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Drennan IR, McLeod SL, Cheskes S. Randomized controlled trials in resuscitation. Resusc Plus 2024; 18:100582. [PMID: 38444863 PMCID: PMC10912727 DOI: 10.1016/j.resplu.2024.100582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024] Open
Abstract
Randomized controlled trials (RCTs) are a gold standard in research and crucial to our understanding of resuscitation science. Many trials in resuscitation have had neutral findings, questioning which treatments are effective in cardiac resuscitation. While it is possible than many interventions do not improve patient outcomes, it is also possible that the large proportion of neutral findings are partially due to design limitations. RCTs can be challenging to implement, and require extensive resources, time, and funding. In addition, conducting RCTs in the out-of-hospital setting provides unique challenges that must be considered for a successful trial. This article will outline many important aspects of conducting trials in resuscitation in the out-of-hospital setting including patient and outcome selection, trial design, and statistical analysis.
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Affiliation(s)
- Ian R. Drennan
- Sunnybrook Centre for Prehospital Medicine, Toronto, Ontario, Canada
- Division of Emergency Medicine, Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Emergency Services, Sunnybrook Health Sciences, Toronto, Ontario, Canada
| | - Shelley L. McLeod
- Division of Emergency Medicine, Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, Ontario, Canada
| | - Sheldon Cheskes
- Sunnybrook Centre for Prehospital Medicine, Toronto, Ontario, Canada
- Division of Emergency Medicine, Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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van Wijk JJ, Musaj A, Hoeks SE, Reiss IKM, Stolker RJ, Staals LM. Oxygenation during general anesthesia in pediatric patients: A retrospective observational study. J Clin Anesth 2024; 94:111406. [PMID: 38325249 DOI: 10.1016/j.jclinane.2024.111406] [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: 09/27/2023] [Revised: 12/17/2023] [Accepted: 01/29/2024] [Indexed: 02/09/2024]
Abstract
STUDY OBJECTIVE Protocols are used in intensive care and emergency settings to limit the use of oxygen. However, in pediatric anesthesiology, such protocols do not exist. This study aimed to investigate the administration of oxygen during pediatric general anesthesia and related these values to PaO2, SpO2 and SaO2. DESIGN Retrospective observational study. SETTING Tertiary pediatric academic hospital, from June 2017 to August 2020. PATIENTS Patients aged 0-18 years who underwent general anesthesia for a diagnostic or surgical procedure with tracheal intubation and an arterial catheter for regular blood withdrawal were included. Patients on cardiopulmonary bypass or those with missing data were excluded. Electronic charts were reviewed for patient characteristics, type of surgery, arterial blood gas analyses, and oxygenation management. INTERVENTIONS No interventions were done. MEASUREMENTS Primary outcome defined as FiO2, PaO2 and SpO2 values were interpreted using descriptive analyses, and the correlation between PaO2 and FiO2 was determined using the weighted Spearman correlation coefficient. MAIN RESULTS Data of 493 cases were obtained. Of these, 267 were excluded for various reasons. Finally, 226 cases with a total of 645 samples were analyzed. The median FiO2 was 36% (IQR 31 to 43), with a range from 20% to 97%, and the median PaO2 was 23.6 kPa (IQR 18.6 to 28.1); 177 mmHg (IQR 140 to 211). The median SpO2 level was 99% (IQR 98 to 100%). The study showed a moderately positive association between PaO2 and FiO2 (r = 0.52, p < 0.001). 574 of 645 samples (89%) contained a PaO2 higher than 13.3 kPa; 100 mmHg. CONCLUSIONS Oxygen administration during general pediatric anesthesia is barely regulated. Hyperoxemia is observed intraoperatively in approximately 90% of cases. Future research should focus on outcomes related to hyperoxemia.
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Affiliation(s)
- Jan J van Wijk
- Department of Anesthesiology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - Albina Musaj
- Department of Anesthesiology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Sanne E Hoeks
- Department of Anesthesiology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - Irwin K M Reiss
- Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - Robert Jan Stolker
- Department of Anesthesiology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - Lonneke M Staals
- Department of Anesthesiology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands.
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3
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Heikkilä E, Setälä P, Jousi M, Nurmi J. Association among blood pressure, end-tidal carbon dioxide, peripheral oxygen saturation and mortality in prehospital post-resuscitation care. Resusc Plus 2024; 17:100577. [PMID: 38375443 PMCID: PMC10875297 DOI: 10.1016/j.resplu.2024.100577] [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: 10/01/2023] [Revised: 01/14/2024] [Accepted: 01/31/2024] [Indexed: 02/21/2024] Open
Abstract
Aim Post-resuscitation care is described as the fourth link in a chain of survival in resuscitation guidelines. However, data on prehospital post-resuscitation care is scarce. We aimed to examine the association among systolic blood pressure (SBP), peripheral oxygen saturation (SpO2) and end-tidal carbon dioxide (EtCO2) after prehospital stabilisation and outcome among patients resuscitated from out-of-hospital cardiac arrest (OHCA). Methods In this retrospective study, we evaluated association of the last measured prehospital SBP, SpO2 and EtCO2 before patient handover with 30-day and one-year mortality in 2,611 patients receiving prehospital post-resuscitation care by helicopter emergency medical services in Finland. Statistical analyses were completed through locally estimated scatterplot smoothing (LOESS) and multivariable logistic regression. The regression analyses were adjusted by sex, age, initial rhythm, bystander CPR, and time interval from collapse to the return of spontaneous circulation (ROSC). Results Mortality related to SBP and EtCO2 values were U-shaped and lowest at 135 mmHg and 4.7 kPa, respectively, whereas higher SpO2 shifted towards lower mortality. In adjusted analyses, increased 30-day mortality and one year mortality was observed in patients with SBP < 100 mmHg (OR 1.9 [95% CI 1.4-2.4]) and SBP < 100 (OR 1.8 [1.2-2.6]) or EtCO2 < 4.0 kPa (OR 1.4 [1.1-1.5]), respectively. SpO2 was not significantly associated with either 30-day or one year mortality. Conclusions After prehospital post-resuscitation stabilization, SBP < 100 mmHg and EtCO2 < 4.0 kPa were observed to be independently associated with higher mortality. The optimal targets for prehospital post-resuscitation care need to be established in the prospective studies.
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Affiliation(s)
- Elina Heikkilä
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Finland
| | - Piritta Setälä
- Emergency Medical Services, Centre for Prehospital Emergency Care, Tampere University Hospital, Tampere, Finland
| | - Milla Jousi
- Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Finland
| | - Jouni Nurmi
- Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Finland
- FinnHEMS Research and Development Unit, Finland 4
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4
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Møller MH, Granholm A, Al Duhailib Z, Alhazzani W, Belley-Cote E, Oczkowski S, Vijayaraghavan BKT, Sjövall F, Butler E, Zampieri FG, Mac Sweeney R, Derde LPG, Ruzycki-Chadwick A, Mer M, Burns KEA, Ergan B, Al-Fares A, Sjoding MW, Valley TS, Rasmussen BS, Schjørring OL, Prescott HC. Higher versus lower oxygenation targets in adult ICU patients: A rapid practice guideline. Acta Anaesthesiol Scand 2024; 68:302-310. [PMID: 38140827 DOI: 10.1111/aas.14366] [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: 10/17/2023] [Revised: 11/17/2023] [Accepted: 12/01/2023] [Indexed: 12/24/2023]
Abstract
The aim of this Intensive Care Medicine Rapid Practice Guideline (ICM-RPG) was to provide evidence-based clinical guidance about the use of higher versus lower oxygenation targets for adult patients in the intensive care unit (ICU). The guideline panel comprised 27 international panelists, including content experts, ICU clinicians, methodologists, and patient representatives. We adhered to the methodology for trustworthy clinical practice guidelines, including the use of the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty of evidence, and used the Evidence-to-Decision framework to generate recommendations. A recently published updated systematic review and meta-analysis constituted the evidence base. Through teleconferences and web-based discussions, the panel provided input on the balance and magnitude of the desirable and undesirable effects, the certainty of evidence, patients' values and preferences, costs and resources, equity, feasibility, acceptability, and research priorities. The updated systematic review and meta-analysis included data from 17 randomized clinical trials with 10,248 participants. There was little to no difference between the use of higher versus lower oxygenation targets for all outcomes with available data, including all-cause mortality, serious adverse events, stroke, functional outcomes, cognition, and health-related quality of life (very low certainty of evidence). The panel felt that values and preferences, costs and resources, and equity favored the use of lower oxygenation targets. The ICM-RPG panel issued one conditional recommendation against the use of higher oxygenation targets: "We suggest against the routine use of higher oxygenation targets in adult ICU patients (conditional recommendation, very low certainty of evidence). Remark: an oxygenation target of SpO2 88%-92% or PaO2 8 kPa/60 mmHg is relevant and safe for most adult ICU patients."
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Affiliation(s)
- Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Guidelines in Intensive Care Medicine, Development and Evaluation (GUIDE) Group, Hamilton, Canada
| | - Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Guidelines in Intensive Care Medicine, Development and Evaluation (GUIDE) Group, Hamilton, Canada
| | - Zainab Al Duhailib
- Guidelines in Intensive Care Medicine, Development and Evaluation (GUIDE) Group, Hamilton, Canada
- Critical Care Medicine Department, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Waleed Alhazzani
- Guidelines in Intensive Care Medicine, Development and Evaluation (GUIDE) Group, Hamilton, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Emilie Belley-Cote
- Guidelines in Intensive Care Medicine, Development and Evaluation (GUIDE) Group, Hamilton, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Simon Oczkowski
- Guidelines in Intensive Care Medicine, Development and Evaluation (GUIDE) Group, Hamilton, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Fredrik Sjövall
- Department for Intensive and Perioperative Care, Skane University Hospital, Malmö, Sweden
- Department for Clinical sciences, Lund University, Lund, Sweden
| | - Ethan Butler
- Department of Intensive Care, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Fernando G Zampieri
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Alberta Health Services, Edmonton, Alberta, Canada
| | - Rob Mac Sweeney
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK
| | - Lennie P G Derde
- Intensive Care Center, Division Vital Functions, University Medical Center Utrecht, Utrecht, the Netherlands
- Julius Center for Health Sciences and Primary Care, Utrecht, the Netherlands
| | - Ally Ruzycki-Chadwick
- Department of Respiratory Therapy General Site, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Mervyn Mer
- Department of Medicine, Divisions of Critical Care and Pulmonology, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Karen E A Burns
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto-St. Michael's Hospital, Toronto, Ontario, Canada
| | - Begüm Ergan
- Department of Pulmonary and Critical Care, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey
| | - Abdulrahman Al-Fares
- Department of Anesthesia, Critical Care Medicine and Pain Medicine, Al-Amiri Hospital, Minister of Health, Kuwait City, Kuwait
- Kuwait Extracorporeal Life Support Program, Al-Amiri Center for Advance Respiratory and Cardiac Failure, Ministry of Health, Kuwait City, Kuwait
| | - Michael W Sjoding
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Thomas S Valley
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- VA Center for Clinical Management Research, Ann Arbor, Michigan, USA
| | - Bodil S Rasmussen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Olav L Schjørring
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Hallie C Prescott
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- VA Center for Clinical Management Research, Ann Arbor, Michigan, USA
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Hirsch KG, Tamura T, Ristagno G, Sekhon MS. Wolf Creek XVII Part 8: Neuroprotection. Resusc Plus 2024; 17:100556. [PMID: 38328750 PMCID: PMC10847936 DOI: 10.1016/j.resplu.2024.100556] [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] [Indexed: 02/09/2024] Open
Abstract
Introduction Post-cardiac arrest brain injury (PCABI) is the primary determinant of clinical outcomes for patients who achieve return of spontaneous circulation after cardiac arrest (CA). There are limited neuroprotective therapies available to mitigate the acute pathophysiology of PCABI. Methods Neuroprotection was one of six focus topics for the Wolf Creek XVII Conference held on June 14-17, 2023 in Ann Arbor, Michigan, USA. Conference invitees included international thought leaders and scientists in the field of CA resuscitation from academia and industry. Participants submitted via online survey knowledge gaps, barriers to translation, and research priorities for each focus topic. Expert panels used the survey results and their own perspectives and insights to create and present a preliminary unranked list for each category that was debated, revised and ranked by all attendees to identify the top 5 for each category. Results Top 5 knowledge gaps included developing therapies for neuroprotection; improving understanding of the pathophysiology, mechanisms, and natural history of PCABI; deploying precision medicine approaches; optimizing resuscitation and CPR quality; and determining optimal timing for and duration of interventions. Top 5 barriers to translation included patient heterogeneity; nihilism & lack of knowledge about cardiac arrest; challenges with the translational pipeline; absence of mechanistic biomarkers; and inaccurate neuro-triage and neuroprognostication. Top 5 research priorities focused on translational research and trial optimization; addressing patient heterogeneity and individualized interventions; improving understanding of pathophysiology and mechanisms; developing mechanistic and outcome biomarkers across post-CA time course; and improving implementation of science and technology. Conclusion This overview can serve as a guide to transform the care and outcome of patients with PCABI. Addressing these topics has the potential to improve both research and clinical care in the field of neuroprotection for PCABI.
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Affiliation(s)
- Karen G. Hirsch
- Department of Neurology, Stanford University, Stanford, CA, United States
| | - Tomoyoshi Tamura
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Giuseppe Ristagno
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Mypinder S. Sekhon
- Division of Critical Care Medicine and Department of Medicine, University of British Columbia, Vancouver, Canada
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Kaiser HA, Bauer T, Riva T, Greif R, Riedel T, Theiler L, Nabecker S. Carbon dioxide and cardiac output as major contributors to cerebral oxygenation during apnoeic oxygenation. Sci Rep 2024; 14:3617. [PMID: 38351038 PMCID: PMC10864331 DOI: 10.1038/s41598-023-49238-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 12/06/2023] [Indexed: 02/16/2024] Open
Abstract
Apnoeic oxygenation has experienced a resurgence in interest in critical care and perioperative medicine. However, its effect on cerebral oxygenation and factors influencing it, have not yet been investigated in detail. By using near-infrared spectroscopy, we intended to provide further evidence for the safety of apnoeic oxygenation and to increase our understanding of the association between cerebral perfusion, haemodynamic, respiratory and demographic factors. In this secondary analysis of a prospective randomized controlled noninferiority trial, we recruited 125 patients, who underwent surgery under general anaesthesia with neuromuscular blockade. Arterial blood samples were taken every 2 min for a total of 15 min under apnoeic oxygenation with 100% oxygen. Near-infrared spectroscopy and cardiac output were continuously measured. Statistical analysis was performed using uni- and multivariable statistics. Ninety-one complete data sets were analysed. In six patients the SpO2 fell below 92% (predefined study termination criterion). The significant average increase of cerebral oxygenation was 0.5%/min and 2.1 mmHg/min for the arterial pressure of carbon dioxide (paCO2). The median cardiac output increased significantly from 5.0 l/min (IQR 4.5-6.0) to 6.5 l/min (IQR 5.7-7.5). The most significant effect on cerebral oxygenation was exhibited by the variable paCO2 and non-specific patient factors, followed by cardiac output and paO2. Apnoeic oxygenation proves to have a high safety profile while significantly increasing cerebral oxygenation, paCO2 and cardiac output. In reverse, NIRS might act as a reliable clinical surrogate of paCO2 and cardiac output during stable arterial oxygenation.
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Grants
- no ID The study was supported by a departmental research grant of the Department of Anaesthesiology and Pain Medicine, University Hospital of Bern, Bern, Switzerland.
- no ID The study was supported by a departmental research grant of the Department of Anaesthesiology and Pain Medicine, University Hospital of Bern, Bern, Switzerland.
- no ID The study was supported by a departmental research grant of the Department of Anaesthesiology and Pain Medicine, University Hospital of Bern, Bern, Switzerland.
- no ID The study was supported by a departmental research grant of the Department of Anaesthesiology and Pain Medicine, University Hospital of Bern, Bern, Switzerland.
- no ID The study was supported by a departmental research grant of the Department of Anaesthesiology and Pain Medicine, University Hospital of Bern, Bern, Switzerland.
- no ID The study was supported by a departmental research grant of the Department of Anaesthesiology and Pain Medicine, University Hospital of Bern, Bern, Switzerland.
- no ID The study was supported by a departmental research grant of the Department of Anaesthesiology and Pain Medicine, University Hospital of Bern, Bern, Switzerland.
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Affiliation(s)
- Heiko Andreas Kaiser
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Bauer
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Riva
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Unit for Research and Innovation, Department of Paediatric Anaesthesia, Istituto Giannina Gaslini, Genova, Italy
| | - Robert Greif
- University of Bern, Bern, Switzerland
- School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
| | - Thomas Riedel
- Department of Paediatrics, Cantonal Hospital Graubünden, Chur, Switzerland
- Division of Respiratory Medicine, Department of Paediatrics, Inselspital, University Children's Hospital, University of Bern, Bern, Switzerland
| | - Lorenz Theiler
- Department of Anaesthesia, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Sabine Nabecker
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
- Department of Anaesthesiology and Pain Management, Sinai Health System, University of Toronto, Toronto, Canada.
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Cao L, Chen Q, Xiang YY, Xiao C, Tan YT, Li H. Effects of Oxygenation Targets on Mortality in Critically Ill Patients in Intensive Care Units: A Systematic Review and Meta-Analysis. Anesth Analg 2024:00000539-990000000-00731. [PMID: 38315626 DOI: 10.1213/ane.0000000000006859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
BACKGROUND The effects of oxygenation targets (partial pressure of arterial oxygen [Pao2], arterial oxygen saturation [Sao2]/peripheral oxygen saturation [Spo2], or inspiratory oxygen concentration [Fio2] on clinical outcomes in critically ill patients remains controversial. We reviewed the existing literature to assess the effects of lower and higher oxygenation targets on the mortality rates of critically ill intensive care unit (ICU) patients. METHODS MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Web of Science databases were searched from their dates of inception to December 31, 2022, for randomized controlled trials (RCTs) comparing lower and higher oxygenation targets for critically ill patients ≥18 years of age undergoing mechanical ventilation, nasal cannula, oxygen mask, or high-flow oxygen therapy in the ICU. Data extraction was conducted independently, and RoB 2.0 software was used to evaluate the quality of each RCT. A random-effects model was used for the meta-analysis to calculate the relative risk (RR). We used the I2 statistic as a measure of statistical heterogeneity. Certainty of evidence was assessed according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. RESULTS We included 12 studies with a total of 7416 patients participating in RCTs. Oxygenation targets were extremely heterogeneous between studies. The meta-analysis found no differences in mortality between lower and higher oxygenation targets for critically ill ICU patients (relative risk [RR], 1.00; 95% confidence interval [CI], 0.93-1.09; moderate certainty). The incidence of serious adverse events (RR, 0.93; 95% CI, 0.85-1.00; high certainty), mechanical ventilation-free days through day 28 (mean difference [MD], -0.05; 95%CI, -1.23 to 1.13; low certainty), the number of patients requiring renal replacement therapy (RRT) (RR, 0.96; 95% CI, 0.84-1.10; low certainty), and ICU length of stay (MD, 1.05; 95% CI, -0.04 to 2.13; very low certainty) also did not differ among patients with lower or higher oxygenation targets. CONCLUSIONS Critically ill ICU patients ≥18 years of age managed with lower and higher oxygenation targets did not differ in terms of mortality, RRT need, mechanical ventilation-free days through day 28, or ICU length of stay. However, due to considerable heterogeneity between specific targets in individual studies, no conclusion can be drawn regarding the effect of oxygenation targets on ICU outcomes.
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Affiliation(s)
- Lei Cao
- From the Department of Anaesthesiology, Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Qi Chen
- Department of Anesthesiology, Chongqing University Cancer Hospital, Chongqing, China
| | - Ying-Ying Xiang
- Department of Anesthesiology, Chongqing University Cancer Hospital, Chongqing, China
| | - Cheng Xiao
- From the Department of Anaesthesiology, Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Yu-Ting Tan
- From the Department of Anaesthesiology, Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Hong Li
- From the Department of Anaesthesiology, Second Affiliated Hospital of Army Medical University, Chongqing, China
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8
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Hirsch KG, Abella BS, Amorim E, Bader MK, Barletta JF, Berg K, Callaway CW, Friberg H, Gilmore EJ, Greer DM, Kern KB, Livesay S, May TL, Neumar RW, Nolan JP, Oddo M, Peberdy MA, Poloyac SM, Seder D, Taccone FS, Uzendu A, Walsh B, Zimmerman JL, Geocadin RG. Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement from the American Heart Association and Neurocritical Care Society. Neurocrit Care 2024; 40:1-37. [PMID: 38040992 PMCID: PMC10861627 DOI: 10.1007/s12028-023-01871-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 06/08/2023] [Indexed: 12/03/2023]
Abstract
The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.
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Affiliation(s)
| | | | - Edilberto Amorim
- San Francisco-Weill Institute for Neurosciences, University of California, San Francisco, USA
| | - Mary Kay Bader
- Providence Mission Hospital Nursing Center of Excellence/Critical Care Services, Mission Viejo, USA
| | | | | | | | | | | | | | - Karl B Kern
- Sarver Heart Center, University of Arizona, Tucson, USA
| | | | | | | | - Jerry P Nolan
- Warwick Medical School, University of Warwick, Coventry, UK
- Royal United Hospital, Bath, UK
| | - Mauro Oddo
- CHUV-Lausanne University Hospital, Lausanne, Switzerland
| | | | | | | | | | - Anezi Uzendu
- St. Luke's Mid America Heart Institute, Kansas City, USA
| | - Brian Walsh
- University of Texas Medical Branch School of Health Sciences, Galveston, USA
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Xu Y, Peng F, Wang S, Yu H. Lower versus higher oxygen targets after resuscitation from out-of-hospital cardiac arrest: A systematic review and meta-analysis of randomized controlled trials. J Crit Care 2024; 79:154448. [PMID: 37862956 DOI: 10.1016/j.jcrc.2023.154448] [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: 04/06/2023] [Revised: 08/02/2023] [Accepted: 10/11/2023] [Indexed: 10/22/2023]
Abstract
PURPOSE To update the existing evidence and gain further insight into effects of lower versus higher oxygen targets on the outcomes in patients resuscitated from out-of-hospital cardiac arrest (OHCA). METHODS We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing lower versus higher oxygen targets on the outcomes among adults resuscitated from OHCA. The primary outcome was short-term survival (in hospital or within 30 days). Subgroup analyses were performed according to timing of study interventions. RESULTS Seven RCTs with 1454 patients were finally included. The short-term survival did not differ between the two groups with a relative risk (RR) of 0.98 (95% CI, 0.86 to 1.11). There were no significant differences in survival at longest follow-up (RR, 1.01; 95% CI, 0.91 to 1.14), favorable neurological outcome (RR, 1.00; 95% CI, 0.91 to 1.11), length of intensive care unit stay (mean difference, -4.94 h; 95% CI, -14.83 to 4.96 h), or risk of re-arrest (RR, 0.68; 95% CI, 0.21 to 2.19). The quality of evidence ranged from moderate to very low. CONCLUSION Current evidence suggests that targeting a lower or higher oxygen therapy in patients after resuscitation from OHCA results in similar short-term survival and other clinical outcomes.
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Affiliation(s)
- Yi Xu
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Fei Peng
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Siying Wang
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Hai Yu
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu 610041, China.
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10
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Nikolovski SS, Lazic AD, Fiser ZZ, Obradovic IA, Tijanic JZ, Raffay V. Recovery and Survival of Patients After Out-of-Hospital Cardiac Arrest: A Literature Review Showcasing the Big Picture of Intensive Care Unit-Related Factors. Cureus 2024; 16:e54827. [PMID: 38529434 PMCID: PMC10962929 DOI: 10.7759/cureus.54827] [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] [Accepted: 02/23/2024] [Indexed: 03/27/2024] Open
Abstract
As an important public health issue, out-of-hospital cardiac arrest (OHCA) requires several stages of high quality medical care, both on-field and after hospital admission. Post-cardiac arrest shock can lead to severe neurological injury, resulting in poor recovery outcome and increased risk of death. These characteristics make this condition one of the most important issues to deal with in post-OHCA patients hospitalized in intensive care units (ICUs). Also, the majority of initial post-resuscitation survivors have underlying coronary diseases making revascularization procedure another crucial step in early management of these patients. Besides keeping myocardial blood flow at a satisfactory level, other tissues must not be neglected as well, and maintaining mean arterial pressure within optimal range is also preferable. All these procedures can be simplified to a certain level along with using targeted temperature management methods in order to decrease metabolic demands in ICU-hospitalized post-OHCA patients. Additionally, withdrawal of life-sustaining therapy as a controversial ethical topic is under constant re-evaluation due to its possible influence on overall mortality rates in patients initially surviving OHCA. Focusing on all of these important points in process of managing ICU patients is an imperative towards better survival and complete recovery rates.
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Affiliation(s)
- Srdjan S Nikolovski
- Pathology and Laboratory Medicine, Cardiovascular Research Institute, Loyola University Chicago Health Science Campus, Maywood, USA
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Aleksandra D Lazic
- Emergency Center, Clinical Center of Vojvodina, Novi Sad, SRB
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Zoran Z Fiser
- Emergency Medicine, Department of Emergency Medicine, Novi Sad, SRB
| | - Ivana A Obradovic
- Anesthesiology, Resuscitation, and Intensive Care, Sveti Vračevi Hospital, Bijeljina, BIH
| | - Jelena Z Tijanic
- Emergency Medicine, Municipal Institute of Emergency Medicine, Kragujevac, SRB
| | - Violetta Raffay
- School of Medicine, European University Cyprus, Nicosia, CYP
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
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11
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Slovis JC, Bach A, Beaulieu F, Zuckerberg G, Topjian A, Kirschen MP. Neuromonitoring after Pediatric Cardiac Arrest: Cerebral Physiology and Injury Stratification. Neurocrit Care 2024; 40:99-115. [PMID: 37002474 PMCID: PMC10544744 DOI: 10.1007/s12028-023-01685-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 01/30/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Significant long-term neurologic disability occurs in survivors of pediatric cardiac arrest, primarily due to hypoxic-ischemic brain injury. Postresuscitation care focuses on preventing secondary injury and the pathophysiologic cascade that leads to neuronal cell death. These injury processes include reperfusion injury, perturbations in cerebral blood flow, disturbed oxygen metabolism, impaired autoregulation, cerebral edema, and hyperthermia. Postresuscitation care also focuses on early injury stratification to allow clinicians to identify patients who could benefit from neuroprotective interventions in clinical trials and enable targeted therapeutics. METHODS In this review, we provide an overview of postcardiac arrest pathophysiology, explore the role of neuromonitoring in understanding postcardiac arrest cerebral physiology, and summarize the evidence supporting the use of neuromonitoring devices to guide pediatric postcardiac arrest care. We provide an in-depth review of the neuromonitoring modalities that measure cerebral perfusion, oxygenation, and function, as well as neuroimaging, serum biomarkers, and the implications of targeted temperature management. RESULTS For each modality, we provide an in-depth review of its impact on treatment, its ability to stratify hypoxic-ischemic brain injury severity, and its role in neuroprognostication. CONCLUSION Potential therapeutic targets and future directions are discussed, with the hope that multimodality monitoring can shift postarrest care from a one-size-fits-all model to an individualized model that uses cerebrovascular physiology to reduce secondary brain injury, increase accuracy of neuroprognostication, and improve outcomes.
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Affiliation(s)
- Julia C Slovis
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA.
| | - Ashley Bach
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA
| | - Forrest Beaulieu
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA
| | - Gabe Zuckerberg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA
| | - Alexis Topjian
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA
| | - Matthew P Kirschen
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA
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12
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Hirsch KG, Abella BS, Amorim E, Bader MK, Barletta JF, Berg K, Callaway CW, Friberg H, Gilmore EJ, Greer DM, Kern KB, Livesay S, May TL, Neumar RW, Nolan JP, Oddo M, Peberdy MA, Poloyac SM, Seder D, Taccone FS, Uzendu A, Walsh B, Zimmerman JL, Geocadin RG. Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement From the American Heart Association and Neurocritical Care Society. Circulation 2024; 149:e168-e200. [PMID: 38014539 PMCID: PMC10775969 DOI: 10.1161/cir.0000000000001163] [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] [Indexed: 11/29/2023]
Abstract
The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.
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13
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Malinverni S, Wilmin S, Stoll T, de Longueville D, Preseau T, Mohler A, Bouazza FZ, Annoni F, Gerard L, Denoel P, Boutrika I. Postresuscitation oxygen reserve index-guided oxygen titration in out-of-hospital cardiac arrest survivors: A randomised controlled trial. Resuscitation 2024; 194:110005. [PMID: 37863418 DOI: 10.1016/j.resuscitation.2023.110005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND AND PURPOSE Hyperoxia after return of spontaneous circulation is potentially harmful, and oxygen titration in a prehospital setting is challenging. This study aimed to compare outcomes of oxygen reserve index-supported prehospital oxygen titration during prehospital transport with those of standard oxygen titration. METHODS AND TRIAL DESIGN We enrolled patients who experienced return of spontaneous circulation after cardiac arrest in a prospective randomized study. Patients were randomly divided (1:1) to undergo oxygen titration based on the oxygen reserve index and SpO2 (intervention) or SpO2 only (control). FIO2 titration targeted SpO2 level maintenance at 94-98%. The primary outcome was the normoxia index, reflecting the proportion of both hyperoxia- and hypoxia-free time during prehospital intervention. RESULTS A total of 92 patients were included in the study. The mean normoxia index was 0.828 in the control group and 0.847 in the intervention group (difference = 0.019 [95 % CI, -0.056-0.095]), with no significant difference between the groups. No significant differences were found in the incidence of hypoxia or hyperoxia between groups. No difference was found in the mean PaO2 at hospital admission (116 mmHg [IQR: 89-168 mmHg] in the control group vs 115 mmHg [IQR: 89-195 mmHg] in the intervention group; p = 0.86). No difference was observed in serum neuron-specific enolase levels 48 h post-ROSC after adjustment for known confounders. CONCLUSION Oxygen reserve index- combined with pulse oximetry-based prehospital oxygen titration did not significantly improve the normoxia index compared with standard oxygen titration based on pulse oximetry alone (NCT03653325).
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Affiliation(s)
- Stefano Malinverni
- Emergency Department, Centre Hospitalier Universitaire Saint-Pierre, Université Libre de Bruxelles, Rue Haute 322, 1000 Brussels, Belgium.
| | - Stéphan Wilmin
- Emergency Department, Centre Hospitalier Universitaire Brugmann, Avenue Jean Joseph Crocq 1, 1020 Bruxelles, Belgium
| | - Timothée Stoll
- Emergency Department, Centre Hospitalier Universitaire Saint-Pierre, Université Libre de Bruxelles, Rue Haute 322, 1000 Brussels, Belgium
| | - Diane de Longueville
- Emergency Department, Centre Hospitalier Universitaire Saint-Pierre, Université Libre de Bruxelles, Rue Haute 322, 1000 Brussels, Belgium
| | - Thierry Preseau
- Emergency Department, Centre Hospitalier Universitaire Brugmann, Avenue Jean Joseph Crocq 1, 1020 Bruxelles, Belgium
| | - Andreas Mohler
- Emergency Department, Centre Hospitalier Universitaire Brugmann, Avenue Jean Joseph Crocq 1, 1020 Bruxelles, Belgium
| | - Fatima Zohra Bouazza
- Emergency Department, Centre Hospitalier Universitaire Saint-Pierre, Université Libre de Bruxelles, Rue Haute 322, 1000 Brussels, Belgium
| | - Filippo Annoni
- Intensive Care Unit, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Ludovic Gerard
- Intensive Care Unit, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Clos Chapelle-aux-Champs 43, 1200 Woluwe-Saint-Lambert, Brussels, Belgium
| | - Paule Denoel
- Emergency Department, Cliniques de l'Europe, Avenue De Fré 206, 1180 Uccle, Belgium
| | - Ikram Boutrika
- Emergency Department, Centre Hospitalier Universitaire Saint-Pierre, Université Libre de Bruxelles, Rue Haute 322, 1000 Brussels, Belgium
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14
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Skrifvars MB. Using the oxygen reserve index to titrate oxygen administration in cardiac arrest patients in the prehospital setting. Resuscitation 2024; 194:110048. [PMID: 37977347 DOI: 10.1016/j.resuscitation.2023.110048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 11/08/2023] [Indexed: 11/19/2023]
Affiliation(s)
- Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Finland.
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15
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Wang CH, Chang WT, Huang CH, Tsai MS, Wang CC, Liu SH, Chen WJ. Optimal inhaled oxygen and carbon dioxide concentrations for post-cardiac arrest cerebral reoxygenation and neurological recovery. iScience 2023; 26:108476. [PMID: 38187189 PMCID: PMC10767205 DOI: 10.1016/j.isci.2023.108476] [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: 06/29/2023] [Revised: 08/17/2023] [Accepted: 11/14/2023] [Indexed: 01/09/2024] Open
Abstract
Prolonged cerebral hypoperfusion after the return of spontaneous circulation (ROSC) from cardiac arrest (CA) may lead to poor neurological recovery. In a 7-min asphyxia-induced CA rat model, four combinations of inhaled oxygen (iO2) and carbon dioxide (iCO2) were administered for 150 min post-ROSC and compared in a randomized animal trial. At the end of administration, the partial pressure of brain tissue oxygenation (PbtO2) monitored in the hippocampal CA1 region returned to the baseline for the 88% iO2 [ΔPbtO2, median: -0.39 (interquartile range: 5.6) mmHg] and 50% iO2 [ΔpbtO2, -2.25 (10.9) mmHg] groups; in contrast, PbtO2 increased substantially in the 88% iO2+12% iCO2 [ΔpbtO2, 35.05 (16.0) mmHg] and 50% iO2+12% iCO2 [ΔpbtO2, 42.03 (31.7) mmHg] groups. Pairwise comparisons (post hoc Dunn's test) indicated the significant role of 12% iCO2 in augmenting PbtO2 during the intervention and improving neurological recovery at 24 h post-ROSC. Facilitating brain reoxygenation may improve post-CA neurological outcomes.
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Affiliation(s)
- Chih-Hung Wang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Wei-Tien Chang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Min-Shan Tsai
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chan-Chi Wang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shing-Hwa Liu
- Institute of Toxicology, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Jone Chen
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Internal Medicine, Min-Sheng General Hospital, Taoyuan, Taiwan
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16
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Lascarrou JB, Ermel C, Cariou A, Laitio T, Kirkegaard H, Søreide E, Grejs AM, Reinikainen M, Colin G, Taccone FS, Le Gouge A, Skrifvars MB. Dysnatremia at ICU admission and functional outcome of cardiac arrest: insights from four randomised controlled trials. Crit Care 2023; 27:472. [PMID: 38041177 PMCID: PMC10693108 DOI: 10.1186/s13054-023-04715-z] [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: 09/25/2023] [Accepted: 10/30/2023] [Indexed: 12/03/2023] Open
Abstract
PURPOSE To evaluate the potential association between early dysnatremia and 6-month functional outcome after cardiac arrest. METHODS We pooled data from four randomised clinical trials in post-cardiac-arrest patients admitted to the ICU with coma after stable return of spontaneous circulation (ROSC). Admission natremia was categorised as normal (135-145 mmol/L), low, or high. We analysed associations between natremia category and Cerebral Performance Category (CPC) 1 or 2 at 6 months, with and without adjustment on the modified Cardiac Arrest Hospital Prognosis Score (mCAHP). RESULTS We included 1163 patients (581 from HYPERION, 352 from TTH48, 120 from COMACARE, and 110 from Xe-HYPOTHECA) with a mean age of 63 ± 13 years and a predominance of males (72.5%). A cardiac cause was identified in 63.6% of cases. Median time from collapse to ROSC was 20 [15-29] minutes. Overall, mean natremia on ICU admission was 137.5 ± 4.7 mmol/L; 211 (18.6%) and 31 (2.7%) patients had hyponatremia and hypernatremia, respectively. By univariate analysis, CPC 1 or 2 at 6 months was significantly less common in the group with hyponatremia (50/211 [24%] vs. 363/893 [41%]; P = 0.001); the mCAHP-adjusted odds ratio was 0.45 (95%CI 0.26-0.79, p = 0.005). The number of patients with hypernatremia was too small for a meaningful multivariable analysis. CONCLUSIONS Early hyponatremia was common in patients with ROSC after cardiac arrest and was associated with a poorer 6-month functional outcome. The mechanisms underlying this association remain to be elucidated in order to determine whether interventions targeting hyponatremia are worth investigating. Registration ClinicalTrial.gov, NCT01994772, November 2013, 21.
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Affiliation(s)
- Jean Baptiste Lascarrou
- Nantes Université, CHU Nantes, Movement - Interactions - Performance, MIP, UR 4334, 44000, Nantes, France.
- Médecine Intensive Reanimation, University Hospital Centre, Nantes, France.
- AfterROSC Network, Nantes, France.
- Service de Médecine Intensive Reanimation, CHU Nantes, 30 Boulevard Jean Monet, 44093, Nantes Cedex 9, France.
| | - Cyrielle Ermel
- Médecine Intensive Reanimation, University Hospital Centre, Nantes, France
| | - Alain Cariou
- AfterROSC Network, Nantes, France
- Université de Paris Cité, INSERM, Paris Cardiovascular Research Centre, Paris, France
- Médecine Intensive Reanimation, AP-HP, CHU Cochin, Paris, France
| | - Timo Laitio
- Division of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital, University of Turku, Turku, Finland
| | - Hans Kirkegaard
- Research Centre for Emergency Medicine and Anaesthesiology and Intensive Care, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Eldar Søreide
- Intensive Care Unit, Department of Anaesthesiology, Stavanger University Hospital and Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Anders M Grejs
- Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Matti Reinikainen
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital, Kuopio, Finland
- University of Eastern Finland, Kuopio, Finland
| | - Gwenhael Colin
- AfterROSC Network, Nantes, France
- Médecine Intensive Reanimation, CHD Vendee, La Roche Sur Yon, France
| | - Fabio Silvio Taccone
- AfterROSC Network, Nantes, France
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | | | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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17
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Yusin G, Farley C, Dorris CS, Yusina S, Zaatari S, Goyal M. The Effect of Early Severe Hyperoxia in Adults Intubated in the Prehosptial Setting or Emergency Department: A Scoping Review. J Emerg Med 2023; 65:e495-e510. [PMID: 37867037 DOI: 10.1016/j.jemermed.2023.08.002] [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: 04/06/2023] [Revised: 07/16/2023] [Accepted: 08/10/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND The detrimental effects of hyperoxia exposure have been well-described in patients admitted to intensive care units. However, data evaluating the effects of short-term, early hyperoxia exposure in patients intubated in the prehospital setting or emergency department (ED) have not been systematically reviewed. OBJECTIVE Our aim was to quantify and describe the existing literature examining the clinical outcomes in ED patients exposed to hyperoxia within the first 24 h of mechanical ventilation. METHODS This review was performed in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for scoping reviews. Two rounds of review using Rayyan QCRI software were performed for title and abstract screening and full-text search. Of the 2739 articles, 27 articles were retrieved after initial screening, of which 5 articles were excluded during the full-text screening, leaving 22 articles for final review and data extraction. RESULTS Of 22 selected publications, 9 described patients with traumatic brain injury, 6 with cardiac arrest, 3 with multisystem trauma, 1 with stroke, 2 with septic shock, and 1 was heterogeneous. Three studies were randomized controlled trials. The available data have widely heterogeneous definitions of hyperoxia exposure, outcomes, and included populations, limiting conclusions. CONCLUSIONS There is a paucity of data that examined the effects of severe hyperoxia exposure in the acute, post-intubation phase of the prehospital and ED settings. Further research with standardized definitions is needed to provide more detailed guidance regarding early oxygen titration in intubated patients.
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Affiliation(s)
- George Yusin
- Georgetown University School of Medicine, Washington, District of Columbia
| | - Charlotte Farley
- Georgetown University School of Medicine, Washington, District of Columbia
| | | | - Sofiya Yusina
- New York University Grossman School of Medicine, New York, NY
| | - Saad Zaatari
- Georgetown University School of Medicine, Washington, District of Columbia; Department of Emergency Medicine, MedStar Health, Washington, District of Columbia
| | - Munish Goyal
- Georgetown University School of Medicine, Washington, District of Columbia; Department of Emergency Medicine, MedStar Health, Washington, District of Columbia
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18
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Zhao Y, Wang Q, Zang B. Effects of lower versus higher oxygen targets on out-of-hospital cardiac arrest. Crit Care 2023; 27:471. [PMID: 38041199 PMCID: PMC10693104 DOI: 10.1186/s13054-023-04740-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 11/14/2023] [Indexed: 12/03/2023] Open
Affiliation(s)
- Yang Zhao
- Department of Critical Care Medicine, Shengjing Hospital of China Medical University, Shenyang, 110000, China
| | - Qian Wang
- Department of Emergency, The Fourth Affiliated Hospital of China Medical University, Shenyang, 110000, China.
| | - Bin Zang
- Department of Critical Care Medicine, Shengjing Hospital of China Medical University, Shenyang, 110000, China.
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19
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Nozawa H, Tsuboi N, Oi T, Takezawa Y, Osawa I, Nishimura N, Nakagawa S. Chloride Reduction Therapy with Furosemide: Short-Term Effects in Children with Acute Respiratory Failure. J Pediatr Intensive Care 2023; 12:296-302. [PMID: 37970141 PMCID: PMC10631838 DOI: 10.1055/s-0041-1733942] [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: 04/05/2021] [Accepted: 06/22/2021] [Indexed: 10/20/2022] Open
Abstract
From the perspective of the Stewart approach, it is known that expansion of the sodium chloride ion difference (SCD) induces alkalosis. We investigated the role of SCD expansion by furosemide-induced chloride reduction in pediatric patients with acute respiratory failure. We included patients admitted to our pediatric intensive care unit intubated for acute respiratory failure without underlying diseases, and excluded patients receiving extracorporeal circulation therapy (extracorporeal membrane oxygenation and/or renal replacement therapy). We classified eligible patients into the following two groups: case-those intubated who received furosemide within 24 hours, and control-those intubated who did not receive furosemide within 48 hours. Primary outcomes included SCD, partial pressure of carbon dioxide (PaCO 2 ), and pH results from arterial blood gas samples obtained over 48 hours following intubation. Multiple regression analysis was also performed to evaluate the effects of SCD and PaCO 2 changes on pH. Twenty-six patients were included of which 13 patients were assigned to each of the two groups. A total of 215 gas samples were analyzed. SCD (median [mEq/L] [interquartile range]) 48 hours after intubation significantly increased in the case group compared with the control group (37 [33-38] vs. 31 [30-34]; p = 0.005). Although hypercapnia persisted in the case group, the pH (median [interquartile range]) remained unchanged in both groups (7.454 [7.420-7.467] vs. 7.425 [7.421-7.436]; p = 0.089). SCD and PaCO 2 were independently associated with pH ( p < 0.001 for each regression coefficient). As a result, we provide evidence that SCD expansion with furosemide may be useful in maintaining pH within the normal range in pediatric patients with acute respiratory failure complicated by concurrent metabolic acidosis.
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Affiliation(s)
- Hisataka Nozawa
- Department of Critical Care and Anesthesia, Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Norihiko Tsuboi
- Department of Critical Care and Anesthesia, Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Tadashi Oi
- Department of Critical Care and Anesthesia, Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Yoshiki Takezawa
- Department of Critical Care and Anesthesia, Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Ichiro Osawa
- Department of Critical Care and Anesthesia, Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Nao Nishimura
- Department of Critical Care and Anesthesia, Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Satoshi Nakagawa
- Department of Critical Care and Anesthesia, Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
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Behringer W, Skrifvars MB, Taccone FS. Postresuscitation management. Curr Opin Crit Care 2023; 29:640-647. [PMID: 37909369 DOI: 10.1097/mcc.0000000000001116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
PURPOSE OF REVIEW To describe the most recent scientific evidence on ventilation/oxygenation, circulation, temperature control, general intensive care, and prognostication after successful resuscitation from adult cardiac arrest. RECENT FINDINGS Targeting a lower oxygen target (90-94%) is associated with adverse outcome. Targeting mild hypercapnia is not associated with improved functional outcomes or survival. There is no compelling evidence supporting improved outcomes associated with a higher mean arterial pressure target compared to a target of >65 mmHg. Noradrenalin seems to be the preferred vasopressor. A low cardiac index is common over the first 24 h but aggressive fluid loading and the use of inotropes are not associated with improved outcome. Several meta-analyses of randomized clinical trials show conflicting results whether hypothermia in the 32-34°C range as compared to normothermia or no temperature control improves functional outcome. The role of sedation is currently under evaluation. Observational studies suggest that the use of neuromuscular blockade may be associated with improved survival and functional outcome. Prophylactic antibiotic does not impact on outcome. No single predictor is entirely accurate to determine neurological prognosis. The presence of at least two predictors of severe neurological injury indicates that an unfavorable neurological outcome is very likely. SUMMARY Postresuscitation care aims for normoxemia, normocapnia, and normotension. The optimal target core temperature remains a matter of debate, whether to implement temperature management within the 32-34°C range or focus on fever prevention, as recommended in the latest European Resuscitation Council/European Society of Intensive Care Medicine guidelines Prognostication of neurological outcome demands a multimodal approach.
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Affiliation(s)
- Wilhelm Behringer
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Finland
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium
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21
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Cheng X, Zhang Y, Deng H, Feng Y, Chong W, Hai Y, Hao P, He J, Li T, Peng L, Wang P, Xiao Y, Fang F. Lower versus higher oxygen targets for out-of-hospital cardiac arrest: a systematic review and meta-analysis. Crit Care 2023; 27:401. [PMID: 37858246 PMCID: PMC10588244 DOI: 10.1186/s13054-023-04684-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 10/11/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Supplemental oxygen is commonly administered to patients after out-of-hospital cardiac arrest. However, the findings from studies on oxygen targeting for out-of-hospital cardiac arrest are inconclusive. Thus, we conducted a systematic review and meta-analysis to evaluate the impact of lower oxygen target compared with higher oxygen target on patients after out-of-hospital cardiac arrest. METHODS We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, from inception to February 6, 2023, for randomized controlled trials comparing lower and higher oxygen target in adults (aged ≥ 18 years) after out-of-hospital cardiac arrest. We screened studies and extracted data independently. The primary outcome was mortality at 90 days after cardiac arrest. We assessed quality of evidence using the grading of recommendations assessment, development, and evaluation approach. This study was registered with PROSPERO, number CRD42023409368. RESULTS The analysis included 7 randomized controlled trials with a total of 1451 participants. Compared with lower oxygen target, the use of a higher oxygen target was not associated with a higher mortality rate (relative risk 0.97, 95% confidence intervals 0.82 to 1.14; I2 = 25%). Findings were robust to trial sequential, subgroup, and sensitivity analysis. CONCLUSION Lower oxygen target did not reduce the mortality compared with higher oxygen target in patients after out-of-hospital cardiac arrest.
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Affiliation(s)
- Xin Cheng
- West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Yu Zhang
- Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Haidong Deng
- Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Yuning Feng
- Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Weelic Chong
- Thomas Jefferson University, Philadelphia, PA, USA
| | - Yang Hai
- Thomas Jefferson University, Philadelphia, PA, USA
| | - Pengfei Hao
- Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Jialing He
- West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Tiangui Li
- Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Liyuan Peng
- Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Peng Wang
- Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Yangchun Xiao
- Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Fang Fang
- West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China.
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22
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Macherey-Meyer S, Heyne S, Meertens MM, Braumann S, Hueser C, Mauri V, Baldus S, Lee S, Adler C. Restrictive versus high-dose oxygenation strategy in post-arrest management following adult non-traumatic cardiac arrest: a meta-analysis. Crit Care 2023; 27:387. [PMID: 37798666 PMCID: PMC10557287 DOI: 10.1186/s13054-023-04669-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 09/28/2023] [Indexed: 10/07/2023] Open
Abstract
PURPOSE Neurological damage is the main cause of death or withdrawal of care in comatose survivors of cardiac arrest (CA). Hypoxemia and hyperoxemia following CA were described as potentially harmful, but reports were inconsistent. Current guidelines lack specific oxygen targets after return of spontaneous circulation (ROSC). OBJECTIVES The current meta-analysis assessed the effects of restrictive compared to high-dose oxygenation strategy in survivors of CA. METHODS A structured literature search was performed. Randomized controlled trials (RCTs) comparing two competing oxygenation strategies in post-ROSC management after CA were eligible. The primary end point was short-term survival (≤ 90 days). The meta-analysis was prospectively registered in PROSPERO database (CRD42023444513). RESULTS Eight RCTs enrolling 1941 patients were eligible. Restrictive oxygenation was applied to 964 patients, high-dose regimens were used in 977 participants. Short-term survival rate was 55.7% in restrictive and 56% in high-dose oxygenation group (8 trials, RR 0.99, 95% CI 0.90 to 1.10, P = 0.90, I2 = 18%, no difference). No evidence for a difference was detected in survival to hospital discharge (5 trials, RR 0.98, 95% CI 0.79 to 1.21, P = 0.84, I2 = 32%). Episodes of hypoxemia more frequently occurred in restrictive oxygenation group (4 trials, RR 2.06, 95% CI 1.47 to 2.89, P = 0.004, I2 = 13%). CONCLUSION Restrictive and high-dose oxygenation strategy following CA did not result in differences in short-term or in-hospital survival. Restrictive oxygenation strategy may increase episodes of hypoxemia, even with restrictive oxygenation targets exceeding intended saturation levels, but the clinical relevance is unknown. There is still a wide gap in the evidence of optimized oxygenation in post-ROSC management and specific targets cannot be concluded from the current evidence.
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Affiliation(s)
- S Macherey-Meyer
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany.
| | - S Heyne
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - M M Meertens
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
- Center of Cardiology, Cardiology III -Angiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - S Braumann
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - C Hueser
- Faculty of Medicine and University Hospital Cologne, Clinic II for Internal Medicine, University of Cologne, Cologne, Germany
- Faculty of Medicine and University Hospital Cologne, Emergency Department, University of Cologne, Cologne, Germany
| | - V Mauri
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - S Baldus
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - S Lee
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - C Adler
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
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23
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Yamamoto R, Yamakawa K, Endo A, Homma K, Sato Y, Takemura R, Yamagiwa T, Shimizu K, Kaito D, Yagi M, Yonemura T, Shibusawa T, Suzuki G, Shoji T, Miura N, Takahashi J, Narita C, Kurata S, Minami K, Wada T, Fujinami Y, Tsubouchi Y, Natsukawa M, Nagayama J, Takayama W, Ishikura K, Yokokawa K, Fujita Y, Nakayama H, Tokuyama H, Shinada K, Taira T, Fukui S, Ushio N, Nakane M, Hoshiyama E, Tampo A, Sageshima H, Takami H, Iizuka S, Kikuchi H, Hagiwara J, Tagami T, Funato Y, Sasaki J, Er-Oxytrac SG. Early restricted oxygen therapy after resuscitation from cardiac arrest (ER-OXYTRAC): protocol for a stepped-wedge cluster randomised controlled trial. BMJ Open 2023; 13:e074475. [PMID: 37714682 PMCID: PMC10510872 DOI: 10.1136/bmjopen-2023-074475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 08/31/2023] [Indexed: 09/17/2023] Open
Abstract
INTRODUCTION Cardiac arrest is a critical condition, and patients often experience postcardiac arrest syndrome (PCAS) even after the return of spontaneous circulation (ROSC). Administering a restricted amount of oxygen in the early phase after ROSC has been suggested as a potential therapy for PCAS; however, the optimal target for arterial partial pressure of oxygen or peripheral oxygen saturation (SpO2) to safely and effectively reduce oxygen remains unclear. Therefore, we aimed to validate the efficacy of restricted oxygen treatment with 94%-95% of the target SpO2 during the initial 12 hours after ROSC for patients with PCAS. METHODS AND ANALYSIS ER-OXYTRAC (early restricted oxygen therapy after resuscitation from cardiac arrest) is a nationwide, multicentre, pragmatic, single-blind, stepped-wedge cluster randomised controlled trial targeting cases of non-traumatic cardiac arrest. This study includes adult patients with out-of-hospital or in-hospital cardiac arrest who achieved ROSC in 39 tertiary centres across Japan, with a target sample size of 1000. Patients whose circulation has returned before hospital arrival and those with cardiac arrest due to intracranial disease or intoxication are excluded. Study participants are assigned to either the restricted oxygen (titration of a fraction of inspired oxygen with 94%-95% of the target SpO2) or the control (98%-100% of the target SpO2) group based on cluster randomisation per institution. The trial intervention continues until 12 hours after ROSC. Other treatments for PCAS, including oxygen administration later than 12 hours, can be determined by the treating physicians. The primary outcome is favourable neurological function, defined as cerebral performance category 1-2 at 90 days after ROSC, to be compared using an intention-to-treat analysis. ETHICS AND DISSEMINATION This study has been approved by the Institutional Review Board at Keio University School of Medicine (approval number: 20211106). Written informed consent will be obtained from all participants or their legal representatives. Results will be disseminated via publications and presentations. TRIAL REGISTRATION NUMBER UMIN Clinical Trials Registry (UMIN000046914).
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Affiliation(s)
- Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Kazuma Yamakawa
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Akira Endo
- Department of Acute Critical Care Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Koichiro Homma
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Yasunori Sato
- Clinical and Translational Research Center, Keio University Hospital, Shinjuku, Tokyo, Japan
| | - Ryo Takemura
- Clinical and Translational Research Center, Keio University Hospital, Shinjuku, Tokyo, Japan
| | - Takeshi Yamagiwa
- Department of Emergency and Critical Care Medicine, Ebina General Hospital, Ebina, Kanagawa, Japan
| | - Keiki Shimizu
- Emergency Medical Center of Tokyo Metropolitan Tama Medical Center, Fuchuu, Tokyo, Japan
| | - Daiki Kaito
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Masayuki Yagi
- Emergency Medicine and Acute Care Surgery, Matsudo City General Hospital, Matsudo, Chiba, Japan
| | - Taku Yonemura
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Ibaraki, Japan
| | - Takayuki Shibusawa
- Department of Emergency and Critical Care Medicine, National Hospital Organization Tokyo Medical Center, Meguro, Tokyo, Japan
| | - Ginga Suzuki
- Critical Care Center, Toho University Omori Medical Center, Ota-ku, Tokyo, Japan
| | - Takahiro Shoji
- Department of Emergency Medicine, Saiseikai Central Hospital, Minato-ku, Tokyo, Japan
| | - Naoya Miura
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Jiro Takahashi
- Department of Acute Medicine, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Chihiro Narita
- Department of Emergency Medicine, Shizuoka General Hospital, Shizuoka City, Shizuoka, Japan
| | - Saori Kurata
- Department of Emergency and Critical Care Medicine, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Kanagawa, Japan
| | - Kazunobu Minami
- Emergency and Critical Care Center, Hyogo Prefectural Nishinomiya Hospital, Nishinomiya City, Hyogo, Japan
| | - Takeshi Wada
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Hokkaido, Japan
| | - Yoshihisa Fujinami
- Department of Emergency Medicine, Kakogawa Central City Hospital, Kakogawa, Hyogo, Japan
| | - Yohei Tsubouchi
- Department of Emergency and Critical Care Medicine, Subaru Health Insurance Society Ota Memorial Hospital, Ota City, Gunma, Japan
| | - Mai Natsukawa
- Department of Emergency and Critical Care Medicine, Yodogawa Christian Hospital, Osaka City, Osaka, Japan
| | - Jun Nagayama
- Japan Red Cross Maebashi Hospital, Maebashi, Gunma, Japan
| | - Wataru Takayama
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Ken Ishikura
- Department of Emergency and Disaster Medicine, Mie University Graduate School of Medicine, Tsu City, Mie, Japan
| | - Kyoko Yokokawa
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Tohoku University Hospital Emergency Center, Sendai, Miyagi, Japan
| | - Yasuo Fujita
- Department of Emergency and Critical Care Center, Akita Redcross Hospital, Akita City, Akita, Japan
| | - Hirofumi Nakayama
- Department of Emergency and Disaster Medicine, Hirosaki University School of Medicine, Hirosaki, Aomori, Japan
| | - Hideki Tokuyama
- Department of Emergency and Critical Care Medicine, Fujita Medical School Bantane Hospital, Nakagawa-ku, Nagoya, Japan
| | - Kota Shinada
- Department of Emergency and Critical Care Medicine, Saga University, Saga City, Saga, Japan
| | - Takayuki Taira
- Department of Emergency and Critical Care Medicine, Ryukyu University hospital, Kunigamigun, Okinawa, Japan
| | - Shoki Fukui
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Noritaka Ushio
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Masaki Nakane
- Department of Emergency and Critical Care Medicine, Yamagata University Hospital, Yamagata City, Yamagata, Japan
| | - Eisei Hoshiyama
- Department of Neurology/Emergency and Critical Care Medicine, Dokkyomedical University, Mibu, Tochigi, Japan
| | - Akihito Tampo
- Department of Emergency Medicine, Asahikawa City Hospital, Asahikawa, Hokkaido, Japan
| | - Hisako Sageshima
- Department of Emergency Medicine, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
| | - Hiroki Takami
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima-ku, Tokyo, Japan
| | - Shinichi Iizuka
- Department of Emergency and Critical Care Medicine, Odawara Municipal Hospital, Odawara, Kanagawa, Japan
| | - Hitoshi Kikuchi
- Department of Emergency Medicine, Sagamihara Kyodo Hospital, Sagamihara City, Kanagawa, Japan
| | - Jun Hagiwara
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Bunkyo-ku, Tokyo, Japan
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Musashikosugi Hospital, Kawasaki, Kanagawa, Japan
| | - Yumi Funato
- Department of Emergency Medicine and Critical Care, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Shinjuku, Tokyo, Japan
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
- Keio University Hospital, Shinjuku-ku, Japan
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Klitgaard TL, Schjørring OL, Nielsen FM, Meyhoff CS, Perner A, Wetterslev J, Rasmussen BS, Barbateskovic M. Higher versus lower fractions of inspired oxygen or targets of arterial oxygenation for adults admitted to the intensive care unit. Cochrane Database Syst Rev 2023; 9:CD012631. [PMID: 37700687 PMCID: PMC10498149 DOI: 10.1002/14651858.cd012631.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
BACKGROUND This is an updated review concerning 'Higher versus lower fractions of inspired oxygen or targets of arterial oxygenation for adults admitted to the intensive care unit'. Supplementary oxygen is provided to most patients in intensive care units (ICUs) to prevent global and organ hypoxia (inadequate oxygen levels). Oxygen has been administered liberally, resulting in high proportions of patients with hyperoxemia (exposure of tissues to abnormally high concentrations of oxygen). This has been associated with increased mortality and morbidity in some settings, but not in others. Thus far, only limited data have been available to inform clinical practice guidelines, and the optimum oxygenation target for ICU patients is uncertain. Because of the publication of new trial evidence, we have updated this review. OBJECTIVES To update the assessment of benefits and harms of higher versus lower fractions of inspired oxygen (FiO2) or targets of arterial oxygenation for adults admitted to the ICU. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Science Citation Index Expanded, BIOSIS Previews, and LILACS. We searched for ongoing or unpublished trials in clinical trial registers and scanned the reference lists and citations of included trials. Literature searches for this updated review were conducted in November 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared higher versus lower FiO2 or targets of arterial oxygenation (partial pressure of oxygen (PaO2), peripheral or arterial oxygen saturation (SpO2 or SaO2)) for adults admitted to the ICU. We included trials irrespective of publication type, publication status, and language. We excluded trials randomising participants to hypoxaemia (FiO2 below 0.21, SaO2/SpO2 below 80%, or PaO2 below 6 kPa) or to hyperbaric oxygen, and cross-over trials and quasi-randomised trials. DATA COLLECTION AND ANALYSIS Four review authors independently, and in pairs, screened the references identified in the literature searches and extracted the data. Our primary outcomes were all-cause mortality, the proportion of participants with one or more serious adverse events (SAEs), and quality of life. We analysed all outcomes at maximum follow-up. Only three trials reported the proportion of participants with one or more SAEs as a composite outcome. However, most trials reported on events categorised as SAEs according to the International Conference on Harmonisation Good Clinical Practice (ICH-GCP) criteria. We, therefore, conducted two analyses of the effect of higher versus lower oxygenation strategies using 1) the single SAE with the highest reported proportion in each trial, and 2) the cumulated proportion of participants with an SAE in each trial. Two trials reported on quality of life. Secondary outcomes were lung injury, myocardial infarction, stroke, and sepsis. No trial reported on lung injury as a composite outcome, but four trials reported on the occurrence of acute respiratory distress syndrome (ARDS) and five on pneumonia. We, therefore, conducted two analyses of the effect of higher versus lower oxygenation strategies using 1) the single lung injury event with the highest reported proportion in each trial, and 2) the cumulated proportion of participants with ARDS or pneumonia in each trial. We assessed the risk of systematic errors by evaluating the risk of bias in the included trials using the Risk of Bias 2 tool. We used the GRADEpro tool to assess the overall certainty of the evidence. We also evaluated the risk of publication bias for outcomes reported by 10b or more trials. MAIN RESULTS We included 19 RCTs (10,385 participants), of which 17 reported relevant outcomes for this review (10,248 participants). For all-cause mortality, 10 trials were judged to be at overall low risk of bias, and six at overall high risk of bias. For the reported SAEs, 10 trials were judged to be at overall low risk of bias, and seven at overall high risk of bias. Two trials reported on quality of life, of which one was judged to be at overall low risk of bias and one at high risk of bias for this outcome. Meta-analysis of all trials, regardless of risk of bias, indicated no significant difference from higher or lower oxygenation strategies at maximum follow-up with regard to mortality (risk ratio (RR) 1.01, 95% confidence interval (C)I 0.96 to 1.06; I2 = 14%; 16 trials; 9408 participants; very low-certainty evidence); occurrence of SAEs: the highest proportion of any specific SAE in each trial RR 1.01 (95% CI 0.96 to 1.06; I2 = 36%; 9466 participants; 17 trials; very low-certainty evidence), or quality of life (mean difference (MD) 0.5 points in participants assigned to higher oxygenation strategies (95% CI -2.75 to 1.75; I2 = 34%, 1649 participants; 2 trials; very low-certainty evidence)). Meta-analysis of the cumulated number of SAEs suggested benefit of a lower oxygenation strategy (RR 1.04 (95% CI 1.02 to 1.07; I2 = 74%; 9489 participants; 17 trials; very low certainty evidence)). However, trial sequential analyses, with correction for sparse data and repetitive testing, could reject a relative risk increase or reduction of 10% for mortality and the highest proportion of SAEs, and 20% for both the cumulated number of SAEs and quality of life. Given the very low-certainty of evidence, it is necessary to interpret these findings with caution. Meta-analysis of all trials indicated no statistically significant evidence of a difference between higher or lower oxygenation strategies on the occurrence of lung injuries at maximum follow-up (the highest reported proportion of lung injury RR 1.08, 95% CI 0.85 to 1.38; I2 = 0%; 2048 participants; 8 trials; very low-certainty evidence). Meta-analysis of all trials indicated harm from higher oxygenation strategies as compared with lower on the occurrence of sepsis at maximum follow-up (RR 1.85, 95% CI 1.17 to 2.93; I2 = 0%; 752 participants; 3 trials; very low-certainty evidence). Meta-analysis indicated no differences regarding the occurrences of myocardial infarction or stroke. AUTHORS' CONCLUSIONS In adult ICU patients, it is still not possible to draw clear conclusions about the effects of higher versus lower oxygenation strategies on all-cause mortality, SAEs, quality of life, lung injuries, myocardial infarction, stroke, and sepsis at maximum follow-up. This is due to low or very low-certainty evidence.
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Affiliation(s)
- Thomas L Klitgaard
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Olav L Schjørring
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Frederik M Nielsen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian S Meyhoff
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Anders Perner
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jørn Wetterslev
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Private Office, Hellerup, Denmark
| | - Bodil S Rasmussen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marija Barbateskovic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Jagarlamudi NS, Soni K, Ahmed SS, Makkapati NSR, Janarthanam S, Vallejo-Zambrano CR, Patel KC, Xavier R, Ponnada PK, Zaheen I, Ehsan M. Unveiling Breakthroughs in Post-resuscitation Supportive Care for Out-of-Hospital Cardiac Arrest Survivors: A Narrative Review. Cureus 2023; 15:e44783. [PMID: 37809191 PMCID: PMC10558054 DOI: 10.7759/cureus.44783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 10/10/2023] Open
Abstract
Survivors of out-of-hospital cardiac arrest (OHCA) experience significant mortality rates and neurological impairment, potentially attributed to the hypoxic-ischemic injury sustained amid the cardiac arrest episode. Post-resuscitation care plays a crucial role in determining outcomes for survivors of OHCA. Supportive therapies have proven to be influential in shaping these outcomes. However, targeting higher blood pressure or oxygen levels during the post-resuscitative phase has not been shown to offer any mortality or neurological benefits. In terms of maintaining hemodynamic instability after resuscitation, it is recommended to use norepinephrine rather than epinephrine. While extracorporeal cardiopulmonary resuscitation has shown promising results, targeted temperature management has been found ineffective in improving outcomes despite its previous potential. This review also investigates various challenges and barriers associated with the practical implementation of these supportive therapies in clinical settings. The review also highlights areas ripe for future research and proposes potential directions to further enhance post-resuscitation supportive care for OHCA survivors.
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Affiliation(s)
| | - Kriti Soni
- Internal Medicine, Dr. D. Y. Patil Medical College, Hospital & Research Center, Pune, IND
| | - Saima S Ahmed
- Internal Medicine, Dow International Medical College, Karachi, PAK
| | | | - Sujaritha Janarthanam
- Internal Medicine, Sri Ramachandra Institute of Higher Education and Research Center, Chennai, IND
| | | | | | - Roshni Xavier
- Internal Medicine, Rajagiri Hospital, Aluva, IND
- Internal Medicine, Carewell Hospital, Malappuram, IND
| | | | - Iqra Zaheen
- Internal Medicine, Jinnah Medical and Dental College, Karachi, PAK
| | - Muhammad Ehsan
- General Medicine, International Medical Graduates (IMG) Helping Hands, Lahore, PAK
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Schoenthal T, Hoiland R, Griesdale DE, Sekhon MS. Cerebral hemodynamics after cardiac arrest: implications for clinical management. Minerva Anestesiol 2023; 89:824-833. [PMID: 37676177 DOI: 10.23736/s0375-9393.23.17268-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
Following resuscitation from cardiac arrest, hypoxic ischemic brain injury (HIBI) ensues, which is the primary determinant of adverse outcome. The pathophysiology of HIBI can be compartmentalized into primary and secondary injury, resulting from cerebral ischemia during cardiac arrest and reperfusion following successful resuscitation, respectively. During the secondary injury phase, increased attention has been directed towards the optimization of cerebral oxygen delivery to prevent additive injury to the brain. During this phase, cerebral hemodynamics are characterized by early hyperemia following resuscitation and then a protracted phase of cerebral hypoperfusion termed "no-reflow" during which additional hypoxic-ischemic injury can occur. As such, identification of therapeutic strategies to optimize cerebral delivery of oxygen is at the forefront of HIBI research. Unfortunately, randomized control trials investigating the manipulation of arterial carbon dioxide tension and mean arterial pressure augmentation as methods to potentially improve cerebral oxygen delivery have shown no impact on clinical outcomes. Emerging literature suggests differential patient-specific phenotypes may exist in patients with HIBI. The potential to personalize therapeutic strategies in the critical care setting based upon patient-specific pathophysiology presents an attractive strategy to improve HIBI outcomes. Herein, we review the cerebral hemodynamic pathophysiology of HIBI, discuss patient phenotypes as it pertains to personalizing care, as well as suggest future directions.
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Affiliation(s)
- Tison Schoenthal
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Ryan Hoiland
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Department of Cellular and Physiological Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Center for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, Faculty of Health and Social Development, University of British Columbia Okanagan, Kelowna, BC, Canada
- International Collaboration on Repair Discoveries, Vancouver, BC, Canada
| | - Donald E Griesdale
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Center for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada -
- International Collaboration on Repair Discoveries, Vancouver, BC, Canada
- Djavad Mowafaghian Center for Brain Health, University of British Columbia, Vancouver, BC, Canada
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Hoiland RL, Robba C, Menon DK, Citerio G, Sandroni C, Sekhon MS. Clinical targeting of the cerebral oxygen cascade to improve brain oxygenation in patients with hypoxic-ischaemic brain injury after cardiac arrest. Intensive Care Med 2023; 49:1062-1078. [PMID: 37507572 PMCID: PMC10499700 DOI: 10.1007/s00134-023-07165-x] [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: 05/13/2023] [Accepted: 07/07/2023] [Indexed: 07/30/2023]
Abstract
The cerebral oxygen cascade includes three key stages: (a) convective oxygen delivery representing the bulk flow of oxygen to the cerebral vascular bed; (b) diffusion of oxygen from the blood into brain tissue; and (c) cellular utilisation of oxygen for aerobic metabolism. All three stages may become dysfunctional after resuscitation from cardiac arrest and contribute to hypoxic-ischaemic brain injury (HIBI). Improving convective cerebral oxygen delivery by optimising cerebral blood flow has been widely investigated as a strategy to mitigate HIBI. However, clinical trials aimed at optimising convective oxygen delivery have yielded neutral results. Advances in the understanding of HIBI pathophysiology suggest that impairments in the stages of the oxygen cascade pertaining to oxygen diffusion and cellular utilisation of oxygen should also be considered in identifying therapeutic strategies for the clinical management of HIBI patients. Culprit mechanisms for these impairments may include a widening of the diffusion barrier due to peri-vascular oedema and mitochondrial dysfunction. An integrated approach encompassing both intra-parenchymal and non-invasive neuromonitoring techniques may aid in detecting pathophysiologic changes in the oxygen cascade and enable patient-specific management aimed at reducing the severity of HIBI.
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Affiliation(s)
- Ryan L Hoiland
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada.
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, Faculty of Health and Social Development, University of British Columbia Okanagan, Kelowna, BC, Canada.
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada.
- Collaborative Entity for REsearching Brain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada.
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - David K Menon
- Department of Medicine, University Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli", IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching Brain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
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Kjaergaard J, Møller JE. Haemodynamic, oxygenation, and ventilation targets after cardiac arrest: the current ABC of post-cardiac arrest intensive care. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:513-517. [PMID: 37459572 DOI: 10.1093/ehjacc/zuad077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 07/06/2023] [Indexed: 08/26/2023]
Affiliation(s)
- Jesper Kjaergaard
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - Jacob Eifer Møller
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark
- Department of Cardiology, Odense University Hospital, JB Winsløvvej 4, Odense 5000, Denmark
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Cheema HA, Shafiee A, Akhondi A, Seighali N, Shahid A, Rehman MEU, Almas T, Hadeed S, Nashwan AJ, Ahmad S. Oxygen targets following cardiac arrest: A meta-analysis of randomized controlled trials. IJC HEART & VASCULATURE 2023; 47:101243. [PMID: 37484065 PMCID: PMC10359856 DOI: 10.1016/j.ijcha.2023.101243] [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: 01/12/2023] [Revised: 06/12/2023] [Accepted: 06/16/2023] [Indexed: 07/25/2023]
Abstract
Introduction The appropriate oxygen target post-resuscitation in out-of-hospital cardiac arrest (OHCA) patients is uncertain. We sought to compare lower versus higher oxygen targets in patients following OHCA. Methods We searched MEDLINE, Embase, the Cochrane Library, and ClinicalTrials.gov until January 2023 to include all randomized controlled trials (RCTs) that evaluated conservative vs. liberal oxygen therapy in OHCA patients. Our primary outcome was all-cause mortality at 90 days while our secondary outcomes were the level of neuron-specific enolase (NSE) at 48 h, ICU length of stay (LOS), and favorable neurological outcome (the proportion of patients with Cerebral Performance Category scores of 1-2 at end of follow-up). We used RevMan 5.4 to pool risk ratios (RRs) and mean differences (MDs). Results Nine trials with 1971 patients were included in our review. There was no significant difference between the conservative and liberal oxygen target groups regarding the rate of all-cause mortality (RR 0.95, 95% CI: 0.80 to 1.13; I2 = 55%). There were no significant differences between the two groups when assessing favorable neurological outcome (RR 1.01, 95% CI: 0.92 to 1.10; I2 = 4%), NSE at 48 h (MD 0.04, 95% CI: -0.67 to 0.76; I2 = 0%), and ICU length of stay (MD -2.86 days, 95% CI: -8.00 to 2.29 days; I2 = 0%). Conclusions Conservative oxygen therapy did not decrease mortality, improve neurologic recovery, or decrease ICU LOS as compared to a liberal oxygen regimen. Future large-scale RCTs comparing homogenous oxygen targets are needed to confirm these findings.
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Affiliation(s)
| | - Arman Shafiee
- Clinical Research Development Unit, Alborz University of Medical Sciences, Karaj, Iran
- Student Research Committee, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Amirhossein Akhondi
- Student Research Committee, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Niloofar Seighali
- Student Research Committee, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Abia Shahid
- Department of Cardiology, King Edward Medical University, Lahore, Pakistan
| | | | - Talal Almas
- Department of Cardiovascular Medicine, Galway University Hospital, Galway, Ireland
| | - Sebastian Hadeed
- Department of Internal Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Soban Ahmad
- Department of Internal Medicine, East Carolina University, Greenville, NC, USA
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Bray J, Skrifvars M, Bernard S. Oxygen targets after cardiac arrest: a narrative review. Resuscitation 2023:109899. [PMID: 37419236 DOI: 10.1016/j.resuscitation.2023.109899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/22/2023] [Accepted: 06/23/2023] [Indexed: 07/09/2023]
Abstract
A significant focus of post-resuscitation research over the last decade has included optimising oxygenation. This has primarily occurred due to an improved understanding of the possible harmful biological effects of high oxygenation, particularly the neurotoxicity of oxygen free radicals. Animal studies and some observational research in humans suggest harm with the occurrence of severe hyperoxaemia (PaO2 >300mmHg) in the post-resuscitation phase. This early data informed in a change in treatment recommendations, with the International Liaison Committee on Resuscitation (ILCOR) recommending the avoidance of hyperoxaemia. However, the optimal oxygenation level for maximal survival has not yet been determined. Recent Phase 3 randomised control trials (RCTs) provide further insight into when oxygen titration should occur. The EXACT RCT suggested that decreasing oxygen fraction post-resuscitation in the prehospital setting, with limited ability to titrate and measure oxygenation, is too soon. The BOX RCT, suggests delaying titration to a normal level in intensive care may be too late. While further RCTs are currently underway in ICU cohorts, titration of oxygen early after arrival at hospital should be considered.
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Affiliation(s)
- Janet Bray
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Markus Skrifvars
- Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Finland
| | - Stephen Bernard
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia The Intensive Care Unit, The Alfred Hospital, Melbourne, Australia
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Skrifvars MB, Meyhoff CS. Optimal oxygen targets in patients undergoing general anesthesia for major non-cardiac surgery-How to handle the conflict between observational and randomized trials? Acta Anaesthesiol Scand 2023; 67:686-687. [PMID: 36973884 DOI: 10.1111/aas.14243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 03/21/2023] [Indexed: 03/29/2023]
Affiliation(s)
- Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Christian S Meyhoff
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
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Crescioli E, Lass Klitgaard Klitgaard T, Perner A, Lilleholt Schjørring O, Steen Rasmussen B. Lower versus higher oxygenation targets in hypoxaemic ICU patients after cardiac arrest. Resuscitation 2023:109838. [PMID: 37196799 DOI: 10.1016/j.resuscitation.2023.109838] [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: 02/16/2023] [Revised: 04/18/2023] [Accepted: 05/09/2023] [Indexed: 05/19/2023]
Abstract
AIM To investigate the effects of lower versus higher oxygenation targets in adult intensive care unit (ICU) patients with hypoxaemic respiratory failure after cardiac arrest. METHODS Subgroup analysis of the international Handling Oxygenation Targets in the ICU (HOT-ICU) trial which randomised 2928 adults with acute hypoxaemia to targets of arterial oxygenation of 8 kPa or 12 kPa in the ICU for up to 90 days. Here, we report all outcomes up to one year in the subgroup of patients enrolled after cardiac arrest. RESULTS The HOT-ICU trial included 335 patients after cardiac arrest: 149 in the lower-oxygenation group and 186 in the higher-oxygenation group. At 90 days, 96/147 patients (65.3%) in the lower-oxygenation group and 111/185 patients (60.0%) in the higher-oxygenation group had died (adjusted relative risk (RR) 1.09, 95% confidence interval (CI) 0.92-1.28, p=0.32); similar results were found at one year (adjusted RR 1.05, 95% CI 0.90-1.21, p=0.53). Serious adverse events (SAEs) in the ICU occurred in 23% of patients in the lower-oxygenation group and 38% in the higher-oxygenation group (adjusted RR 0.61, 95% CI 0.43-0.86, p=0.005); the difference was mainly due to more new episodes of shock in the higher-oxygenation group. No statistically significant differences were observed in other secondary outcomes. CONCLUSION A lower oxygenation target in adult ICU patients with hypoxaemic respiratory failure after cardiac arrest did not result in lower mortality, but fewer SAEs occurred in this group compared to the higher-oxygenation group. All analyses are exploratory only, large-scale trials are needed for confirmation. CLINICAL TRIAL REGISTRY Clinicaltrials.gov number NCT03174002 (registered May 30, 2017); EudraCT 2017-000632-34 (registered February 14, 2017).
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Affiliation(s)
- Elena Crescioli
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | | | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Olav Lilleholt Schjørring
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Bodil Steen Rasmussen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Nafae RM, Shouman W, Abdelmoneam SH, Shehata SM. Conservative versus conventional oxygen therapy in type I acute respiratory failure patients in respiratory intensive care unit, Zagazig University. Monaldi Arch Chest Dis 2023; 94. [PMID: 37144390 DOI: 10.4081/monaldi.2023.2536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 04/26/2023] [Indexed: 05/06/2023] Open
Abstract
The present study aimed to assess the effect of a conservative (permissive hypoxemia) versus conventional (normoxia) protocol for oxygen supplementation on the outcome of type I respiratory failure patients admitted to respiratory intensive care unit (ICU). This randomized controlled clinical trial was carried out at the Respiratory ICU, Chest Department of Zagazig University Hospital, for 18 months, starting in July 2018. On admission, 56 enrolled patients with acute respiratory failure were randomized in a 1:1 ratio into the conventional group [oxygen therapy was supplied to maintain oxygen saturation (SpO2) between 94% and 97%] and the conservative group (oxygen therapy was administered to maintain SpO2 values between 88% and 92%). Different outcomes were assessed, including ICU mortality, the need for mechanical ventilation (MV) (invasive or non-invasive), and ICU length of stay. In the current study, the partial pressure of oxygen was significantly higher among the conventional group at all times after the baseline reading, and bicarbonate was significantly higher among the conventional group at the first two readings. There was no significant difference in serum lactate level in follow-up readings. The mean duration of MV and ICU length of stay was 6.17±2.05 and 9.25±2.22 days in the conventional group versus 6.46±2.0 and 9.53±2.16 days in the conservative group, respectively, without significant differences between both groups. About 21.4% of conventional group patients died, while 35.7% of conservative group patients died without a significant difference between both groups. We concluded that conservative oxygen therapy may be applied safely to patients with type I acute respiratory failure.
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Affiliation(s)
| | - Waheed Shouman
- Chest Department, Faculty of Medicine, Zagazig University.
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Li X, Liu D, Liu C, Mao Z, Liu Y, Yi H, Zhou F. Conservative versus liberal oxygen therapy in relation to all-cause mortality among patients in the intensive care unit: a systematic review of randomized controlled trials with meta-analysis and trial sequential analysis. Med Intensiva 2023; 47:73-83. [PMID: 35644886 DOI: 10.1016/j.medine.2021.08.015] [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: 04/19/2021] [Accepted: 08/22/2021] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To evaluate the benefits and harmful effects of conservative versus liberal oxygen therapy in patients admitted to the Intensive Care Unit (ICU). DESIGN A systematic review and meta-analysis was carried out. SETTING ICU. PARTICIPANTS Adult patients (aged 18 years or older) were randomized to either a lower oxygenation target strategy (conservative oxygen therapy) or a higher oxygenation target strategy (liberal oxygen therapy) in the ICU. INTERVENTIONS Patients received different oxygenation target strategies. RESULTS Ten studies involving 5429 adult patients admitted to the ICU were included in the meta-analysis. The pooled results showed no decreased all-cause mortality at 28 days (RR 0.90; 95%CI 0.75-1.09; p = 0.28), 90 days (RR 1.02; 95%CI 0.92-1.13; p = 0.71) or longest follow-up (RR 0.97; 95%CI 0.88-1.08; p = 0.63) among patients administered conservative oxygen therapy. Secondary outcomes were comparable between the two groups. The results of sensitivity analyses and subgroup analyses were consistent with the main analyses. CONCLUSION No beneficial or harmful effects of conservative oxygen therapy were found compared to liberal oxygen therapy in relation to all-cause mortality among adult patients in the ICU. Conservative oxygen therapy did not reduce all-cause mortality at 28 days, 90 days or longest follow-up. Other important clinical outcomes were also comparable between the two groups.
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Affiliation(s)
- X Li
- Department of Critical Care Medicine, The First Medical Centre, Chinese PLA General Hospital, PR China; Medical School of Chinese PLA, PR China.
| | - D Liu
- Department of Emergency Medicine, The Fourth Medical Centre, Chinese PLA General Hospital, PR China.
| | - C Liu
- Medical School of Chinese PLA, PR China.
| | - Z Mao
- Department of Critical Care Medicine, The First Medical Centre, Chinese PLA General Hospital, PR China.
| | - Y Liu
- Department of Emergency Medicine, Peking Union Medical College Hospital, PR China
| | - H Yi
- Department of Critical Care Medicine, The First Medical Centre, Chinese PLA General Hospital, PR China; Medical School of Chinese PLA, PR China
| | - F Zhou
- Department of Critical Care Medicine, The First Medical Centre, Chinese PLA General Hospital, PR China.
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Bernard SA, Bray JE, Smith K, Stephenson M, Finn J, Grantham H, Hein C, Masters S, Stub D, Perkins GD, Dodge N, Martin C, Hopkins S, Cameron P. Effect of Lower vs Higher Oxygen Saturation Targets on Survival to Hospital Discharge Among Patients Resuscitated After Out-of-Hospital Cardiac Arrest: The EXACT Randomized Clinical Trial. JAMA 2022; 328:1818-1826. [PMID: 36286192 PMCID: PMC9608019 DOI: 10.1001/jama.2022.17701] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The administration of a high fraction of oxygen following return of spontaneous circulation in out-of-hospital cardiac arrest may increase reperfusion brain injury. OBJECTIVE To determine whether targeting a lower oxygen saturation in the early phase of postresuscitation care for out-of-hospital cardiac arrest improves survival at hospital discharge. DESIGN, SETTING, AND PARTICIPANTS This multicenter, parallel-group, randomized clinical trial included unconscious adults with return of spontaneous circulation and a peripheral oxygen saturation (Spo2) of at least 95% while receiving 100% oxygen. The trial was conducted in 2 emergency medical services and 15 hospitals in Victoria and South Australia, Australia, between December 11, 2017, and August 11, 2020, with data collection from ambulance and hospital medical records (final follow-up date, August 25, 2021). The trial enrolled 428 of a planned 1416 patients. INTERVENTIONS Patients were randomized by paramedics to receive oxygen titration to achieve an oxygen saturation of either 90% to 94% (intervention; n = 216) or 98% to 100% (standard care; n = 212) until arrival in the intensive care unit. MAIN OUTCOMES AND MEASURES The primary outcome was survival to hospital discharge. There were 9 secondary outcomes collected, including hypoxic episodes (Spo2 <90%) and prespecified serious adverse events, which included hypoxia with rearrest. RESULTS The trial was stopped early due to the COVID-19 pandemic. Of the 428 patients who were randomized, 425 were included in the primary analysis (median age, 65.5 years; 100 [23.5%] women) and all completed the trial. Overall, 82 of 214 patients (38.3%) in the intervention group survived to hospital discharge compared with 101 of 211 (47.9%) in the standard care group (difference, -9.6% [95% CI, -18.9% to -0.2%]; unadjusted odds ratio, 0.68 [95% CI, 0.46-1.00]; P = .05). Of the 9 prespecified secondary outcomes collected during hospital stay, 8 showed no significant difference. A hypoxic episode prior to intensive care was observed in 31.3% (n = 67) of participants in the intervention group and 16.1% (n = 34) in the standard care group (difference, 15.2% [95% CI, 7.2%-23.1%]; OR, 2.37 [95% CI, 1.49-3.79]; P < .001). CONCLUSIONS AND RELEVANCE Among patients achieving return of spontaneous circulation after out-of-hospital cardiac arrest, targeting an oxygen saturation of 90% to 94%, compared with 98% to 100%, until admission to the intensive care unit did not significantly improve survival to hospital discharge. Although the trial is limited by early termination due to the COVID-19 pandemic, the findings do not support use of an oxygen saturation target of 90% to 94% in the out-of-hospital setting after resuscitation from cardiac arrest. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03138005.
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Affiliation(s)
- Stephen A Bernard
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Melbourne, Victoria, Australia
- Alfred Hospital, Melbourne, Victoria, Australia
| | - Janet E Bray
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Alfred Hospital, Melbourne, Victoria, Australia
- Prehospital, Resuscitation and Emergency Care Research Unit, Curtin University, Perth, Western Australia, Australia
| | - Karen Smith
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Michael Stephenson
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Judith Finn
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Prehospital, Resuscitation and Emergency Care Research Unit, Curtin University, Perth, Western Australia, Australia
| | - Hugh Grantham
- Prehospital, Resuscitation and Emergency Care Research Unit, Curtin University, Perth, Western Australia, Australia
- SA Ambulance Service, Adelaide, South Australia, Australia
- Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Cindy Hein
- Flinders University, Adelaide, South Australia, Australia
| | - Stacey Masters
- Prehospital, Resuscitation and Emergency Care Research Unit, Curtin University, Perth, Western Australia, Australia
| | - Dion Stub
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Melbourne, Victoria, Australia
- Alfred Hospital, Melbourne, Victoria, Australia
| | | | - Natasha Dodge
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Catherine Martin
- Monash University, Data Science and AI Platform, Melbourne, Victoria, Australia
| | | | - Peter Cameron
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Alfred Hospital, Melbourne, Victoria, Australia
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Wang C, Huang C, Tsai M, Wang C, Chang W, Liu S, Chen W. Inhaled Carbon Dioxide Improves Neurological Outcomes by Downregulating Hippocampal Autophagy and Apoptosis in an Asphyxia‐Induced Cardiac Arrest and Resuscitation Rat Model. J Am Heart Assoc 2022; 11:e027685. [PMID: 36314493 PMCID: PMC9673650 DOI: 10.1161/jaha.122.027685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Background Protracted cerebral hypoperfusion following cardiac arrest (CA) may cause poor neurological recovery. We hypothesized that inhaled carbon dioxide (CO2) could augment cerebral blood flow (CBF) and improve post‐CA neurological outcomes. Methods and Results After 6‐minute asphyxia‐induced CA and resuscitation, Wistar rats were randomly allocated to 4 groups (n=25/group) and administered with different inhaled CO2 concentrations, including control (0% CO2), 4% CO2, 8% CO2, and 12% CO2. Invasive monitoring was maintained for 120 minutes, and neurological outcomes were evaluated with neurological function score at 24 hours post‐CA. After the 120‐minute experiment, CBF was 242.3% (median; interquartile range, 221.1%–267.4%) of baseline in the 12% CO2 group while CBF fell to 45.8% (interquartile range, 41.2%–58.1%) of baseline in the control group (P<0.001). CBF increased along with increasing inhaled CO2 concentrations with significant linear trends (P<0.001). At 24 hours post‐CA, compared with the control group (neurological function score, 9 [interquartile range, 8–9]), neurological recovery was significantly better in the 12% CO2 group (neurological function score, 10 [interquartile range, 9.8–10]) (P<0.001) while no survival difference was observed. Brain tissue malondialdehyde (P=0.02) and serum neuron‐specific enolase (P=0.002) and S100β levels (P=0.002) were significantly lower in the 12% CO2 group. TUNEL (terminal deoxynucleotidyl transferase–mediated biotin–deoxyuridine triphosphate nick‐end labeling)‐positive cell densities in hippocampal CA1 (P<0.001) and CA3 (P<0.001) regions were also significantly reduced in the 12% CO2 group. Western blotting showed that beclin‐1 (P=0.02), p62 (P=0.02), and LAMP2 (lysosome‐associated membrane protein 2) (P=0.01) expression levels, and the LC3B‐II:LC3B‐I ratio (P=0.02) were significantly lower in the 12% CO2 group. Conclusions Administering inhaled CO2 augmented post‐CA CBF, mitigated oxidative brain injuries, ameliorated neuronal injury, and downregulated apoptosis and autophagy, thereby improving neurological outcomes.
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Affiliation(s)
- Chih‐Hung Wang
- Department of Emergency Medicine National Taiwan University Hospital Taipei Taiwan
- Department of Emergency Medicine, College of Medicine National Taiwan University Taipei Taiwan
| | - Chien‐Hua Huang
- Department of Emergency Medicine National Taiwan University Hospital Taipei Taiwan
- Department of Emergency Medicine, College of Medicine National Taiwan University Taipei Taiwan
| | - Min‐Shan Tsai
- Department of Emergency Medicine National Taiwan University Hospital Taipei Taiwan
- Department of Emergency Medicine, College of Medicine National Taiwan University Taipei Taiwan
| | - Chan‐Chi Wang
- Department of Emergency Medicine National Taiwan University Hospital Taipei Taiwan
- Department of Emergency Medicine, College of Medicine National Taiwan University Taipei Taiwan
| | - Wei‐Tien Chang
- Department of Emergency Medicine National Taiwan University Hospital Taipei Taiwan
- Department of Emergency Medicine, College of Medicine National Taiwan University Taipei Taiwan
| | - Shing‐Hwa Liu
- Institute of Toxicology, College of Medicine National Taiwan University Taipei Taiwan
- Department of Medical Research China Medical University Hospital, China Medical University Taichung Taiwan
- Department of Pediatrics National Taiwan University Hospital Taipei Taiwan
| | - Wen‐Jone Chen
- Department of Emergency Medicine National Taiwan University Hospital Taipei Taiwan
- Department of Emergency Medicine, College of Medicine National Taiwan University Taipei Taiwan
- Division of Cardiology, Department of Internal Medicine National Taiwan University Hospital and National Taiwan University College of Medicine Taipei Taiwan
- Division of Cardiology, Department of Internal Medicine Min‐Shen General Hospital Taoyuan Taiwan
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37
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Olsen MH, Jensen AKG, Dankiewicz J, Skrifvars MB, Reinikainen M, Tiainen M, Saxena M, Aneman A, Gluud C, Ullén S, Nielsen N, Jakobsen JC. Interactions in the 2×2×2 factorial randomised clinical STEPCARE trial and the potential effects on conclusions: a protocol for a simulation study. Trials 2022; 23:889. [PMID: 36273179 PMCID: PMC9587583 DOI: 10.1186/s13063-022-06796-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 09/27/2022] [Indexed: 11/28/2022] Open
Abstract
Background
Randomised clinical trials with a factorial design may assess the effects of multiple interventions in the same population. Factorial trials are carried out under the assumption that the trial interventions have no interactions on outcomes. Here, we present a protocol for a simulation study investigating the consequences of different levels of interactions between the trial interventions on outcomes for the future 2×2×2 factorial designed randomised clinical Sedation, TEmperature, and Pressure after Cardiac Arrest and REsuscitation (STEPCARE) trial in comatose patients after out-of-hospital cardiac arrest. Methods By simulating a multisite trial with 50 sites and 3278 participants, and a presumed six-month all-cause mortality of 60% in the control population, we will investigate the validity of the trial results with different levels of interaction effects on the outcome. The primary simulation outcome of the study is the risks of type-1 and type-2 errors in the simulated scenarios, i.e. at what level of interaction is the desired alpha and beta level exceeded. When keeping the overall risk of type-1 errors ≤ 5% and the risk of type-2 errors ≤ 10%, we will quantify the maximum interaction effect we can accept if the planned sample size is increased by 5% to take into account possible interaction between the trial interventions. Secondly, we will assess how interaction effects influence the minimal detectable difference we may confirm or reject to take into account 5% (small interaction effect), 10% (moderate), or 15% (large) positive interactions in simulations with no ‘true’ intervention effect (type-1 errors) and small (5%), moderate (10%), or large negative interactions (15%) in simulations with ‘true’ intervention effects (type-2 errors). Moreover, we will investigate how much the sample size must be increased to account for a small, moderate, or large interaction effects. Discussion This protocol for a simulation study will inform the design of a 2×2×2 factorial randomised clinical trial of how potential interactions between the assessed interventions might affect conclusions. Protocolising this simulation study is important to ensure valid and unbiased results. Trial registration Not relevant
Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06796-7.
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Affiliation(s)
- Markus Harboe Olsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark. .,Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | - Aksel Karl Georg Jensen
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Josef Dankiewicz
- Department of Clinical Sciences, Cardiology, Lund University, Skåne University Hospital Lund, Lund, Sweden
| | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Matti Reinikainen
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Marjaana Tiainen
- Department of Anesthesiology, Intensive Care, and Pain Medicine, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | - Manoj Saxena
- Critical Care Division, the George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Anders Aneman
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, Sydney, Australia.,South Western Clinical School, University of New South Wales, Sydney, Australia
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Susann Ullén
- Clinical Studies Sweden - Forum South, Skåne University Hospital, Lund, Sweden
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Anesthesiology and Intensive Care, Lund University, Helsingborg Hospital, Helsingborg, Sweden
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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38
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Schmidt H, Kjaergaard J, Hassager C, Mølstrøm S, Grand J, Borregaard B, Roelsgaard Obling LE, Venø S, Sarkisian L, Mamaev D, Jensen LO, Nyholm B, Høfsten DE, Josiassen J, Thomsen JH, Thune JJ, Lindholm MG, Stengaard Meyer MA, Winther-Jensen M, Sørensen M, Frydland M, Beske RP, Frikke-Schmidt R, Wiberg S, Boesgaard S, Lind Jørgensen V, Møller JE. Oxygen Targets in Comatose Survivors of Cardiac Arrest. N Engl J Med 2022; 387:1467-1476. [PMID: 36027567 DOI: 10.1056/nejmoa2208686] [Citation(s) in RCA: 77] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The appropriate oxygenation target for mechanical ventilation in comatose survivors of out-of-hospital cardiac arrest is unknown. METHODS In this randomized trial with a 2-by-2 factorial design, we randomly assigned comatose adults with out-of-hospital cardiac arrest in a 1:1 ratio to either a restrictive oxygen target of a partial pressure of arterial oxygen (Pao2) of 9 to 10 kPa (68 to 75 mm Hg) or a liberal oxygen target of a Pao2 of 13 to 14 kPa (98 to 105 mm Hg); patients were also assigned to one of two blood-pressure targets (reported separately). The primary outcome was a composite of death from any cause or hospital discharge with severe disability or coma (Cerebral Performance Category [CPC] of 3 or 4; categories range from 1 to 5, with higher values indicating more severe disability), whichever occurred first within 90 days after randomization. Secondary outcomes were neuron-specific enolase levels at 48 hours, death from any cause, the score on the Montreal Cognitive Assessment (ranging from 0 to 30, with higher scores indicating better cognitive ability), the score on the modified Rankin scale (ranging from 0 to 6, with higher scores indicating greater disability), and the CPC at 90 days. RESULTS A total of 789 patients underwent randomization. A primary-outcome event occurred in 126 of 394 patients (32.0%) in the restrictive-target group and in 134 of 395 patients (33.9%) in the liberal-target group (hazard ratio, 0.95; 95% confidence interval, 0.75 to 1.21; P = 0.69). At 90 days, death had occurred in 113 patients (28.7%) in the restrictive-target group and in 123 (31.1%) in the liberal-target group. On the CPC, the median category was 1 in the two groups; on the modified Rankin scale, the median score was 2 in the restrictive-target group and 1 in the liberal-target group; and on the Montreal Cognitive Assessment, the median score was 27 in the two groups. At 48 hours, the median neuron-specific enolase level was 17 μg per liter in the restrictive-target group and 18 μg per liter in the liberal-target group. The incidence of adverse events was similar in the two groups. CONCLUSIONS Targeting of a restrictive or liberal oxygenation strategy in comatose patients after resuscitation for cardiac arrest resulted in a similar incidence of death or severe disability or coma. (Funded by the Novo Nordisk Foundation; BOX ClinicalTrials.gov number, NCT03141099.).
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Affiliation(s)
- Henrik Schmidt
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Jesper Kjaergaard
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Christian Hassager
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Simon Mølstrøm
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Johannes Grand
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Britt Borregaard
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Laust E Roelsgaard Obling
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Søren Venø
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Laura Sarkisian
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Dmitry Mamaev
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Lisette O Jensen
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Benjamin Nyholm
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Dan E Høfsten
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Jakob Josiassen
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Jakob H Thomsen
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Jens J Thune
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Matias G Lindholm
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Martin A Stengaard Meyer
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Matilde Winther-Jensen
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Marc Sørensen
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Martin Frydland
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Rasmus P Beske
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Ruth Frikke-Schmidt
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Sebastian Wiberg
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Søren Boesgaard
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Vibeke Lind Jørgensen
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
| | - Jacob E Møller
- From the Departments of Anesthesiology and Intensive Care (H.S., S.M., S.V., D.M.) and Cardiology (B.B., L.S., L.O.J., J.E.M.), Odense University Hospital, and the Department of Clinical Research, University of Southern Denmark (H.S., C.H., B.B., L.O.J., J.E.M.), Odense, and the Departments of Cardiology (J.K., C.H., J.G., L.E.R.O., B.N., D.E.H., J.J., J.H.T., M.G.L., M.A.S.M., M.F., M.W.-J., R.P.B., R.F.-S., S.W., S.B., J.E.M.) and Cardiothoracic Anesthesiology (M.S., V.L.J.), the Heart Center, and the Department of Clinical Biochemistry, Center of Diagnostic Investigation (R.F.-S.), Copenhagen University Hospital Rigshospitalet, the Department of Clinical Medicine, University of Copenhagen (J.K., C.H., R.F.-S.), and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen - all in Denmark
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Tavazzi G, van Diepen S, Morrow D. Oxygenation targets in post-resuscitation care: a perspective of the BOX randomized clinical trial. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:716-717. [PMID: 36093759 DOI: 10.1093/ehjacc/zuac110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Guido Tavazzi
- Department of Medical, Surgical, Diagnostic and Pediatric Science, University of Pavia, Pavia, Italy
- Anesthesiology and Intensive Care Unit, 18631 Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Sean van Diepen
- Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - David Morrow
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Lee HY, Jung YH, Jeung KW, Noh E, Lee J, Kim JC, Lee BK, Heo T, Min YI. Supranormal arterial oxygen tension only during the first six hours after cardiac arrest is associated with unfavourable outcomes. Acta Anaesthesiol Scand 2022; 66:1247-1256. [DOI: 10.1111/aas.14135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 07/21/2022] [Accepted: 08/08/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Hyoung Youn Lee
- Trauma centre Chonnam National University Hospital Gwangju Republic of Korea
| | - Yong Hun Jung
- Department of Emergency Medicine Chonnam National University Hospital Gwangju Republic of Korea
- Department of Emergency Medicine Chonnam National University Medical School Gwangju Republic of Korea
| | - Kyung Woon Jeung
- Department of Emergency Medicine Chonnam National University Hospital Gwangju Republic of Korea
- Department of Emergency Medicine Chonnam National University Medical School Gwangju Republic of Korea
| | - Eul Noh
- Department of Emergency Medicine Chonnam National University Hwasun Hospital Hwasun‐gun Jeollanam‐do Republic of Korea
| | - Jiho Lee
- Department of Emergency Medicine Chonnam National University Hospital Gwangju Republic of Korea
| | - Jung Chul Kim
- Division of Trauma Surgery, Department of Surgery Chonnam National University Hospital Gwangju Republic of Korea
| | - Byung Kook Lee
- Department of Emergency Medicine Chonnam National University Hospital Gwangju Republic of Korea
- Department of Emergency Medicine Chonnam National University Medical School Gwangju Republic of Korea
| | - Tag Heo
- Department of Emergency Medicine Chonnam National University Hospital Gwangju Republic of Korea
- Department of Emergency Medicine Chonnam National University Medical School Gwangju Republic of Korea
| | - Yong Il Min
- Department of Emergency Medicine Chonnam National University Hospital Gwangju Republic of Korea
- Department of Emergency Medicine Chonnam National University Medical School Gwangju Republic of Korea
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Brain-Lung Crosstalk: Management of Concomitant Severe Acute Brain Injury and Acute Respiratory Distress Syndrome. Curr Treat Options Neurol 2022; 24:383-408. [PMID: 35965956 PMCID: PMC9363869 DOI: 10.1007/s11940-022-00726-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2022] [Indexed: 12/15/2022]
Abstract
Purpose of Review To summarize pathophysiology, key conflicts, and therapeutic approaches in managing concomitant severe acute brain injury (SABI) and acute respiratory distress syndrome (ARDS). Recent Findings ARDS is common in SABI and independently associated with worse outcomes in all SABI subtypes. Most landmark ARDS trials excluded patients with SABI, and evidence to guide decisions is limited in this population. Potential areas of conflict in the management of patients with both SABI and ARDS are (1) risk of intracranial pressure (ICP) elevation with high levels of positive end-expiratory pressure (PEEP), permissive hypercapnia due to lung protective ventilation (LPV), or prone ventilation; (2) balancing a conservative fluid management strategy with ensuring adequate cerebral perfusion, particularly in patients with symptomatic vasospasm or impaired cerebrovascular blood flow; and (3) uncertainty about the benefit and harm of corticosteroids in this population, with a mortality benefit in ARDS, increased mortality shown in TBI, and conflicting data in other SABI subtypes. Also, the widely adapted partial pressure of oxygen (PaO2) target of > 55 mmHg for ARDS may exacerbate secondary brain injury, and recent guidelines recommend higher goals of 80–120 mmHg in SABI. Distinct pathophysiology and trajectories among different SABI subtypes need to be considered. Summary The management of SABI with ARDS is highly complex, and conventional ARDS management strategies may result in increased ICP and decreased cerebral perfusion. A crucial aspect of concurrent management is to recognize the risk of secondary brain injury in the individual patient, monitor with vigilance, and adjust management during critical time windows. The care of these patients requires meticulous attention to oxygenation and ventilation, hemodynamics, temperature management, and the neurological exam. LPV and prone ventilation should be utilized, and supplemented with invasive ICP monitoring if there is concern for cerebral edema and increased ICP. PEEP titration should be deliberate, involving measures of hemodynamic, pulmonary, and brain physiology. Serial volume status assessments should be performed in SABI and ARDS, and fluid management should be individualized based on measures of brain perfusion, the neurological exam, and cardiopulmonary status. More research is needed to define risks and benefits in corticosteroids in this population.
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Winiszewski H, Guinot PG, Schmidt M, Besch G, Piton G, Perrotti A, Lorusso R, Kimmoun A, Capellier G. Optimizing PO 2 during peripheral veno-arterial ECMO: a narrative review. Crit Care 2022; 26:226. [PMID: 35883117 PMCID: PMC9316319 DOI: 10.1186/s13054-022-04102-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 07/13/2022] [Indexed: 01/01/2023] Open
Abstract
During refractory cardiogenic shock and cardiac arrest, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is used to restore a circulatory output. However, it also impacts significantly arterial oxygenation. Recent guidelines of the Extracorporeal Life Support Organization (ELSO) recommend targeting postoxygenator partial pressure of oxygen (PPOSTO2) around 150 mmHg. In this narrative review, we intend to summarize the rationale and evidence for this PPOSTO2 target recommendation. Because this is the most used configuration, we focus on peripheral VA-ECMO. To date, clinicians do not know how to set the sweep gas oxygen fraction (FSO2). Because of the oxygenator's performance, arterial hyperoxemia is common during VA-ECMO support. Interpretation of oxygenation is complex in this setting because of the dual circulation phenomenon, depending on both the native cardiac output and the VA-ECMO blood flow. Such dual circulation results in dual oxygenation, with heterogeneous oxygen partial pressure (PO2) along the aorta, and heterogeneous oxygenation between organs, depending on the mixing zone location. Data regarding oxygenation during VA-ECMO are scarce, but several observational studies have reported an association between hyperoxemia and mortality, especially after refractory cardiac arrest. While hyperoxemia should be avoided, there are also more and more studies in non-ECMO patients suggesting the harm of a too restrictive oxygenation strategy. Finally, setting FSO2 to target strict normoxemia is challenging because continuous monitoring of postoxygenator oxygen saturation is not widely available. The threshold of PPOSTO2 around 150 mmHg is supported by limited evidence but aims at respecting a safe margin, avoiding both hypoxemia and severe hyperoxemia.
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Affiliation(s)
- Hadrien Winiszewski
- Service de Réanimation Médicale, centre hospitalier universitaire de Besançon, Besançon, France. .,Research Unit EA 3920 and SFR FED 4234, University of Franche Comté, Besancon, France.
| | - Pierre-Grégoire Guinot
- Service d'Anesthésie-Réanimation Chirurgicale, centre hospitalier universitaire de Dijon, Dijon, France
| | - Matthieu Schmidt
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France
| | - Guillaume Besch
- Service d'Anesthésie-Réanimation Chirurgicale, centre hospitalier universitaire de Besançon, Besançon, France.,Research Unit EA 3920 and SFR FED 4234, University of Franche Comté, Besancon, France
| | - Gael Piton
- Service de Réanimation Médicale, centre hospitalier universitaire de Besançon, Besançon, France.,Research Unit EA 3920 and SFR FED 4234, University of Franche Comté, Besancon, France
| | - Andrea Perrotti
- Service de Chirurgie Cardiaque, centre hospitalier universitaire de Besançon, Besançon, France.,Research Unit EA 3920 and SFR FED 4234, University of Franche Comté, Besancon, France
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Antoine Kimmoun
- Service de Médecine Intensive Réanimation, centre hospitalier universitaire de Nancy Brabois, Vandœuvre-lès-Nancy, France
| | - Gilles Capellier
- Service de Réanimation Médicale, centre hospitalier universitaire de Besançon, Besançon, France.,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Clayton, Australia.,Research Unit EA 3920 and SFR FED 4234, University of Franche Comté, Besancon, France
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Crescioli E, Krejberg KU, Klitgaard TL, Mølgaard Nielsen F, Barbateskovic M, Skrubbeltrang C, Møller MH, Schjørring OL, Rasmussen BS. Long-term effects of lower versus higher oxygenation levels in adult ICU patients - a systematic review. Acta Anaesthesiol Scand 2022; 66:910-922. [PMID: 35749059 PMCID: PMC9540426 DOI: 10.1111/aas.14107] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/01/2022] [Accepted: 06/16/2022] [Indexed: 11/28/2022]
Abstract
Background Oxygen therapy is a common treatment in the intensive care unit (ICU) with both potentially desirable and undesirable long‐term effects. This systematic review aimed to assess the long‐term outcomes of lower versus higher oxygenation strategies in adult ICU survivors. Methods We included randomised clinical trials (RCTs) comparing lower versus higher oxygen supplementation or oxygenation strategies in adults admitted to the ICU. We searched major electronic databases and trial registers. We included all non‐mortality long‐term outcomes. Prespecified co‐primary outcomes were the long‐term cognitive function measures, the overall score of any valid health‐related quality of life (HRQoL) evaluation, standardised 6‐min walk test, and lung diffusion capacity. The protocol was published and prospectively registered in the PROSPERO database (CRD42021223630). Results The review included 17 RCTs comprising 6592 patients, and six trials with 825 randomised patients reported one or more outcomes of interest. We observed no difference in cognitive evaluation via Telephone Interview for Cognitive Status (one trial, 409 patients) (mean score: 30.6 ± 4.5 in the lower oxygenation group vs. 30.4 ± 4.3 in the higher oxygenation group). The trial was judged at overall high risk of bias and the certainty of evidence was very low. Any difference was neither observed in HRQoL measured via EuroQol 5 dimensions 5 level questionnaire and EQ Visual Analogue Score (one trial, 499 patients) (mean score: 70.1 ± 22 in the lower oxygenation group vs. 67.6 ± 22.4 in the higher oxygenation group). The trial was judged as having high risk of bias, the certainty of evidence was very low. No trial reported neither the standardised 6‐min walk test nor lung diffusion test. Conclusion The evidence is very uncertain about the effect of a lower versus a higher oxygenation strategy on both the cognitive function and HRQoL. A lower versus a higher oxygenation strategy may have a little to no effect on both outcomes but the certainty of evidence is very low. No evidence was found for the effects on the standardised 6‐min walking test and diffusion capacity test.
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Affiliation(s)
- Elena Crescioli
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - Thomas Lass Klitgaard
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Frederik Mølgaard Nielsen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Marija Barbateskovic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Capital Region of Denmark, Denmark
| | | | - Morten Hylander Møller
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Olav Lilleholt Schjørring
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Bodil Steen Rasmussen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Resuscitation guideline highlights. Curr Opin Crit Care 2022; 28:284-289. [PMID: 35653249 DOI: 10.1097/mcc.0000000000000933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review was to give an overview of the most significant updates in resuscitation guidelines and provide some insights into the new topics being considered in upcoming reviews. RECENT FINDINGS Recent updates to resuscitation guidelines have highlighted the importance of the earlier links in the chain-of-survival aimed to improve early recognition, early cardiopulmonary resuscitation (CPR) and defibrillation. Empowering lay rescuers with the support of emergency medical dispatchers or telecommunicators and engaging the community through dispatching volunteers and Automated External Defibrillators, are considered key in improving cardiac arrest outcomes. Novel CPR strategies such as passive insufflation and head-up CPR are being explored, but lack high-certainty evidence. Increased focus on survivorship also highlights the need for more evidence based guidance on how to facilitate the necessary follow-up and rehabilitation after cardiac arrest. Many of the systematic and scoping reviews performed within cardiac arrest resuscitation domains identifies significant knowledge gaps on key elements of our resuscitation practices. There is an urgent need to address these gaps to further improve survival from cardiac arrest in all settings. SUMMARY A continuous evidence evaluation process for resuscitation after cardiac arrest is triggered by new evidence or request by the resuscitation community, and provides more current and relevant guidance for clinicians.
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Chen WT, Tsai MS, Huang CH, Chang WT, Chen WJ. Protocolized Post-Cardiac Arrest Care with Targeted Temperature Management. ACTA CARDIOLOGICA SINICA 2022; 38:391-399. [PMID: 35673335 PMCID: PMC9121749 DOI: 10.6515/acs.202205_38(3).20211220a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 12/20/2021] [Indexed: 06/15/2023]
Abstract
Improvements in teamwork and resuscitation science have considerably increased the success rate of cardiopulmonary resuscitation. Cerebral injury, myocardial dysfunction, systemic ischemia and reperfusion response, and precipitating pathology after the return of spontaneous circulation (ROSC) constitute post-cardiac arrest syndrome. Because the entire body is involved in cardiac arrest and the early post-arrest period, protocolized post-arrest care consisting of cardiovascular optimization, ventilation and oxygenation adjustment, coronary revascularization, targeted temperature management (TTM), and control of seizures and blood sugar would benefit survival and neurological outcomes. Emergent coronary angiography is suggested for cardiac arrest survivors suspected of having ST-elevation myocardial infarction, however the superiority of culprit or complete revascularization in patients with multivessel coronary lesions remains undetermined. High-quality TTM should be considered for comatose patients who are successfully resuscitated from cardiac arrest, however the optimal target temperature may depend on the severity of their condition. The optimal timing for making prognostication should be no earlier than 72 h after rewarming in TTM patients, and 72 h following ROSC in non-TTM patients. To predict neurological recovery correctly may need the use of several prognostic tools together, including clinical neurological examinations, brain images, neurological studies and biomarkers.
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Affiliation(s)
| | | | | | | | - Wen-Jone Chen
- Department of Emergency Medicine
- Department of Internal Medicine (Cardiology division), National Taiwan University Medical College and Hospital, Taipei, Taiwan
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Francoeur CL, Lauzier F, Brassard P, Turgeon AF. Near Infrared Spectroscopy for Poor Grade Aneurysmal Subarachnoid Hemorrhage-A Concise Review. Front Neurol 2022; 13:874393. [PMID: 35518206 PMCID: PMC9062216 DOI: 10.3389/fneur.2022.874393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
Delayed cerebral ischemia (DCI) disproportionately affects poor grade aneurysmal subarachnoid hemorrhage (aSAH) patients. An unreliable neurological exam and the lack of appropriate monitoring leads to unrecognized DCI, which in turn is associated with severe long-term deficits and higher mortality. Near Infrared Spectroscopy (NIRS) offers simple, continuous, real time, non-invasive cerebral monitoring. It provides regional cerebral oxygen saturation (c-rSO2), which reflects the balance between cerebral oxygen consumption and supply. Reports have demonstrated a good correlation with other cerebral oxygen and blood flow monitoring, and credible cerebrovascular reactivity indices were also derived from NIRS signals. Multiple critical c-rSO2 values have been reported in aSAH patients, based on various thresholds, duration, variation from baseline or cerebrovascular reactivity indices. Some were associated with vasospasm, some with DCI and others with clinical outcomes. However, the poor grade aSAH population has not been specifically studied and no randomized clinical trial has been published. The available literature does not support a specific NIRS-based intervention threshold to guide diagnostic or treatment in aSAH patients. We review herein the fundamental basic concepts behind NIRS technology, relationship of c-rSO2 to other brain monitoring values and their potential clinical interpretation. We follow with a critical evaluation of the use of NIRS in the aSAH population, more specifically its ability to diagnose vasospasm, to predict DCI and its association to outcome. In summary, NIRS might offer significant potential for poor grade aSAH in the future. However, current evidence does not support its use in clinical decision-making, and proper technology evaluation is required.
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Affiliation(s)
- Charles L. Francoeur
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), Centre Hospitalier Universitaire (CHU) de Québec—Université Laval Research Centre, Université Laval, Québec City, QC, Canada
- Department of Anesthesiology and Critical Care, CHU de Québec—Université Laval, Critical Care Division, Québec City, QC, Canada
- Critical Care Medicine Service, CHU de Québec—Université Laval, Québec City, QC, Canada
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), Centre Hospitalier Universitaire (CHU) de Québec—Université Laval Research Centre, Université Laval, Québec City, QC, Canada
- Department of Anesthesiology and Critical Care, CHU de Québec—Université Laval, Critical Care Division, Québec City, QC, Canada
- Critical Care Medicine Service, CHU de Québec—Université Laval, Québec City, QC, Canada
| | - Patrice Brassard
- Department of Kinesiology, Faculty of Medicine, Université Laval, Québec City, QC, Canada
- Research Center of the Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, QC, Canada
| | - Alexis F. Turgeon
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), Centre Hospitalier Universitaire (CHU) de Québec—Université Laval Research Centre, Université Laval, Québec City, QC, Canada
- Department of Anesthesiology and Critical Care, CHU de Québec—Université Laval, Critical Care Division, Québec City, QC, Canada
- Critical Care Medicine Service, CHU de Québec—Université Laval, Québec City, QC, Canada
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Kashiura M, Yasuda H, Kishihara Y, Tominaga K, Nishihara M, Hiasa KI, Tsutsui H, Moriya T. Association between short-term neurological outcomes and extreme hyperoxia in patients with out-of-hospital cardiac arrest who underwent extracorporeal cardiopulmonary resuscitation: a retrospective observational study from a multicenter registry. BMC Cardiovasc Disord 2022; 22:163. [PMID: 35410132 PMCID: PMC9003952 DOI: 10.1186/s12872-022-02598-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 03/28/2022] [Indexed: 01/14/2023] Open
Abstract
Background To investigate the impact of hyperoxia that developed immediately after extracorporeal membrane oxygenation (ECMO)-assisted cardiopulmonary resuscitation (ECPR) on patients’ short-term neurological outcomes after out-of-hospital cardiac arrest (OHCA). Methods This study retrospectively analyzed data from the Japanese OHCA registry from June 2014 to December 2017. We analyzed adult patients (≥ 18 years) who had undergone ECPR. Eligible patients were divided into the following three groups based on their initial partial pressure of oxygen in arterial blood (PaO2) levels after ECMO pump-on: normoxia group, PaO2 ≤ 200 mm Hg; moderate hyperoxia group, 200 mm Hg < PaO2 ≤ 400 mm Hg; and extreme hyperoxia group, PaO2 > 400 mm Hg. The primary and secondary outcomes were 30-day favorable neurological outcomes. Logistic regression statistical analysis model of 30-day favorable neurological outcomes was performed after adjusting for multiple propensity scores calculated using pre-ECPR covariates and for confounding factors post-ECPR. Results Of the 34,754 patients with OHCA enrolled in the registry, 847 were included. The median PaO2 level was 300 mm Hg (interquartile range: 148–427 mm Hg). Among the eligible patients, 277, 313, and 257 were categorized as normoxic, moderately hyperoxic, and extremely hyperoxic, respectively. Moderate hyperoxia was not significantly associated with 30-day neurologically favorable outcomes compared with normoxia as a reference (adjusted odds ratio, 0.86; 95% confidence interval: 0.55–1.35; p = 0.51). However, extreme hyperoxia was associated with less 30-day neurologically favorable outcomes when compared with normoxia (adjusted odds ratio, 0.48; 95% confidence interval: 0.29–0.82; p = 0.007). Conclusions For patients with OHCA who received ECPR, extreme hyperoxia (PaO2 > 400 mm Hg) was associated with 30-day poor neurological outcomes. Avoidance of extreme hyperoxia may improve neurological outcomes in patients with OHCA treated with ECPR. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-022-02598-6.
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Affiliation(s)
- Masahiro Kashiura
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama-shi, Saitama, 330-8503, Japan.
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama-shi, Saitama, 330-8503, Japan
| | - Yuki Kishihara
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama-shi, Saitama, 330-8503, Japan
| | - Keiichiro Tominaga
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama-shi, Saitama, 330-8503, Japan
| | - Masaaki Nishihara
- Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan.,Kyushu University Hospital, Fukuoka, Japan
| | - Ken-Ichi Hiasa
- Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | | | - Takashi Moriya
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama-shi, Saitama, 330-8503, Japan
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Abstract
Patients admitted to intensive care often require treatment with invasive mechanical ventilation and high concentrations of oxygen. Mechanical ventilation can cause acute lung injury that may be exacerbated by oxygen therapy. Uncertainty remains about which oxygen therapy targets result in the best clinical outcomes for these patients. This review aims to determine whether higher or lower oxygenation targets are beneficial for mechanically ventilated adult patients.
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Kjaergaard J, Schmidt H, Møller JE, Hassager C. The “Blood pressure and oxygenation targets in post resuscitation care, a randomized clinical trial”: design and statistical analysis plan. Trials 2022; 23:177. [PMID: 35209951 PMCID: PMC8867659 DOI: 10.1186/s13063-022-06101-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 02/10/2022] [Indexed: 12/27/2022] Open
Abstract
Background Comatose patients admitted after resuscitation from cardiac arrest have a significant risk of poor outcome due to hypoxic brain injury. While numerous studies have investigated and challenged the target temperature as the efficacious part of the guideline endorsed Targeted Temperature Management (TTM) protocols, our knowledge and how the remaining parts of the TTM are optimized remain sparse. The present randomized trial investigated two aspects of the TTM protocol: target blood pressure during the ICU stay and oxygenation during mechanical ventilation. Furthermore, the efficacy of device-based post-TTM fever management is addressed. Methods Investigator-initiated, dual-center, randomized clinical trial in comatose OHCA patients admitted to an intensive cardiac care unit. Patients are eligible for inclusion if unconscious, older than 18 years of age, and have return of spontaneous circulation for more than 20 min. Intervention: allocation 1:1:1:1 into a group defined by (a) blood pressure targets in double-blind intervention targeting a mean arterial blood pressure of 63 or 77 mmHg and (b) restrictive (9–10 kPa) or liberal (13–14 kPa) of arterial oxygen concentration during mechanical ventilation. As a subordinate intervention, device-based active fever management is discontinued after 36 h or 72. Patients will otherwise receive protocolized standard of care according to international guidelines, including targeted temperature management at 36 °C for 24 h, sedation with fentanyl and propofol, and multimodal neuro-prognostication. Primary endpoint: Discharge from hospital in poor neurological status (Cerebral Performance category 3 or 4) or death, whichever comes first. Secondary outcomes: Time to initiation of renal replacement therapy or death, neuron-specific enolase (NSE) level at 48 h, MOCA score at day 90, Modified Ranking Scale (mRS) and CPC at 3 months, NT-pro-BNP at 90 days, eGFR and LVEF at 90 days, daily cumulated vasopressor requirement during ICU stay, and need for a combination of vasopressors and inotropic agents or mechanical circulatory support. Discussion We hypothesize that low or high target blood pressure and restrictive and liberal oxygen administration will have an impact on mortality by reducing the risk and degree of hypoxic brain injury. This will be assessment neurological outcome and biochemical and neuropsychological testing after 90 days. Trial registration ClinicalTrials.gov NCT03141099. Registered on May 2017 (retrospectively registered)
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50
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Martín-Fernández M, Heredia-Rodríguez M, González-Jiménez I, Lorenzo-López M, Gómez-Pesquera E, Poves-Álvarez R, Álvarez FJ, Jorge-Monjas P, Beltrán-DeHeredia J, Gutiérrez-Abejón E, Herrera-Gómez F, Guzzo G, Gómez-Sánchez E, Tamayo-Velasco Á, Aller R, Pelosi P, Villar J, Tamayo E. Hyperoxemia in postsurgical sepsis/septic shock patients is associated with reduced mortality. Crit Care 2022; 26:4. [PMID: 35000603 PMCID: PMC8744280 DOI: 10.1186/s13054-021-03875-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 12/20/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Despite growing interest in treatment strategies that limit oxygen exposure in ICU patients, no studies have compared conservative oxygen with standard oxygen in postsurgical patients with sepsis/septic shock, although there are indications that it may improve outcomes. It has been proven that high partial pressure of oxygen in arterial blood (PaO2) reduces the rate of surgical-wound infections and mortality in patients under major surgery. The aim of this study is to examine whether PaO2 is associated with risk of death in adult patients with sepsis/septic shock after major surgery. METHODS We performed a secondary analysis of a prospective observational study in 454 patients who underwent major surgery admitted into a single ICU. Patients were stratified in two groups whether they had hyperoxemia, defined as PaO2 > 100 mmHg (n = 216), or PaO2 ≤ 100 mmHg (n = 238) at the day of sepsis/septic shock onset according to SEPSIS-3 criteria maintained during 48 h. Primary end-point was 90-day mortality after diagnosis of sepsis. Secondary endpoints were ICU length of stay and time to extubation. RESULTS In patients with PaO2 ≤ 100 mmHg, we found prolonged mechanical ventilation (2 [8] vs. 1 [4] days, p < 0.001), higher ICU stay (8 [13] vs. 5 [9] days, p < 0.001), higher organ dysfunction as assessed by SOFA score (9 [3] vs. 7 [5], p < 0.001), higher prevalence of septic shock (200/238, 84.0% vs 145/216) 67.1%, p < 0.001), and higher 90-day mortality (37.0% [88] vs. 25.5% [55], p = 0.008). Hyperoxemia was associated with higher probability of 90-day survival in a multivariate analysis (OR 0.61, 95%CI: 0.39-0.95, p = 0.029), independent of age, chronic renal failure, procalcitonin levels, and APACHE II score > 19. These findings were confirmed when patients with severe hypoxemia at the time of study inclusion were excluded. CONCLUSIONS Oxygenation with a PaO2 above 100 mmHg was independently associated with lower 90-day mortality, shorter ICU stay and intubation time in critically ill postsurgical sepsis/septic shock patients. Our findings open a new venue for designing clinical trials to evaluate the boundaries of PaO2 in postsurgical patients with severe infections.
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Affiliation(s)
- Marta Martín-Fernández
- Department of Medicine, Toxicology and Dermatology, University of Valladolid, Valladolid, Spain
- BioCritic, Group for Biomedical Research in Critical Care Medicine, Valladolid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - María Heredia-Rodríguez
- BioCritic, Group for Biomedical Research in Critical Care Medicine, Valladolid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Anaesthesiology and Critical Care, Hospital Clínico Universitario de Salamanca, Salamanca, Spain
| | | | - Mario Lorenzo-López
- BioCritic, Group for Biomedical Research in Critical Care Medicine, Valladolid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Anaesthesiology and Critical Care, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Estefanía Gómez-Pesquera
- BioCritic, Group for Biomedical Research in Critical Care Medicine, Valladolid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Anaesthesiology and Critical Care, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Rodrigo Poves-Álvarez
- BioCritic, Group for Biomedical Research in Critical Care Medicine, Valladolid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Anaesthesiology and Critical Care, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - F. Javier Álvarez
- BioCritic, Group for Biomedical Research in Critical Care Medicine, Valladolid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Pharmacology, University of Valladolid, Valladolid, Spain
| | - Pablo Jorge-Monjas
- BioCritic, Group for Biomedical Research in Critical Care Medicine, Valladolid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Anaesthesiology and Critical Care, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | - Eduardo Gutiérrez-Abejón
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Pharmacology, University of Valladolid, Valladolid, Spain
| | - Francisco Herrera-Gómez
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Transplantation Center, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Gabriella Guzzo
- Transplantation Center, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Esther Gómez-Sánchez
- BioCritic, Group for Biomedical Research in Critical Care Medicine, Valladolid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Anaesthesiology and Critical Care, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Álvaro Tamayo-Velasco
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Hematology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Rocío Aller
- Department of Medicine, Toxicology and Dermatology, University of Valladolid, Valladolid, Spain
- BioCritic, Group for Biomedical Research in Critical Care Medicine, Valladolid, Spain
- Department of Gastroenterology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- IRCCS for Oncology and Neurosciences, San Martino Policlinico Hospital, Genoa, Italy
| | - Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Research Unit, Hospital Universitario Dr. Negrín, Barranco de la Ballena s/n, 4th Floor-South Wing, 35019 Las Palmas de Gran Canaria, Spain
- Li Ka Shing Knowledge Institute at St. Michael’s Hospital, Toronto, ON Canada
| | - Eduardo Tamayo
- BioCritic, Group for Biomedical Research in Critical Care Medicine, Valladolid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Anaesthesiology and Critical Care, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
- Department of Surgery, University of Valladolid, Valladolid, Spain
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