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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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2
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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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3
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Ho I, Kuo M, Hsu P, Lee I, Hsu T, Lin Y, Huang C. The impacts of anemia burden on clinical outcomes in patients with out-of-hospital cardiac arrest. Clin Cardiol 2024; 47:e24175. [PMID: 37872851 PMCID: PMC10777437 DOI: 10.1002/clc.24175] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/09/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND Out-of-hospital cardiac arrest (OHCA) has low survival rates, and few patients achieve a desirable neurological outcome. Anemia is common among OHCA patients and has been linked to worse outcomes, but its impact following the return of spontaneous circulation (ROSC) is unclear. This study examines the relationship between anemia burden and clinical outcomes in OHCA patients. HYPOTHESIS Higher anemia burden after ROSC may be related to higher mortality and worse neurologic outcomes. METHODS Patients who experienced OHCA and had ROSC were enrolled retrospectively. Anemia burden was defined as the area under curve from the target hemoglobin level over a 72-h period after OHCA. Hemoglobin level was measured at 12-h intervals. The clinical outcomes of the study included mortality and neurological outcomes at Day 30. RESULTS The study enrolled 258 nontraumatic OHCA patients who achieved ROSC between January 2017 and December 2021. Among the 162 patients who survived more than 72 h, a higher anemia burden, specifically target hemoglobin levels below 7 (hazard ratio [HR]: 1.129, 95% confidence interval [CI]: 1.013-1.259, p = .029), 8 (HR: 1.099, 95% CI: 1.014-1.191, p = .021), and 9 g/dL (HR: 1.066, 95% CI: 1.001-1.134, p = .046) was associated with higher 30-day mortality. Additionally, anemia burden with target hemoglobin levels below 7 (HR: 1.129, 95% CI: 1.016-1.248; p = .024) and 8 g/dL (HR: 1.088; 95% CI: 1.008-1.174, p = .031) was linked to worse neurological outcomes. CONCLUSIONS Anemia burden predicts 30-day mortality and neurological outcomes in OHCA patients who survive more than 72 h. Maintaining higher hemoglobin levels within the first 72 h after ROSC may improve short-term outcomes.
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Affiliation(s)
- I‐Wei Ho
- Division of Cardiology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan
| | - Ming‐Jen Kuo
- Division of Cardiology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan
- School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Pai‐Feng Hsu
- Division of Cardiology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan
- School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Healthcare and Services CenterTaipei Veterans General HospitalTaipeiTaiwan
| | - I‐Hsin Lee
- Department of EmergencyTaipei Veterans General HospitalTaipeiTaiwan
| | - Teh‐Fu Hsu
- Department of EmergencyTaipei Veterans General HospitalTaipeiTaiwan
| | - Yenn‐Jiang Lin
- Division of Cardiology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan
- School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Heart Rhythm CenterTaipei Veterans General HospitalTaipeiTaiwan
| | - Chin‐Chou Huang
- Division of Cardiology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan
- School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Institute of Pharmacology, School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
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4
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Hou H, Pang L, Zhao L, Liu Z, Xing JH. Hemoglobin as a prognostic marker for neurological outcomes in post-cardiac arrest patients: a meta-analysis. Sci Rep 2023; 13:18531. [PMID: 37898729 PMCID: PMC10613227 DOI: 10.1038/s41598-023-45818-5] [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: 08/26/2023] [Accepted: 10/24/2023] [Indexed: 10/30/2023] Open
Abstract
The aim of this study was to investigate the relationship between serum level of hemoglobin and neurological outcomes following cardiac arrest. Relevant studies were identified by searching electronic databases including PubMed, Web of Science, Cochrane Library, and Embase from June 2012 through April 2023. Articles were rigorously reviewed for their study inclusion and exclusion criteria. Pooled effect date was determined using the standardized mean difference (SMD) and 95% confidence intervals (CI). The Newcastle-Ottawa Scale was used to evaluate study quality. Subgroup analyses were conducted to determine confounding factors affecting patient outcomes. Study heterogeneity, sensitivity, and publication bias were also determined.This meta-analysis included 11 studies involving 2519 patients. Our results suggest that high serum level of hemoglobin may improve neurological prognosis(SMD = 0.60, 95%CI = 0.49-0.71, I2 = 10.85). The findings of this study indicate that serum level of hemoglobin may be associated with better neurological prognosis, perhaps an appropriate increase in serum haemoglobin levels can improve the neurological prognosis of patients in cardiac arrest.
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Affiliation(s)
- Hongxiang Hou
- Department of Emergency, the First Hospital of Jilin University, Xinmin Street 1, Chaoyang District, Changchun, China
| | - Li Pang
- Department of Emergency, the First Hospital of Jilin University, Xinmin Street 1, Chaoyang District, Changchun, China
| | - Liang Zhao
- Rehabilitation Department, the First Hospital of Jilin University, Changchun, China
| | - Zuolong Liu
- Department of Emergency, the First Hospital of Jilin University, Xinmin Street 1, Chaoyang District, Changchun, China
| | - Ji-Hong Xing
- Department of Emergency, the First Hospital of Jilin University, Xinmin Street 1, Chaoyang District, Changchun, China.
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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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6
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Sekhon MS, Stukas S, Hirsch-Reinshagen V, Thiara S, Schoenthal T, Tymko M, McNagny KM, Wellington C, Hoiland R. Neuroinflammation and the immune system in hypoxic ischaemic brain injury pathophysiology after cardiac arrest. J Physiol 2023. [PMID: 37639379 DOI: 10.1113/jp284588] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 08/15/2023] [Indexed: 08/31/2023] Open
Abstract
Hypoxic ischaemic brain injury after resuscitation from cardiac arrest is associated with dismal clinical outcomes. To date, most clinical interventions have been geared towards the restoration of cerebral oxygen delivery after resuscitation; however, outcomes in clinical trials are disappointing. Therefore, alternative disease mechanism(s) are likely to be at play, of which the response of the innate immune system to sterile injured tissue in vivo after reperfusion has garnered significant interest. The innate immune system is composed of three pillars: (i) cytokines and signalling molecules; (ii) leucocyte migration and activation; and (iii) the complement cascade. In animal models of hypoxic ischaemic brain injury, pro-inflammatory cytokines are central to propagation of the response of the innate immune system to cerebral ischaemia-reperfusion. In particular, interleukin-1 beta and downstream signalling can result in direct neural injury that culminates in cell death, termed pyroptosis. Leucocyte chemotaxis and activation are central to the in vivo response to cerebral ischaemia-reperfusion. Both parenchymal microglial activation and possible infiltration of peripherally circulating monocytes might account for exacerbation of an immunopathological response in humans. Finally, activation of the complement cascade intersects with multiple aspects of the innate immune response by facilitating leucocyte activation, further cytokine release and endothelial activation. To date, large studies of immunomodulatory therapies have not been conducted; however, lessons learned from historical studies using therapeutic hypothermia in humans suggest that quelling an immunopathological response might be efficacious. Future work should delineate the precise pathways involved in vivo in humans to target specific signalling molecules.
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Affiliation(s)
- Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
- International Centre for Repair Discoveries, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
| | - Sophie Stukas
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Veronica Hirsch-Reinshagen
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
- International Centre for Repair Discoveries, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Sonny Thiara
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
| | - Tison Schoenthal
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
| | - Michael Tymko
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
| | - Kelly M McNagny
- Department of Medical Genetics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Biomedical Research Centre, University of British Columbia, Vancouver, BC, Canada
| | - Cheryl Wellington
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
- International Centre for Repair Discoveries, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Ryan Hoiland
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
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7
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Shor L, Helviz Y, Einav S. Anemia before in-hospital cardiac arrest and survival from cardio-pulmonary resuscitation-a retrospective cohort study. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2022; 2:51. [PMID: 37386534 DOI: 10.1186/s44158-022-00080-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 11/24/2022] [Indexed: 07/01/2023]
Abstract
BACKGROUND Multiple patient-related variables have been associated with reduced rates of survival to hospital discharge (SHD) after in-hospital cardiac arrest (IHCA). As opposed to most of these, anemia may be reversible. This retrospective single-center study aims to examine the relationship between prearrest hemoglobin levels, comorbidities, and survival after cardiopulmonary resuscitation (CPR) among patients with non-traumatic IHCA. Patients were classified as anemic (hemoglobin < 10 g/dL) or non-anemic (hemoglobin ≥ 10 g/dL) based on their lowest hemoglobin measurement in the 48 h preceding the arrest. The primary outcome was SHD. The secondary outcome was return of spontaneous circulation (ROSC). RESULTS Of 1515 CPR reports screened, 773 patients were included. Half of the patients (50.5%, 390) were classified as anemic. Anemic patients had higher Charlson Comorbidity Indices (CCIs), less cardiac causes, and more metabolic causes for the arrest. An inverse association was found between CCI and lowest hemoglobin. Overall, 9.1% (70 patients) achieved SHD and 49.5% (383) achieved ROSC. Similar rates of SHD (7.3 vs. 10.7%, p = 0.118) and ROSC (49.5 vs. 51.0%, p = 0.688) were observed in anemic and non-anemic patients. These findings remained consistent after adjustment for comorbidities, in sensitivity analyses on the independent variable (i.e., hemoglobin) and on potential confounders and in subgroups based on sex or blood transfusion in the 72 h preceding the arrest. CONCLUSIONS Prearrest hemoglobin levels lower than 10 g/dL were not associated with lower rates of SHD or ROSC in IHCA patients after controlling for comorbidities. Further studies are required to confirm our findings and to establish whether post-arrest hemoglobin levels reflect the severity of the inflammatory post-resuscitation processes.
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Affiliation(s)
- Lior Shor
- Department of Military Medicine and "Tzameret", Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Medical Corps, Israel Defense Forces, Jerusalem, Israel
| | - Yigal Helviz
- General Intensive Care Unit, Shaare Zedek Medical Center, 12 Shmuel Bait St, PO Box 3235, 9103102, Jerusalem, Israel.
- Faculty of Medicine, Hebrew University, Jerusalem, Israel.
| | - Sharon Einav
- General Intensive Care Unit, Shaare Zedek Medical Center, 12 Shmuel Bait St, PO Box 3235, 9103102, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
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8
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Liu Z, Liu T, Cai J, Wu G, Wang G, Wang Y, Tang W, Yang Z, Liu Q. Quantitative magnetic resonance imaging assessment of brain injury after successful cardiopulmonary resuscitation in a rat model of asphyxia cardiac arrest. Brain Imaging Behav 2021; 16:270-280. [PMID: 34296380 DOI: 10.1007/s11682-021-00500-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2021] [Indexed: 12/22/2022]
Abstract
The aim of this study was to use dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and diffusion-weighted magnetic resonance imaging (DWI) to measure changes in blood-brain barrier (BBB) permeability and cerebral edema over time in a rat model of asphyxial cardiac arrest (ACA). ACA was established by endotracheal tube clamping. Male rats were randomized into a sham group (n = 5) and three ACA groups (n = 18). After return of spontaneous circulation (ROSC), the rats were randomized to perform DWI and DCE-MRI exam in the 6 h, 24 h and 72 h timepoint (ROSC + 6 h, ROSC + 24 h, and ROSC + 72 h). Results shows that fifteen of 18 animals achieved successful resuscitation in the ACA groups. The average apparent diffusion coefficient(ADC) value of the whole brain in ROSC + 6 h was markedly lower than those of the sham, ROSC + 24 h, and ROSC + 72 h. The aquaporin-4(AQP4) score in ROSC + 6 h was significantly higher than those in the other groups, which were negatively correlated with the ADC values. The ratio of whole brain to masseter muscle of volume transfer constant (rKtrans), tissue interstitium-to-plasma rate constant(rKep), and fractional extra-cellular space volume(rVe) in ROSC + 6 h were all significantly higher than those in the sham, ROSC + 24 h, and ROSC + 72 h. The transforming growth factor β1(TGF-β1) and vascular endothelial growth factor A(VEGF-a) scores in ROSC + 6 h were significantly higher than those in the other groups, which were all positively correlated with rKtrans and rKep. In conclusions, brain injury is a frequent complication after CA and resuscitation. DWI and DCE-MRI can quantitatively evaluate brain injury in term of cerebral edema and BBB permeability after successful CPR.
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Affiliation(s)
- Zhifeng Liu
- The Fourth Affiliated Hospital of Guanzhou Medical University, Guangzhou, 511300, China.,Zengcheng District People's Hospital of Guangzhou, Guangzhou, 511300, China
| | - Tangchun Liu
- Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yan Jiang Xi Road, Guangzhou, 510120, China
| | - Jinhui Cai
- The Fourth Affiliated Hospital of Guanzhou Medical University, Guangzhou, 511300, China.,Zengcheng District People's Hospital of Guangzhou, Guangzhou, 511300, China.,The Seventh Affiliated Hospital, Sun Yat-Sen University, 628 Zhenyuan Road, Xinhu Street, Guangming New District, Shenzhen, 518107, Guangdong, China
| | - Gongfa Wu
- The Fourth Affiliated Hospital of Guanzhou Medical University, Guangzhou, 511300, China.,Zengcheng District People's Hospital of Guangzhou, Guangzhou, 511300, China
| | - Guangyi Wang
- Guangdong Provincial People's Hospital, Guangzhou, 510080, China
| | - Yue Wang
- Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yan Jiang Xi Road, Guangzhou, 510120, China
| | - Wanchun Tang
- Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yan Jiang Xi Road, Guangzhou, 510120, China.,Weil Institute of Emergency and Critical Care Research, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Zhengfei Yang
- Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yan Jiang Xi Road, Guangzhou, 510120, China. .,Weil Institute of Emergency and Critical Care Research, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA.
| | - Qingyu Liu
- The Seventh Affiliated Hospital, Sun Yat-Sen University, 628 Zhenyuan Road, Xinhu Street, Guangming New District, Shenzhen, 518107, Guangdong, China.
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9
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Hoiland RL, Ainslie PN, Wellington CL, Cooper J, Stukas S, Thiara S, Foster D, Fergusson N, Conway EM, Menon DK, Gooderham PA, Hirsch-Reinshagen V, Griesdale D, Sekhon M. Brain Hypoxia Is Associated With Neuroglial Injury in Humans Post-Cardiac Arrest. Circ Res 2021; 129:583-597. [PMID: 34287000 PMCID: PMC8376277 DOI: 10.1161/circresaha.121.319157] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Supplemental Digital Content is available in the text. Secondary brain hypoxia portends significant mortality in ischemic brain diseases; yet, our understanding of hypoxic ischemic brain injury (HIBI) pathophysiology in humans remains rudimentary.
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Affiliation(s)
- Ryan L Hoiland
- Health and Exercise Sciences, University of British Columbia Okanagan, CANADA
| | | | | | | | - Sophie Stukas
- Pathology and Laboratory Medicine, University of British Columbia, CANADA
| | - Sonny Thiara
- Critical Care Medicine, University of British Columbia
| | - Denise Foster
- Critical Care Medicine, University of British Columbia, CANADA
| | | | - Edward M Conway
- Centre for Blood Research, University of British Columbia, CANADA
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10
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Schriefl C, Schoergenhofer C, Ettl F, Poppe M, Clodi C, Mueller M, Grafeneder J, Jilma B, Magnet IAM, Buchtele N, Boegl MS, Holzer M, Sterz F, Schwameis M. Change of Hemoglobin Levels in the Early Post-cardiac Arrest Phase Is Associated With Outcome. Front Med (Lausanne) 2021; 8:639803. [PMID: 34179033 PMCID: PMC8219926 DOI: 10.3389/fmed.2021.639803] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 05/17/2021] [Indexed: 11/18/2022] Open
Abstract
Background: The post-cardiac arrest (CA) phase is characterized by high fluid requirements, endothelial activation and increased vascular permeability. Erythrocytes are large cells and may not leave circulation despite massive capillary leak. We hypothesized that dynamic changes in hemoglobin concentrations may reflect the degree of vascular permeability and may be associated with neurologic function after CA. Methods: We included patients ≥18 years, who suffered a non-traumatic CA between 2013 and 2018 from the prospective Vienna Clinical Cardiac Arrest Registry. Patients without return of spontaneous circulation (ROSC), with extracorporeal life support, with any form of bleeding, undergoing surgery, receiving transfusions, without targeted temperature management or with incomplete datasets for multivariable analysis were excluded. The primary outcome was neurologic function at day 30 assessed by the Cerebral Performance Category scale. Differences of hemoglobin concentrations at admission and 12 h after ROSC were calculated and associations with neurologic function were investigated by uni- and multivariable logistic regression. Results: Two hundred and seventy-five patients were eligible for analysis of which 143 (52%) had poor neurologic function. For every g/dl increase in hemoglobin from admission to 12 h the odds of poor neurologic function increased by 26% (crude OR 1.26, 1.07–1.49, p = 0.006). The effect remained unchanged after adjustment for fluid balance and traditional prognostication markers (adjusted OR 1.27, 1.05–1.54, p = 0.014). Conclusion: Increasing hemoglobin levels in spite of a positive fluid balance may serve as a surrogate parameter of vascular permeability and are associated with poor neurologic function in the early post-cardiac arrest period.
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Affiliation(s)
- Christoph Schriefl
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Florian Ettl
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Michael Poppe
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Christian Clodi
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Matthias Mueller
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Juergen Grafeneder
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | | | - Nina Buchtele
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | | | - Michael Holzer
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Fritz Sterz
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Michael Schwameis
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
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11
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Zama Cavicchi F, Iesu E, Franchi F, Nobile L, Annoni F, Vincent JL, Scolletta S, Creteur J, Taccone FS. Low hemoglobin and venous saturation levels are associated with poor neurological outcomes after cardiac arrest. Resuscitation 2020; 153:202-208. [PMID: 32592732 DOI: 10.1016/j.resuscitation.2020.06.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 06/14/2020] [Accepted: 06/16/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Hemoglobin (Hb) is a main determinant of tissue oxygen delivery and anemia could be particularly harmful in post-anoxic brain injury. The aim of this study was to evaluate the association of Hb and venous Hb oxygen saturation (SvO2/ScvO2) with long-term neurological outcome in patients admitted after cardiac arrest (CA). METHODS Analysis of adult CA patients admitted to the Department of Intensive Care of the Erasme University Hospital (Brussels, Belgium) over 9 years. We retrieved all data concerning CA characteristics as well as Hb during the first 48 h since injury as well as the need for red blood cells transfusions (RBCT). Minimum Hb and Hb oxygen saturation values were recorded. Neurological outcome was evaluated 3 months after CA. Unfavorable neurological outcome (UO) was defined as a Cerebral Performance Categories (CPC) score of 3-5. RESULTS We treated 414 patients patients with CA, including 231 (56%) out-of-hospital cardiac arrest (OHCA) and 158 (38%) with an initial shockable rhythm. Median Hb concentration on admission was 12.0 [9.9-13.7] g/dL and the lowest Hb concentration was 10.0 [8.1-11.0] g/dL; 127 patients (31%) received at least one RBCT. Hb oxygen saturation on admission was 67 [59-74]%, while the lowest value was 60 [53-68]%. Low Hb and Hb oxygen saturation values were independently associated with UO; the optimal cut-off to predict UO was <9.9 g/dL and <60%, respectively. CONCLUSIONS Low hemoglobin values and low values of oxygen venous saturation are significantly associated with unfavorable neurological outcome in adult patients resuscitated from cardiac arrest.
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Affiliation(s)
- Federica Zama Cavicchi
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Enrica Iesu
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Federico Franchi
- Department of Emergency Medicine, Surgery and Neurosciences, Intensive Care Unit, Università di Siena, Siena, Italy
| | - Leda Nobile
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Filippo Annoni
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Sabino Scolletta
- Department of Emergency Medicine, Surgery and Neurosciences, Intensive Care Unit, Università di Siena, Siena, Italy
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
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12
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Demaret P, Karam O, Labreuche Bst J, Chiusolo F, Mayordomo Colunga J, Erickson S, Nellis ME, Perez MH, Ray S, Tucci M, Willems A, Duhamel A, Lebrun F, Loeckx I, Mulder A, Leteurtre S. How 217 Pediatric Intensivists Manage Anemia at PICU Discharge: Online Responses to an International Survey. Pediatr Crit Care Med 2020; 21:e342-e353. [PMID: 32217901 DOI: 10.1097/pcc.0000000000002307] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To describe the management of anemia at PICU discharge by pediatric intensivists. DESIGN Self-administered, online, scenario-based survey. SETTING PICUs in Australia/New Zealand, Europe, and North America. SUBJECTS Pediatric intensivists. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Respondents were asked to report their decisions regarding RBC transfusions, iron, and erythropoietin prescription to children ready to be discharged from PICU, who had been admitted for hemorrhagic shock, cardiac surgery, craniofacial surgery, and polytrauma. Clinical and biological variables were altered separately in order to assess their effect on the management of anemia. Two-hundred seventeen responses were analyzed. They reported that the mean (± SEM) transfusion threshold was a hemoglobin level of 6.9 ± 0.09 g/dL after hemorrhagic shock, 7.6 ± 0.10 g/dL after cardiac surgery, 7.0 ± 0.10 g/dL after craniofacial surgery, and 7.0 ± 0.10 g/dL after polytrauma (p < 0.001). The most important increase in transfusion threshold was observed in the presence of a cyanotic heart disease (mean increase ranging from 1.80 to 2.30 g/dL when compared with baseline scenario) or left ventricular dysfunction (mean increase, 1.41-2.15 g/dL). One third of respondents stated that they would not prescribe iron at PICU discharge, regardless of the hemoglobin level or the baseline scenario. Most respondents (69.4-75.0%, depending on the scenario) did not prescribe erythropoietin. CONCLUSIONS Pediatric intensivists state that they use restrictive transfusion strategies at PICU discharge similar to those they use during the acute phase of critical illness. Supplemental iron is less frequently prescribed than RBCs, and prescription of erythropoietin is uncommon. Optimal management of post-PICU anemia is currently unknown. Further studies are required to highlight the consequences of this anemia and to determine appropriate management.
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Affiliation(s)
- Pierre Demaret
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHC, Liège, Belgium.,Univ. Lille, EA 2694 - Santé Publique: épidémiologie et qualité des soins, F-59000 Lille, France
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, VA
| | - Julien Labreuche Bst
- Univ. Lille, CHU Lille, EA 2694 - Santé publique: épidémiologie et qualité des soins, F-59000 Lille, France
| | - Fabrizio Chiusolo
- Anesthesia and Critical Care, Bambino Gesù Children's Hospital, Rome, Italy
| | - Juan Mayordomo Colunga
- Sección de Cuidados Intensivos Pediátricos, Área de Gestión Clínica de Pediatría, Hospital Universitario Central de Asturias, Oviedo, Spain.,CIBER-Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.,Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | - Simon Erickson
- Division of Pediatric Critical Care, Princess Margaret Hospital, Perth, WA, Australia
| | - Marianne E Nellis
- Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital - Weill Cornell Medicine, New York, NY
| | - Marie-Hélène Perez
- Pediatric Intensive Care Unit, Department of Pediatrics, University Hospital of Lausanne, Lausanne, Switzerland
| | - Samiran Ray
- Pediatric Intensive Care Unit, Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
| | - Marisa Tucci
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Sainte-Justine Hospital and Université de Montréal, Montreal, QC, Canada
| | - Ariane Willems
- Pediatric Intensive Care Unit, Department of Intensive Care, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Alain Duhamel
- Univ. Lille, CHU Lille, EA 2694 - Santé publique: épidémiologie et qualité des soins, F-59000 Lille, France
| | - Frédéric Lebrun
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHC, Liège, Belgium
| | - Isabelle Loeckx
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHC, Liège, Belgium
| | - André Mulder
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHC, Liège, Belgium
| | - Stéphane Leteurtre
- Univ. Lille, EA 2694 - Santé Publique: épidémiologie et qualité des soins, F-59000 Lille, France.,CHU Lille, Pediatric Intensive Care Unit, CHU Lille, F-59000 Lille, France
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13
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Xie D, Ge X, Ma Y, Tang J, Wang Y, Zhu Y, Gao C, Pan S. Clemastine improves hypomyelination in rats with hypoxic-ischemic brain injury by reducing microglia-derived IL-1β via P38 signaling pathway. J Neuroinflammation 2020; 17:57. [PMID: 32061255 PMCID: PMC7023767 DOI: 10.1186/s12974-019-1662-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 11/26/2019] [Indexed: 12/31/2022] Open
Abstract
Background Microglia activation is associated with the development of hypoxic–ischemic brain injury (HIBI). Neuroinflammation suppression might be a suitable therapeutic target in hypoxic oligodendrocyte injury. This study aims to determine whether clemastine can improve hypomyelination by suppressing the activated microglia and promoting the maturation of oligodendrocyte progenitor cells (OPCs) in HIBI. Methods A bilateral common carotid artery occlusion (BCCAO) rat model that received continuous intraperitoneal injection (1 mg/kg) for 14 days was employed to elaborate the neuroprotection effects of clemastine. Interleukin-1β (IL-1β), nod-like receptor protein 3 (NLRP3), histamine H1 receptor, and OPC differentiation levels in the corpus callosum were measured. Primary cultured OPCs and co-culture of microglia and OPCs were used to explore the link between microglia activation and hypomyelination. Data were evaluated by one-way ANOVA with Fisher’s protected least significant difference test. Results Clemastine treatment could reverse hypomyelination and restrain the upregulation of IL-1β and NLRP3 in the corpus callosum of BCCAO rats. Primary cultured OPCs treated with IL-1β showed failed maturation. However, clemastine could also reverse the OPC maturation arrest by activating the extracellular signal-regulated kinase (ERK) signaling pathway. Co-culture of microglia and OPCs with oxygen glucose deprivation treatment exhibited IL-1β and NLRP3 upregulation. Clemastine could downregulate NLRP3 and IL-1β and reverse hypomyelination by inhibiting the p38 signaling pathway. Conclusions Clemastine could restrain microglia activation, improve axonal hypomyelination in BCCAO rats, and thus might be a viable strategy to inhibit hypomyelination in the corpus callosum of patients with HIBI.
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Affiliation(s)
- Di Xie
- Department of Emergency, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Yangpu District, Shanghai, China
| | - Xiaoli Ge
- Department of Emergency, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Yangpu District, Shanghai, China
| | - Yanli Ma
- Department of Emergency, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Yangpu District, Shanghai, China
| | - Jialong Tang
- Department of Emergency, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Yangpu District, Shanghai, China
| | - Yang Wang
- Department of Emergency, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Yangpu District, Shanghai, China
| | - Yajie Zhu
- Department of Emergency, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Yangpu District, Shanghai, China
| | - Chengjin Gao
- Department of Emergency, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Yangpu District, Shanghai, China.
| | - Shuming Pan
- Department of Emergency, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Yangpu District, Shanghai, China.
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14
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Pistoia F, Carolei A, Bodien YG, Greenfield S, Kaplan S, Sacco S, Pistarini C, Casalena A, De Tanti A, Cazzulani B, Bellaviti G, Sarà M, Giacino J. The Comorbidities Coma Scale (CoCoS): Psychometric Properties and Clinical Usefulness in Patients With Disorders of Consciousness. Front Neurol 2019; 10:1042. [PMID: 31681139 PMCID: PMC6812466 DOI: 10.3389/fneur.2019.01042] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 09/13/2019] [Indexed: 11/18/2022] Open
Abstract
Although comorbidities have a well-known impact on the functional recovery of patients with disorders of consciousness, including coma, vegetative state (VS), and minimally conscious state (MCS), a specific tool for their assessment in this challenging group of patients is lacking. For this aim, a multistep process was used to develop and validate the Comorbidities Coma Scale (CoCoS) in a sample of 162 patients with a diagnosis of coma, VS or MCS admitted to four Acute Inpatient Rehabilitation Units. To establish the psychometric properties of the scale, content validity, and internal consistency were investigated through Exploratory Factor Analysis in the whole sample (n = 162). Interrater reliability, assessed by the weighted Cohen's kappa (Kw), and concurrent validity of the scale as compared to the Greenfield Scale, assessed by ρ Spearman's correlation coefficient, were investigated in a subsample of patients (n = 52) within two of the above units. Our findings provided evidence of a good content validity of the scale, with the identification of a 12-factor structure representing the different comorbid dimensions of the target population. Inter-rater reliability was excellent in both the rehabilitation units where the assessment was made [Kw 0.98 (95% CI 0.96–0.99)]. CoCoS total scores correlated significantly with total scores of the Greenfield Scale (ρ = 0.932, 95% CI 0.89–0.96; P < 0.0001) indicating that CoCoS has concurrent validity while being more informative about the specific pattern of comorbidities of these challenging patients. The CoCos is a new tool which standardizes the approach to assessment of comorbid conditions and reliably identifies the category and severity of each comorbidity detected. It may be used for both clinical and research applications.
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Affiliation(s)
- Francesca Pistoia
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, L'Aquila, Italy
| | - Antonio Carolei
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, L'Aquila, Italy
| | - Yelena G Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital-Harvard Medical School, Boston, MA, United States.,Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Sheldon Greenfield
- Health Policy Research Institute, University of California, Irvine, Irvine, CA, United States
| | - Sherrie Kaplan
- Health Policy Research Institute, University of California, Irvine, Irvine, CA, United States
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, L'Aquila, Italy
| | - Caterina Pistarini
- Salvatore Maugeri Foundation, Scientific Institute of Nervi, Nervi, Italy
| | | | | | | | - Gianluca Bellaviti
- Salvatore Maugeri Foundation, Scientific Institute of Pavia, Pavia, Italy
| | - Marco Sarà
- Post-Coma Rehabilitative Unit, San Raffaele Hospital, Cassino, Italy
| | - Joseph Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital-Harvard Medical School, Boston, MA, United States
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15
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Han R, Zhang G, Qiao X, Guo Y, Sun L, Li J, Gao C, Sun X. α7 Nicotinic Acetylcholine Receptor Mediates the Neuroprotection of Remote Ischemic Postconditioning in a Rat Model of Asphyxial Cardiac Arrest. J Surg Res 2019; 246:6-18. [PMID: 31541709 DOI: 10.1016/j.jss.2019.07.091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 07/10/2019] [Accepted: 07/23/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND Remote ischemic postconditioning (RIPost) has been shown to reduce the ischemia-reperfusion injury of the heart and brain. However, the protection mechanisms have not yet been fully elucidated. We have observed that RIPost could alleviate the brain injury after cardiac arrest (CA). The aim of this study was to explore whether α7 nicotinic acetylcholine receptor (α7nAChR) mediates the neuroprotection of RIPost in a rat model of asphyxial CA. MATERIALS AND METHODS Asphyxial CA model was induced by occlusion of the tracheal tube for 8 min and resuscitated later. RIPost produced by three cycles of 15-min occlusion and 15-min release of the right hind limb by a tourniquet was performed respectively at the moment and the third hour after restoration of spontaneous circulation. The α7nAChR agonist PHA-543613 and the antagonist methyllycaconitine (MLA) were used to investigate the role of α7nAChR in mediating neuroprotective effects. RESULTS Results showed that α7nAChR was decreased in hippocampus and cortex after resuscitation, whereas RIPost could attenuate the reduction. The use of PHA-543613 provided neuroprotective effects against cerebral injury after CA. Furthermore, RIPost decreased the levels of neuron-specific enolase, inflammatory mediators, the number of apoptotic cells, and phosphorylation of nuclear factor-κB while increased the phosphorylation of signal transducer and activator of transcription-3. However, the above effects of RIPost were attenuated by α7nAChR antagonist methyllycaconitine. CONCLUSIONS Neuroprotection of RIPost was related with the activation of α7nAChR, which could suppress nuclear factor-κB and activate signal transducer and activator of transcription-3 in a rat asphyxial CA model.
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Affiliation(s)
- Ruili Han
- Department of Anesthesiology, The Second Affiliated Hospital of Air Force Medical University, Tangdu Hospital of Fourth Military Medical University, Xi'an, China
| | - Guihe Zhang
- Department of Anesthesiology, Daxing Hospital, Xi'an, China
| | - Xiaoli Qiao
- Department of Anesthesiology, The Fourth People's Hospital of Shaanxi Province, Xi'an, China
| | - Yu Guo
- Department of Anesthesiology, The Second Affiliated Hospital of Air Force Medical University, Tangdu Hospital of Fourth Military Medical University, Xi'an, China
| | - Li Sun
- Department of Anesthesiology, The Second Affiliated Hospital of Air Force Medical University, Tangdu Hospital of Fourth Military Medical University, Xi'an, China
| | - Jiangjing Li
- Department of Anesthesiology, The Second Affiliated Hospital of Air Force Medical University, Tangdu Hospital of Fourth Military Medical University, Xi'an, China
| | - Changjun Gao
- Department of Anesthesiology, The Second Affiliated Hospital of Air Force Medical University, Tangdu Hospital of Fourth Military Medical University, Xi'an, China.
| | - Xude Sun
- Department of Anesthesiology, The Second Affiliated Hospital of Air Force Medical University, Tangdu Hospital of Fourth Military Medical University, Xi'an, China.
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16
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Abstract
OBJECTIVE To determine the prevalence and risk markers of anemia at PICU discharge. DESIGN Bicenter retrospective cohort study. SETTING Two multidisciplinary French PICUs. PATIENTS All children admitted during a 5-year period, staying in the PICU for at least 2 days, and for whom a hemoglobin was available at PICU discharge. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patient, admission, and PICU stay characteristics were retrospectively collected in the electronic medical records of each participating PICU. Anemia was defined according to the World Health Organization criteria. Among the 3,170 patients included for analysis, 1,868 (58.9%) were anemic at discharge from PICU. The proportion of anemic children differed between age categories, whereas the median hemoglobin level did not exhibit significant variations according to age. After multivariate adjustment, anemia at PICU admission was the strongest predictor of anemia at PICU discharge, and the strength of this association varied according to age (interaction). Children anemic at PICU admission had a reduced risk of anemia at PICU discharge if transfused with RBCs during the PICU stay, if less than 6 months old, or if creatinine level at PICU admission was low. Children not anemic at PICU admission had an increased risk of anemia at PICU discharge if they were thrombocytopenic at PICU admission, if they had higher C-reactive protein levels, and if they received plasma transfusion, inotropic/vasopressor support, or mechanical ventilation during the PICU stay. CONCLUSIONS Anemia is frequent after pediatric critical illness. Anemia status at PICU admission defines different subgroups of critically ill children with specific prevalence and risk markers of anemia at PICU discharge. Further studies are required to confirm our results, to better define anemia during pediatric critical illness, and to highlight the causes of post-PICU stay anemia, its course, and its association with post-PICU outcomes.
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17
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Iiya M, Shimizu M, Takahashi K, Fujii H, Suzuki M, Yamawake N, Nishizaki M. Combination of hemoglobin and low-flow duration can predict neurological outcome in the initial phase of out-of-hospital cardiac arrest. J Crit Care 2018; 47:269-273. [DOI: 10.1016/j.jcrc.2018.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 07/02/2018] [Accepted: 07/13/2018] [Indexed: 12/31/2022]
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18
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Schulz A, Stammet P, Dierolf AM, Vögele C, Beyenburg S, Werer C, Devaux Y. Late heartbeat-evoked potentials are associated with survival after cardiac arrest. Resuscitation 2018; 126:7-13. [DOI: 10.1016/j.resuscitation.2018.02.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 01/19/2018] [Accepted: 02/09/2018] [Indexed: 12/20/2022]
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19
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Kim D, Kim SH, Park KN, Oh SH, Kim YM, Youn CS. Hemoglobin concentration is associated with neurologic outcome after cardiac arrest in patients treated with targeted temperature management. Clin Exp Emerg Med 2018; 5:150-155. [PMID: 29706055 PMCID: PMC6166041 DOI: 10.15441/ceem.17.250] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 02/14/2018] [Indexed: 01/20/2023] Open
Abstract
Objective The objective of this study was to test the hypothesis that hemoglobin concentration after return of spontaneous circulation (ROSC) is associated with neurologic outcome after cardiac arrest in patients treated with targeted temperature management. Methods We studied consecutive adult patients with out-of-hospital cardiac arrest treated with targeted temperature management between January 2009 and December 2015. We investigated the association between post ROSC hemoglobin concentrations and good neurologic outcome (defined as Cerebral Performance Category of 1 and 2) at hospital discharge using multivariate logistic regression analysis. Results A total of 246 subjects were ultimately included in this study. The mean age was 54 years (standard deviation, 17); 168 (68%) subjects were male. Eighty-seven (35%) subjects had a good neurologic outcome at hospital discharge. Hemoglobin concentrations were higher in the good outcome group than in the poor outcome group (14.4±2.0 vs. 12.8±2.5 g/dL, P<0.001). Multivariate logistic regression analysis showed that hemoglobin concentrations were associated with good neurologic outcome at hospital discharge after adjusting for other confounding factors (adjusted odds ratio, 1.186; 95% confidence interval, 1.008 to 1.395). Conclusion In post ROSC patients, hemoglobin concentrations after ROSC were associated with neurologic outcome at hospital discharge.
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Affiliation(s)
- Daesung Kim
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Soo Hyun Kim
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Kyu Nam Park
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Sang Hoon Oh
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Young Min Kim
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Chun Song Youn
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
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20
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Demaret P, Karam O, Tucci M, Lacroix J, Behal H, Duhamel A, Lebrun F, Mulder A, Leteurtre S. Anemia at pediatric intensive care unit discharge: prevalence and risk markers. Ann Intensive Care 2017; 7:107. [PMID: 29067568 PMCID: PMC5655401 DOI: 10.1186/s13613-017-0328-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 10/11/2017] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Anemia is prevalent at pediatric intensive care unit (PICU) admission and incident during PICU stay, but little is known about anemia at PICU discharge . Anemia after critical illness is an important issue because it could impact post-PICU outcome. We aimed to estimate the prevalence of anemia at PICU discharge and to determine its risk markers. METHODS This is an ancillary study of a prospective observational study on transfusion practices conducted in the PICU of a tertiary care children's hospital. All children consecutively admitted to the PICU during a 1-year period were considered for inclusion. Data were prospectively collected from medical charts, except for hemoglobin (Hb) levels at PICU and hospital discharge that were collected retrospectively. Anemia was defined by an Hb concentration below the lower limit of the normal range for age. RESULTS Among the 679 children retained for analysis, 390 (57.4%) were anemic at PICU discharge. After multivariate adjustment, anemia at PICU admission was the strongest risk marker of anemia at PICU discharge. The strength of this association varied according to age (interaction): The odds ratio (OR) (95% CI) of anemia at PICU discharge was 4.85 (1.67-14.11) for 1-5-month-old infants anemic versus not anemic at PICU admission, and it was 73.13 (13.43, 398.19) for adolescents anemic versus not anemic at PICU admission. Children admitted after a non-cardiac surgery had an increased risk of anemia at PICU discharge [OR 2.30 (1.37, 3.88), p = 0.002]. The proportion of anemic children differed between age categories, while the median Hb level did not exhibit significant variations according to age. CONCLUSIONS Anemia is highly prevalent at PICU discharge and is strongly predicted by anemia at PICU admission. The usual age-based definitions of anemia may not be relevant for critically ill children. The consequences of anemia at PICU discharge are unknown and deserve further scrutiny.
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Affiliation(s)
- Pierre Demaret
- Pediatric Intensive Care Unit, Department of Pediatrics, CHC, Liège, Belgium. .,Université de Lille, EA 2694 - Santé Publique: épidémiologie et qualité des soins, 59000, Lille, France.
| | - Oliver Karam
- Pediatric Critical Care Unit, Geneva University Hospital, Geneva, Switzerland.,Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, VA, USA
| | - Marisa Tucci
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, Canada
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, Canada
| | - Hélène Behal
- Université de Lille, EA 2694 - Santé Publique: épidémiologie et qualité des soins, Unité de Biostatistique, 59000, Lille, France
| | - Alain Duhamel
- Université de Lille, EA 2694 - Santé Publique: épidémiologie et qualité des soins, Unité de Biostatistique, 59000, Lille, France
| | - Frédéric Lebrun
- Pediatric Intensive Care Unit, Department of Pediatrics, CHC, Liège, Belgium
| | - André Mulder
- Pediatric Intensive Care Unit, Department of Pediatrics, CHC, Liège, Belgium
| | - Stéphane Leteurtre
- Université de Lille, EA 2694 - Santé Publique: épidémiologie et qualité des soins, 59000, Lille, France.,Pediatric Intensive Care Unit, CHU Lille, 59000, Lille, France
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21
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Sekhon MS, Ainslie PN, Griesdale DE. Clinical pathophysiology of hypoxic ischemic brain injury after cardiac arrest: a "two-hit" model. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:90. [PMID: 28403909 PMCID: PMC5390465 DOI: 10.1186/s13054-017-1670-9] [Citation(s) in RCA: 308] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Hypoxic ischemic brain injury (HIBI) after cardiac arrest (CA) is a leading cause of mortality and long-term neurologic disability in survivors. The pathophysiology of HIBI encompasses a heterogeneous cascade that culminates in secondary brain injury and neuronal cell death. This begins with primary injury to the brain caused by the immediate cessation of cerebral blood flow following CA. Thereafter, the secondary injury of HIBI takes place in the hours and days following the initial CA and reperfusion. Among factors that may be implicated in this secondary injury include reperfusion injury, microcirculatory dysfunction, impaired cerebral autoregulation, hypoxemia, hyperoxia, hyperthermia, fluctuations in arterial carbon dioxide, and concomitant anemia.Clarifying the underlying pathophysiology of HIBI is imperative and has been the focus of considerable research to identify therapeutic targets. Most notably, targeted temperature management has been studied rigorously in preventing secondary injury after HIBI and is associated with improved outcome compared with hyperthermia. Recent advances point to important roles of anemia, carbon dioxide perturbations, hypoxemia, hyperoxia, and cerebral edema as contributing to secondary injury after HIBI and adverse outcomes. Furthermore, breakthroughs in the individualization of perfusion targets for patients with HIBI using cerebral autoregulation monitoring represent an attractive area of future work with therapeutic implications.We provide an in-depth review of the pathophysiology of HIBI to critically evaluate current approaches for the early treatment of HIBI secondary to CA. Potential therapeutic targets and future research directions are summarized.
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Affiliation(s)
- Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Room 2438, Jim Pattison Pavilion, 2nd Floor, 855 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada. .,Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia Okanagan, Kelowna, BC, Canada.
| | - Philip N Ainslie
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Donald E Griesdale
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Room 2438, Jim Pattison Pavilion, 2nd Floor, 855 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada.,Department of Anaesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada.,Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, 899 West 12th Avenue, Vancouver, BC V5Z 1M9, Canada
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