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Bian W, Bian W, Li Y, Feng X, Song M, Zhou P. Hypothermia may reduce mortality and improve neurologic outcomes in adult patients treated with VA-ECMO: A systematic review and meta-analysis. Am J Emerg Med 2023; 70:163-170. [PMID: 37327682 DOI: 10.1016/j.ajem.2023.05.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/08/2023] [Accepted: 05/21/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND VA-ECMO can greatly reduce mortality in critically ill patients, and hypothermia attenuates the deleterious effects of ischemia-reperfusion injury. We aimed to study the effects of hypothermia on mortality and neurological outcomes in VA-ECMO patients. METHODS A systematic search of the PubMed, Embase, Web of Science, and Cochrane Library databases was performed from the earliest available date to 31 December 2022. The primary outcome was discharge or 28-day mortality and favorable neurological outcomes in VA-ECMO patients, and the secondary outcome was bleeding risk in VA-ECMO patients. The results are presented as odds ratios (ORs) and 95% confidence intervals (CIs). Based on the heterogeneity assessed by the I2 statistic, meta-analyses were performed using random or fixed-effects models. GRADE methodology was used to rate the certainty in the findings. RESULTS A total of 27 articles (3782 patients) were included. Hypothermia (33-35 °C) lasting at least 24 h can significantly reduce discharge or 28-day mortality (OR, 0.45; 95% CI, 0.33-0.63; I2 = 41%) and significantly improve favorable neurological outcomes (OR, 2.08; 95% CI, 1.66-2.61; I2 = 3%) in VA-ECMO patients. Additionally, there was no risk associated with bleeding (OR, 1.15; 95% CI, 0.86-1.53; I2 = 12%). In our subgroup analysis according to in-hospital or out-of-hospital cardiac arrest, hypothermia reduced short-term mortality in both VA-ECMO-assisted in-hospital (OR, 0.30; 95% CI, 0.11-0.86; I2 = 0.0%) and out-of-hospital cardiac arrest (OR, 0.41; 95% CI, 0.25-0.69; I2 = 52.3%). Out-of-hospital cardiac arrest patients assisted by VA-ECMO for favorable neurological outcomes were consistent with the conclusions of this paper (OR, 2.10; 95% CI, 1.63-2.72; I2 = 0.5%). CONCLUSIONS Our results show that mild hypothermia (33-35 °C) lasting at least 24 h can greatly reduce short-term mortality and significantly improve favorable short-term neurologic outcomes in VA-ECMO-assisted patients without bleeding-related risks. As the grade assessment indicated that the certainty of the evidence was relatively low, hypothermia as a strategy for VA-ECMO-assisted patient care may need to be treated with caution.
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Affiliation(s)
- Wentao Bian
- School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Wenkai Bian
- Xi'an Radio Research Institute, Xian, Shaanxi Province, China
| | - Yi Li
- Emergency Intensive Care Unit, Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
| | - Xuanlin Feng
- Emergency Intensive Care Unit, Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
| | - Menglong Song
- Emergency Intensive Care Unit, Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
| | - Ping Zhou
- Emergency Intensive Care Unit, Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China.
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Left Ventricular Function Changes Induced by Moderate Hypothermia Are Rapidly Reversed After Rewarming-A Clinical Study. Crit Care Med 2021; 50:e52-e60. [PMID: 34259452 DOI: 10.1097/ccm.0000000000005170] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Targeted temperature management (32-36°C) is used for neuroprotection in cardiac arrest survivors. The isolated effects of hypothermia on myocardial function, as used in clinical practice, remain unclear. Based on experimental results, we hypothesized that hypothermia would reversibly impair diastolic function with less tolerance to increased heart rate in patients with uninsulted hearts. DESIGN Prospective clinical study, from June 2015 to May 2018. SETTING Cardiothoracic surgery operation room, Oslo University Hospital. PATIENTS Twenty patients with left ventricular ejection fraction greater than 55%, undergoing ascending aorta graft-replacement connected to cardiopulmonary bypass were included. INTERVENTIONS Left ventricular function was assessed during reduced cardiopulmonary bypass support at 36°C, 32°C prior to graft-replacement, and at 36°C postsurgery. Electrocardiogram, hemodynamic, and echocardiographic recordings were made at spontaneous heart rate and 90 beats per minute at comparable loading conditions. MEASUREMENTS AND MAIN RESULTS Hypothermia decreased spontaneous heart rate, and R-R interval was prolonged (862 ± 170 to 1,156 ± 254 ms, p < 0.001). Although systolic and diastolic fractions of R-R interval were preserved (0.43 ± 0.07 and 0.57 ± 0.07), isovolumic relaxation time increased and diastolic filling time was shortened. Filling pattern changed from early to late filling. Systolic function was preserved with unchanged myocardial strain and stroke volume index, but cardiac index was reduced with maintained mixed venous oxygen saturation. At increased heart rate, systolic fraction exceeded diastolic fraction (0.53 ± 0.05 and 0.47 ± 0.05) with diastolic impairment. Strain and stroke volume index were reduced, the latter to 65% of stroke volume index at spontaneous heart rate. Cardiac index decreased, but mixed venous oxygen saturation was maintained. After rewarming, myocardial function was restored. CONCLUSIONS In patients with normal left ventricular function, hypothermia impaired diastolic function. At increased heart rate, systolic function was subsequently reduced due to impeded filling. Changes in left ventricular function were rapidly reversed after rewarming.
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Chen S, Lachance BB, Gao L, Jia X. Targeted temperature management and early neuro-prognostication after cardiac arrest. J Cereb Blood Flow Metab 2021; 41:1193-1209. [PMID: 33444088 PMCID: PMC8142127 DOI: 10.1177/0271678x20970059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Targeted temperature management (TTM) is a recommended neuroprotective intervention for coma after out-of-hospital cardiac arrest (OHCA). However, controversies exist concerning the proper implementation and overall efficacy of post-CA TTM, particularly related to optimal timing and depth of TTM and cooling methods. A review of the literature finds that optimizing and individualizing TTM remains an open question requiring further clinical investigation. This paper will summarize the preclinical and clinical trial data to-date, current recommendations, and future directions of this therapy, including new cooling methods under investigation. For now, early induction, maintenance for at least 24 hours, and slow rewarming utilizing endovascular methods may be preferred. Moreover, timely and accurate neuro-prognostication is valuable for guiding ethical and cost-effective management of post-CA coma. Current evidence for early neuro-prognostication after TTM suggests that a combination of initial prediction models, biomarkers, neuroimaging, and electrophysiological methods is the optimal strategy in predicting neurological functional outcomes.
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Affiliation(s)
- Songyu Chen
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Brittany Bolduc Lachance
- Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Liang Gao
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiaofeng Jia
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Orthopedics, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Anatomy and Neurobiology, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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李 建, 吴 文, 杜 邦, 徐 凤, 李 宁, 列 锦, 何 晓. [Impact of mild hypothermia therapy on hemodynamics during the induction stage in neonates with moderate to severe hypoxic-ischemic encephalopathy]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021; 23:133-137. [PMID: 33627206 PMCID: PMC7921535 DOI: 10.7499/j.issn.1008-8830.2009083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 12/16/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To study the changes in hemodynamics during the induction stage of systemic mild hypothermia therapy in neonates with moderate to severe hypoxic-ischemic encephalopathy (HIE). METHODS A total of 21 neonates with HIE who underwent systemic mild hypothermia therapy in the Department of Neonatology, Dongguan Children's Hospital Affiliated to Guangdong Medical University, from July 2017 to April 2020 were enrolled. The rectal temperature of the neonates was lowered to 34℃ after 1-2 hours of induction and maintained at this level for 72 hours using a hypothermia blanket. The impedance method was used for noninvasive hemodynamic monitoring, and the changes in heart rate (HR), mean arterial pressure (MAP), stroke volume (SV), cardiac output (CO), cardiac index (CI), and total peripheral resistance (TPR) from the start of hypothermia induction to the achievement of target rectal temperature (34℃). Blood lactic acid (LAC) and resistance index (RI) of the middle cerebral artery were recorded simultaneously. RESULTS The 21 neonates with HIE had a mean gestational age of (39.6±1.1) weeks, a mean birth weight of (3 439±517) g, and a mean 5-minute Apgar score of 6.8±2.0. From the start of hypothermia induction to the achievement of target rectal temperature (34℃), there were significant reductions in HR, CO, and CI (P < 0.05), while there was no significant change in SV and MAP (P > 0.05). There was a significant increase in TPR (P < 0.05) and a significant reduction in LAC (P < 0.05), while there was no significant change in RI (P > 0.05). CONCLUSIONS The systemic mild hypothermia therapy may have a significant impact on hemodynamics in neonates with moderate to severe HIE, and continuous hemodynamic monitoring is required during the treatment.
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Affiliation(s)
- 建波 李
- />广东医科大学附属东莞儿童医院新生儿科, 广东东莞 523325Department of Neonatology, Dongguan Children's Hospital Affiliated to Guangdong Medical University, Dongguan, Guangdong 523325, China
| | - 文燊 吴
- />广东医科大学附属东莞儿童医院新生儿科, 广东东莞 523325Department of Neonatology, Dongguan Children's Hospital Affiliated to Guangdong Medical University, Dongguan, Guangdong 523325, China
| | - 邦 杜
- />广东医科大学附属东莞儿童医院新生儿科, 广东东莞 523325Department of Neonatology, Dongguan Children's Hospital Affiliated to Guangdong Medical University, Dongguan, Guangdong 523325, China
| | - 凤丹 徐
- />广东医科大学附属东莞儿童医院新生儿科, 广东东莞 523325Department of Neonatology, Dongguan Children's Hospital Affiliated to Guangdong Medical University, Dongguan, Guangdong 523325, China
| | - 宁 李
- />广东医科大学附属东莞儿童医院新生儿科, 广东东莞 523325Department of Neonatology, Dongguan Children's Hospital Affiliated to Guangdong Medical University, Dongguan, Guangdong 523325, China
| | - 锦艮 列
- />广东医科大学附属东莞儿童医院新生儿科, 广东东莞 523325Department of Neonatology, Dongguan Children's Hospital Affiliated to Guangdong Medical University, Dongguan, Guangdong 523325, China
| | - 晓光 何
- />广东医科大学附属东莞儿童医院新生儿科, 广东东莞 523325Department of Neonatology, Dongguan Children's Hospital Affiliated to Guangdong Medical University, Dongguan, Guangdong 523325, China
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Lee DH, Lee BK, Cho YS, Jung YH, Lee HY, You YH, Lee DH, Kim YH, Cha KC, Jeung KW. Slow Heart Rate Within 72 Hours After Cardiac Arrest Is Associated with Good Neurologic Outcome in Out-of-Hospital Cardiac Arrest Survivors Who Undergo Targeted Temperature Management with 33°C. Ther Hypothermia Temp Manag 2020; 11:145-154. [PMID: 32634049 DOI: 10.1089/ther.2020.0021] [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] [Indexed: 11/12/2022] Open
Abstract
We aimed to verify whether slow heart rate (HR) is associated with neurologic outcome and the factors that can contribute to the development of bradycardia in out-of-hospital cardiac arrest (OHCA) survivors who underwent targeted temperature management (TTM). We extracted the data of comatose adult OHCA survivors who underwent TTM between October 2015 and December 2018 from the prospective multicenter registry. Data on HR recorded every 6 hours within 72 hours after return of spontaneous circulation and calculated minimal, mean, and maximal HR and time to the lowest HR were obtained. HR <50 bpm was defined as bradycardia. The primary outcome was a 6-month neurologic outcome based on Pittsburgh-Glasgow Cerebral Performance Category Scale. Of the 814 included patients, 508 (62.4%) had poor neurologic outcome and 197 (24.2%) had bradycardia. Bradycardia (odds ratio [OR], 0.574; 95% confidence interval [CI], 0.362-0.192), minimal HR (OR, 1.023; 95% CI, 1.008-1.037), and mean HR (OR, 1.016; 95% CI, 1.002-1.030) were independently associated with poor neurologic outcome, but not maximal HR and time to the lowest HR. Preexisting arrhythmia (OR, 2.067; 95% CI, 1.037-4.118), renal disease (OR, 2.028; 95% CI, 1.153-3.567), cardiac etiology (OR, 1.526; 95% CI, 1.045-2.228), downtime (OR, 0.985; 95% CI, 0.974-0.996), and serum lactate levels (OR, 0.936; 95% CI, 0.900-0.974) were independently associated with bradycardia. Bradycardia and decreased mean and minimal HR were independently associated with good neurologic outcomes. Bradycardia was associated with preexisting arrhythmia, renal disease, cardiac etiology, shorter downtime, and lower serum lactate level.
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Affiliation(s)
- Dong Hun Lee
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Yong Soo Cho
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Yong Hun Jung
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Hyoung Youn Lee
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Yeon Ho You
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Dong Hoon Lee
- Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Yong Hwan Kim
- Department of Emergency Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Kyoung-Chul Cha
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Kyung Woon Jeung
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
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Resuscitation highlights in 2019. Resuscitation 2020; 148:234-241. [DOI: 10.1016/j.resuscitation.2020.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 02/02/2020] [Indexed: 11/22/2022]
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Qin S, Chen MH, Fang W, Tan XF, Xie L, Yang YG, Qin T, Li N. Cerebral protection of epigallocatechin gallate (EGCG) via preservation of mitochondrial function and ERK inhibition in a rat resuscitation model. DRUG DESIGN DEVELOPMENT AND THERAPY 2019; 13:2759-2768. [PMID: 31496652 PMCID: PMC6689542 DOI: 10.2147/dddt.s215358] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 07/19/2019] [Indexed: 12/16/2022]
Abstract
Background Various and opposite roles of epigallocatechin gallate (EGCG) have been reported in different studies. We aimed to investigate how EGCG affects the cerebral injury in a cardiac arrest/cardiopulmonary resuscitation (CA/CPR) model of rat. Methods The rats which were subjected to CA/CPR randomly received low dose of EGCG (3 mg/kg, Low-EGCG group, n=16), high dose of EGCG (9 mg/kg, High-EGCG group, n=16) and equal volume of 0.9% saline solution (NS group, n=16) at the first minute after return of spontaneous circulation (ROSC). The rats underwent anesthesia and intubation were defined as Sham group (n=16). Twenty-four hours after ROSC, neural defect score (NDS), ROS fluorescence intensity, degree of mitochondrial permeability transition pore (mPTP) opening, ATP contents and mitochondrial ATP synthase expression were evaluated in the four groups. The expression of extracellular signal-regulated kinase (ERK) activity and cleaved-caspase 3 were also detected by Western blot. Results CA/CPR induced severe ischemia-reperfusion injury (IRI), resulted in mitochondrial dysfunction and upregulated phosphorylation of ERK. EGCG dose-dependently alleviated the IRI after CA/CPR, inhibited ERK activity and restored mitochondrial function and, as indicated by improved NDS, reduced ROS level, decreased mPTP opening, elevated ATP content, increased ATPase expression and downregulated cleaved-caspase 3 level. Conclusion EGCG alleviated global cerebral IRI by restoring mitochondrial dysfunction and ERK modulation in a rat CA/CPR model, which might make it a potential candidate agent against IRI after CA/CPR in the future. Further study is needed to determine whether higher dosage of EGCG might aggravate cerebral IRI post-CA/CPR.
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Affiliation(s)
- Sina Qin
- Intensive Care Unit, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Meng-Hua Chen
- Intensive Care Unit, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Wei Fang
- Intensive Care Unit, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Xiao-Feng Tan
- Intensive Care Unit, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Lu Xie
- Intensive Care Unit, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Ye-Gui Yang
- Intensive Care Unit, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Tao Qin
- Intensive Care Unit, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Nuo Li
- Intensive Care Unit, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China
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