza a(H1N1)2009 pandemic

PURPOSE

We aimed to determine whether serum procalcitonin (PCT) values could help in identifying flu in patient admitted to the emergency department (ED) with influenza-like illness (ILI) during influenza A(H1N1)2009 pandemic.

METHODS

An observational retrospective cohort study was performed in a referral ED for emerging infectious diseases. All patients tested for influenza A(H1N1)2009 by Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR) and procalcitonin between June 2009 and January 2010 were analyzed. PCT was studied for its negative predictive value of bacterial infection. Patients PCT-/RT-PCR + were considered as true positive.

RESULTS

On the 80 patients included, 16 were positive for influenza A(H1N1)2009 RT-PCR, all but one of them had low PCT concentrations. Conversely, 19 (30%) of the 64 patients with negative RT-PCR had elevated PCT concentrations. For a PCT threshold <0.25 μg/L, sensitivity was 0.94, specificity 0.30, positive predictive value 0.25 and negative predictive value 0.95 for the diagnosis of flu.

CONCLUSION

In the context of an influenza pandemic, serum PCT measurement may be useful for clinical decisions in the ED as most of RT-PCR confirmed patients have low PCT values. Patients with PCT above 0.25 μg/L are unlikely to have a unique diagnosis of flu.

Effect of simulated patient death on emergency worker's anxiety: a cluster randomized trial

Objective

Simulation-based teaching offers promising and diverse teaching possibilities. We aim to assess whether the death of the manikin increased anxiety amongst learner compared to similar simulation-based course where the manikin stays alive.

Methods

We conducted a cluster randomized study amongst multidisciplinary teams of emergency workers. Teams of physicians, nurses, and healthcare assistants were randomly assigned to participate in a simulation-based course where the simulated patient died (death group) or not (life group). We assessed anxiety at 1 month after the teaching using Spielberger STAI-state anxiety questionnaire. We compared reduction of anxiety when facing a life-threatening situation in both groups.

Results

We included 25 teams for a total of 129 participants. We analysed 63 participants in the death group and 57 in the life group. Baseline characteristics were similar in both groups, including baseline anxiety (STAI-state score 39.6 (7.8) in the death group vs 38.6 (7.1) in the life group). We report a significant reduction in both groups 1 month after the training: 6.6 (7.8) vs 6 (8.0), mean difference 0.5 (−2.4; 3.4). At 3 months, we report a significant greater reduction of anxiety in the death group (mean difference 4 [0.1; 7.9]).

Conclusion

We observed in our sample that unexpected simulated patient death did not increase anxiety amongst multidisciplinary emergency workers.

[Evaluation of the measurement of hemoglobin by the Hemocue System® in the preterm neonate less than 28 days old]

BACKGROUND

Hemoglobin (Hb) measurement is essential for the monitoring of anemia in preterm neonates to assess if any bleeding (pulmonary, cerebral, digestive) is present. EDTA samples require 500 μL vs. 10 μL for the Hemocue(®) system. This system has been evaluated and validated in adults and children but not in preterm neonates with fetal hemoglobin. The aim of the study was to compare Hb measurement with the Hemocue(®) system vs. the EDTA laboratory system on fetal Hb in preterm neonates.

MATERIALS AND METHODS

This was a prospective study conducted in the preterm intensive care unit in the Amiens Hospital. Preterm neonates, before 28 days of life, requiring EDTA (Hb) measurement were included. Two Hemocues(®) were performed at the same time. Postnatal age (correlated to the fetal hemoglobin level decrease), blood sample site, and other factors that could influence the Hb result were evaluated.

RESULTS

Seventy-six EDTA and 152 Hemocue(®) samples from 38 preterm neonates were included. The term was 28.1±3.7 weeks of gestation, the birth weight was 1215.5±657 g. We found a good correlation between the Hemocue(®) and EDTA samples (Hemocue(®)=EDTA*0.94-0.4; R(2)=0.63; P<0.001). The influence of confounding factors was insignificant.

CONCLUSION

The use of the Hemocue(®) system showed a good correlation with the EDTA measurement of fetal Hb, with a moderate bias (-0.2±1.5 g/dL), which remained stable for the first 28 days of life.

Deletion of extracellular matrix metalloproteinase inducer/CD147 induces altered cardiac extracellular matrix remodeling in aging mice

Extracellular matrix metalloproteinase inducer (EMMPRIN), known for its ability to induce matrix metalloproteinase (MMP) expression, was proposed to play a role in the adverse cardiac extracellular matrix remodeling. After observing an age-associated increase in cardiac EMMPRIN expression in both mice and rats, the role and mechanism of action of EMMPRIN was investigated in the myocardial age-associated changes using 3, 12 and 24 month old EMMPRIN knock-out (KO) vs. wild-type (WT) mice, by cardiac echocardiography, Western blots, immunohistochemistry, ELISA and histology. Adilated cardiomyopathy characterized by a decreased ejection fraction and an enlargement of left ventricular chamber (LV) associated with LV hypertrophy, occurred in KO mice as soon as 12 month old. The increase in interstitial collagen deposition during aging in WT mice could not be detected in KO mice. This may be related to the reduced activation (48% reduction; P < 0.05) and signaling (smad2/3 nuclear translocation) of TGF-β in the 12 month old KO mice which paralleled with a greater reduction in the TGF-β known activating enzymes such as MT1-MMP and MMP-1 (33% and 37% reduction respectively, between 3 and 12 month old in KO mice; P < 0.05) as well as uPA. These findings demonstrate that EMMPRIN gene silencing is associated with an aberrant extracellular matrix remodeling, characterized by the absence of a detected age-associated fibrosis and consequently to dilated cardiopathy, indicating that a fine regulation of EMMPRIN is essential for the coordinated ECM remodeling during aging.

French survey of the first three-years of liver transplantation activity from uncontrolled donors deceased after cardiac death

OBJECTIVE

To assess the first three years of French activity related to liver transplantation from uncontrolled donation after cardiac death (uDCD).

STUDY DESIGN

Prospective and observational study in the three active centres authorized by the French Biomedicine Agency.

PATIENTS AND METHODS

All patients deceased between 2010 and 2012 after an uncontrolled cardiac arrest admitted to one of three centres (Pitié-Salpêtrière, Saint-Louis or Bicêtre hospitals, AP-HP, Paris, France) and potentially eligible for liver recovery were included. Abdominal normothermic oxygenated recirculation (ANOR) was used for graft preservation.

RESULTS

One hundred twenty-six potential uDCD donors were identified as eligible for liver recovery after hospital admission. The main causes of organ recovery failure were technical failure related to ANOR (29 patients, 23%), refusal of consent (39 patients, 31% of potential uDCD donors and 40% of asked relatives) and abnormal hepatic transaminases up to 200 UI.L(-1) during ANOR (24 patients, 19%). Finally, 11 livers were transplanted. Process efficiency was 9% [95% CI: 4-15%]. One-year recipient survival was 82%, [95% CI: 48-98%] and one-year graft survival was 64% [95% CI: 31-89%].

CONCLUSION

Liver transplantation from uDCD donors is achievable in France, despite low process efficiency.