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Molina M, Fernández-Ruiz M, Gonzalez E, Cabrera J, Praga M, Rodriguez A, Tejido-Sánchez A, Medina-Polo J, Mateos A, Rubio-Chacón C, Sanchez A, Pla A, Andrés A. Prophylactic Anticoagulation Reduces the Risk of Kidney Graft Venous Thrombosis in Recipients From Uncontrolled Donation After Circulatory Death Donors With High Renal Resistive Index. Transplant Direct 2024; 10:e1649. [PMID: 38817627 PMCID: PMC11139466 DOI: 10.1097/txd.0000000000001649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/13/2024] [Accepted: 03/21/2024] [Indexed: 06/01/2024] Open
Abstract
Background Uncontrolled donation after circulatory death (uDCD) increases organ availability for kidney transplantation (KT) at the expense of a higher risk of primary graft nonfunction (PNF). At least half of the cases of PNF are secondary to graft venous thrombosis. The potential benefit from prophylactic anticoagulation in this scenario remains unclear. Methods In this single-center retrospective study we compared 2 consecutive cohorts of KT from uDCD with increased (≥0.8) renal resistive index (RRI) in the Doppler ultrasound examination performed within the first 24-72 h after transplantation: 36 patients did not receive anticoagulation ("nonanticoagulation group") and 71 patients underwent prophylactic anticoagulation until normalization of RRI in follow-up Doppler examinations ("anticoagulation group"). Results Anticoagulation was initiated at a median of 2 d (interquartile range, 2-3) after transplantation and maintained for a median of 12 d (interquartile range, 7-18). In 4 patients (5.6%), anticoagulation had to be prematurely stopped because of the development of a hemorrhagic complication. In comparison with the nonanticoagulation group, recipients in the anticoagulation group had a lower 2-wk cumulative incidence of graft venous thrombosis (19.4% versus 0.0%; P < 0.001) and PNF (19.4% versus 2.8%; P = 0.006). The competing risk analysis with nonthrombotic causes of PNF as the competitive event confirmed the higher risk of graft thrombosis in the nonanticoagulation group (P = 0.0001). The anticoagulation group had a higher incidence of macroscopic hematuria (21.1% versus 5.6%; P = 0.049) and blood transfusion requirements (39.4% versus 19.4%; P = 0.050) compared with the nonanticoagulation group. No graft losses or deaths were attributable to complications potentially associated with anticoagulation. Conclusions Early initiation of prophylactic anticoagulation in selected KT recipients from uDCD with an early Doppler ultrasound RRI of ≥0.8 within the first 24-72 h may reduce the incidence of graft venous thrombosis as a cause of PNF.
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Affiliation(s)
- Maria Molina
- Department of Nephrology, Hospital Universitario “12 de Octubre”, Madrid, Spain
- Department of Nephrology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- REMAR-IGTP Group, Germans Trias i Pujol Research Institute (IGTP), Can Ruti Campus, Badalona, Spain
- Department of Medicine, School of Medicine, Universitat Autonoma de Barcelona, Barcelona, Spain
- RICORS2040 (Kidney Disease), Badalona, Barcelona, Spain
| | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario “12 de Octubre”, Instituto de Investigación Hospital “12 de Octubre” (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Esther Gonzalez
- Department of Nephrology, Hospital Universitario “12 de Octubre”, Madrid, Spain
- Instituto de Investigación Hospital “12 de Octubre” (imas12), Madrid, Spain
| | - Jimena Cabrera
- Programa de Prevención y Tratamiento de las Glomerulopatías, Centro de Nefrología, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
- Department of Nephrology, Hospital Evangelico, Montevideo, Uruguay
| | - Manuel Praga
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
- Instituto de Investigación Hospital “12 de Octubre” (imas12), Madrid, Spain
| | - Alfredo Rodriguez
- Department of Urology, Hospital Universitario “12 de Octubre”, Instituto de Investigación Hospital “12 de Octubre” (imas12), Madrid, Spain
| | - Angel Tejido-Sánchez
- Department of Urology, Hospital Universitario “12 de Octubre”, Instituto de Investigación Hospital “12 de Octubre” (imas12), Madrid, Spain
| | - Jose Medina-Polo
- Department of Urology, Hospital Universitario “12 de Octubre”, Instituto de Investigación Hospital “12 de Octubre” (imas12), Madrid, Spain
| | - Alonso Mateos
- Servicio de Urgencia Médica de la Comunidad de Madrid, SUMMA 112
- Facultad de medicina, Universidad Francisco de Vitoria, Madrid, Spain
| | | | - Angel Sanchez
- Department of Interventional Radiology, Hospital Universitario “12 de Octubre”, Instituto de Investigación Hospital “12 de Octubre” (imas12), Madrid, Spain
| | - Ana Pla
- Department of Interventional Radiology, Hospital Universitario “12 de Octubre”, Instituto de Investigación Hospital “12 de Octubre” (imas12), Madrid, Spain
| | - Amado Andrés
- Department of Nephrology, Hospital Universitario “12 de Octubre”, Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
- Instituto de Investigación Hospital “12 de Octubre” (imas12), Madrid, Spain
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Taha D, Drop JG, Wildschut ED, De Hoog M, van Ommen CH, Reis Miranda DD. Evaluation of an aPTT guided versus a multimodal heparin monitoring approach in patients on extra corporeal membrane oxygenation: A retrospective cohort study. Perfusion 2024:2676591241253474. [PMID: 38739366 DOI: 10.1177/02676591241253474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024]
Abstract
INTRODUCTION Bleeding and thrombotic complications are common in extracorporeal membrane oxygenation (ECMO) patients and are associated with increased mortality and morbidity. The optimal anticoagulation monitoring protocol in these patients is unknown. This study aims to compare the incidence of thrombotic and hemorrhagic complications before and after a protocol change. In addition, the association between hemostatic complications, coagulation tests and risk factors is evaluated. METHODS This is a retrospective single center cohort study of adult ECMO patients. We collected demographics, ECMO parameters and coagulation test results. Outcomes of the aPTT guided and multimodal protocol, including aPTT, anti-Xa assay and rotational thromboelastometry were compared and the association between coagulation tests, risk factors and hemostatic complications was determined using a logistic regression analysis for repeated measurements. RESULTS In total, 250 patients were included, 138 in the aPTT protocol and 112 in the multimodal protocol. The incidence of thrombosis (aPTT: 14%; multimodal: 12%) and bleeding (aPTT: 36%; multimodal: 40%), did not significantly differ between protocols. In the aPTT guided protocol, the aPTT was associated with thrombosis (Odds Ratio [OR] 1.015; 95% confidence interval [CI] 1.004-1.027). In both protocols, surgical interventions were risk factors for bleeding and thrombotic complications (aPTT: OR 93.2, CI 39.9-217.6; multimodal OR 17.5, CI 6.5-46.9). DISCUSSION The incidence of hemostatic complications was similar between both protocols and surgical interventions were a risk factor for hemostatic complications. Results from this study help to elucidate the role of coagulation tests and risk factors in predicting hemostatic complications in patients undergoing ECMO support.
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Affiliation(s)
- Diman Taha
- Department of Adult Intensive Care, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Joppe G Drop
- Department of Pediatric Hematology, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Enno D Wildschut
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Matthijs De Hoog
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
| | - C Heleen van Ommen
- Department of Pediatric Hematology, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
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Benoit JL, Hogan AN, Connelly KM, McMullan JT. Intra-arrest blood-based biomarkers for out-of-hospital cardiac arrest: A scoping review. J Am Coll Emerg Physicians Open 2024; 5:e13131. [PMID: 38500598 PMCID: PMC10945310 DOI: 10.1002/emp2.13131] [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: 10/30/2023] [Revised: 01/29/2024] [Accepted: 02/02/2024] [Indexed: 03/20/2024] Open
Abstract
Objective Blood-based biomarkers play a central role in the diagnosis and treatment of critically ill patients, yet none are routinely measured during the intra-arrest phase of out-of-hospital cardiac arrest (OHCA). Our objective was to describe methodological aspects, sources of evidence, and gaps in research surrounding intra-arrest blood-based biomarkers for OHCA. Methods We used scoping review methodology to summarize existing literature. The protocol was designed a priori following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews. Inclusion criteria were peer-reviewed scientific studies on OHCA patients with at least one blood draw intra-arrest. We excluded in-hospital cardiac arrest and animal studies. There were no language, date, or study design exclusions. We conducted an electronic literature search using PubMed and Embase and hand-searched secondary literature. Data charting/synthesis were performed in duplicate using standardized data extraction templates. Results The search strategy identified 11,834 records, with 118 studies evaluating 105 blood-based biomarkers included. Only eight studies (7%) had complete reporting. The median number of studies per biomarker was 2 (interquartile range 1-4). Most studies were conducted in Asia (63 studies, 53%). Only 22 studies (19%) had blood samples collected in the prehospital setting, and only six studies (5%) had samples collected by paramedics. Pediatric patients were included in only three studies (3%). Out of eight predefined biomarker categories of use, only two were routinely assessed: prognostic (97/105, 92%) and diagnostic (61/105, 58%). Conclusions Despite a large body of literature on intra-arrest blood-based biomarkers for OHCA, gaps in methodology and knowledge are widespread.
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Affiliation(s)
- Justin L. Benoit
- Department of Emergency MedicineUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Andrew N. Hogan
- Department of Emergency MedicineUT Southwestern Medical CenterDallasTexasUSA
| | | | - Jason T. McMullan
- Department of Emergency MedicineUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
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Bae MI, Kim TH, Yoon HJ, Song SW, Min N, Lee J, Ham SY. Myocardial Injury after Non-Cardiac Surgery in Patients Who Underwent Open Repair for Abdominal Aortic Aneurysm: A Retrospective Study. J Clin Med 2024; 13:959. [PMID: 38398272 PMCID: PMC10888606 DOI: 10.3390/jcm13040959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 02/02/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Myocardial injury after non-cardiac surgery (MINS) has been known to be associated with mortality in various surgical patients; however, its prognostic role in abdominal aortic aneurysm (AAA) open repair remains underexplored. This study aimed to investigate the role of MINS as a predictor of mortality in patients who underwent AAA open repair. METHODS This retrospective study investigated 352 patients who underwent open repair for non-ruptured AAA. The predictors of 30-day and 1-year mortalities were investigated using logistic regression analysis. RESULTS MINS was diagnosed in 41% of the patients after AAA open repair in this study. MINS was an independent risk factor of 30-day mortality (odds ratio [OR]: 10.440, 95% confidence interval [CI]: 1.278-85.274, p = 0.029) and 1-year mortality (OR: 5.189, 95% CI: 1.357-19.844, p = 0.016). Kaplan-Meier survival curves demonstrated significantly lower overall survival rates in patients with MINS compared to those without MINS (p = 0.003). CONCLUSION This study revealed that MINS is a common complication after AAA open repair and is an independent risk factor of 30-day and 1-year mortalities. Patients with MINS have lower overall survival rates than those without MINS.
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Affiliation(s)
- Myung Il Bae
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (M.I.B.); (H.J.Y.); (N.M.); (J.L.)
| | - Tae-Hoon Kim
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul 03722, Republic of Korea;
| | - Hei Jin Yoon
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (M.I.B.); (H.J.Y.); (N.M.); (J.L.)
| | - Suk-Won Song
- Department of Cardiovascular Surgery, Ewha Womans University Aorta and Vascular Hospital, Seoul 07804, Republic of Korea
| | - Narhyun Min
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (M.I.B.); (H.J.Y.); (N.M.); (J.L.)
| | - Jongyun Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (M.I.B.); (H.J.Y.); (N.M.); (J.L.)
| | - Sung Yeon Ham
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (M.I.B.); (H.J.Y.); (N.M.); (J.L.)
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
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Ding X, Wang Y, Ma W, Peng Y, Huang J, Wang M, Zhu H. Development of early prediction model of in-hospital cardiac arrest based on laboratory parameters. Biomed Eng Online 2023; 22:116. [PMID: 38057823 DOI: 10.1186/s12938-023-01178-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 11/23/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND In-hospital cardiac arrest (IHCA) is an acute disease with a high fatality rate that burdens individuals, society, and the economy. This study aimed to develop a machine learning (ML) model using routine laboratory parameters to predict the risk of IHCA in rescue-treated patients. METHODS This retrospective cohort study examined all rescue-treated patients hospitalized at the First Medical Center of the PLA General Hospital in Beijing, China, from January 2016 to December 2020. Five machine learning algorithms, including support vector machine, random forest, extra trees classifier (ETC), decision tree, and logistic regression algorithms, were trained to develop models for predicting IHCA. We included blood counts, biochemical markers, and coagulation markers in the model development. We validated model performance using fivefold cross-validation and used the SHapley Additive exPlanation (SHAP) for model interpretation. RESULTS A total of 11,308 participants were included in the study, of which 7779 patients remained. Among these patients, 1796 (23.09%) cases of IHCA occurred. Among five machine learning models for predicting IHCA, the ETC algorithm exhibited better performance, with an AUC of 0.920, compared with the other four machine learning models in the fivefold cross-validation. The SHAP showed that the top ten factors accounting for cardiac arrest in rescue-treated patients are prothrombin activity, platelets, hemoglobin, N-terminal pro-brain natriuretic peptide, neutrophils, prothrombin time, serum albumin, sodium, activated partial thromboplastin time, and potassium. CONCLUSIONS We developed a reliable machine learning-derived model that integrates readily available laboratory parameters to predict IHCA in patients treated with rescue therapy.
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Affiliation(s)
- Xinhuan Ding
- Medical School of Chinese PLA, Beijing, 100853, China
- Department of Emergency, The First Medical Center, Chinese PLA General Hospital, Fuxing Road 28, Beijing, 100853, People's Republic of China
| | - Yingchan Wang
- Department of Emergency, The First Medical Center, Chinese PLA General Hospital, Fuxing Road 28, Beijing, 100853, People's Republic of China
| | - Weiyi Ma
- Medical School of Chinese PLA, Beijing, 100853, China
- Department of Emergency, The First Medical Center, Chinese PLA General Hospital, Fuxing Road 28, Beijing, 100853, People's Republic of China
| | - Yaojun Peng
- Medical School of Chinese PLA, Beijing, 100853, China
- Department of Emergency, The First Medical Center, Chinese PLA General Hospital, Fuxing Road 28, Beijing, 100853, People's Republic of China
| | - Jingjing Huang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510000, Guangdong, China
- Department of Emergency, Hainan Hospital of PLA General Hospital, Sanya, 572013, Hainan, China
| | - Meng Wang
- Medical School of Chinese PLA, Beijing, 100853, China
- Department of Emergency, The First Medical Center, Chinese PLA General Hospital, Fuxing Road 28, Beijing, 100853, People's Republic of China
| | - Haiyan Zhu
- Medical School of Chinese PLA, Beijing, 100853, China.
- Department of Emergency, The First Medical Center, Chinese PLA General Hospital, Fuxing Road 28, Beijing, 100853, People's Republic of China.
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Zhang B, McCracken BM, Mahmood CC, Leander D, Greer N, Cranford JA, Hsu CH, Tiba MH, Neumar RW, Greineder CF. Coagulofibrinolytic effects of recombinant soluble thrombomodulin in prolonged porcine cardiac arrest. Resusc Plus 2023; 16:100477. [PMID: 37811363 PMCID: PMC10550843 DOI: 10.1016/j.resplu.2023.100477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 09/08/2023] [Accepted: 09/11/2023] [Indexed: 10/10/2023] Open
Abstract
Aim To evaluate coagulofibrinolytic abnormalities and the effects of ART-123 (recombinant human thrombomodulin alpha) in a porcine model of cardiac arrest and prolonged cardiopulmonary resuscitation (CA/CPR). Methods Fifteen pigs (n = 5 per group) underwent 8 minutes of no-flow CA followed by 50 minutes of mechanical CPR, while 2 pigs underwent sham arrest. CA/CPR animals were randomized to receive saline or 1 mg/kg ART-123 pre-arrest (5 minutes prior to ventricular fibrillation) or post-arrest (2 minutes after initiation of CPR). Arterial and venous blood samples were drawn at multiple time points for blood gas analysis and measurement of plasma and whole blood markers of coagulation and fibrinolysis. Results In saline-treated CA/CPR, but not sham animals, robust and persistent activation of coagulation and fibrinolysis was observed throughout resuscitation. After 50 minutes of CPR, plasma tests and thromboelastography indicated a mix of hypercoagulability and consumptive coagulopathy. ART-123 had a robust anticoagulant effect, reducing both thrombin-antithrombin (TAT) complexes and d-dimer (p < 0.05 for each). The duration of anticoagulant effect varied depending on the timing of ART-123 administration. Similarly, ART-123 when given prior to cardiac arrest was found to have pro-fibrinolytic effects, increasing free tissue plasminogen activator (tPA, p = 0.02) and decreasing free plasminogen activator inhibitor-1 (PAI-1, p = 0.04). Conclusion A porcine model of prolonged CA/CPR reproduces many of the coagulofibrinolytic abnormalities observed in human cardiac arrest patients. ART-123 demonstrates a combination of anticoagulant and profibrinolytic effects, depending on the timing of its administration relative to cardiac arrest.
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Affiliation(s)
- Boya Zhang
- Departments of Emergency Medicine, University of Michigan, United States
- Pharmacology, University of Michigan, United States
| | - Brendan M. McCracken
- Departments of Emergency Medicine, University of Michigan, United States
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, United States
| | - Carmen Colmenero Mahmood
- Departments of Emergency Medicine, University of Michigan, United States
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, United States
| | - Danielle Leander
- Departments of Emergency Medicine, University of Michigan, United States
| | - Nicholas Greer
- Departments of Emergency Medicine, University of Michigan, United States
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, United States
| | - James A. Cranford
- Departments of Emergency Medicine, University of Michigan, United States
| | - Cindy H. Hsu
- Departments of Emergency Medicine, University of Michigan, United States
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, United States
| | - Mohamad Hakam Tiba
- Departments of Emergency Medicine, University of Michigan, United States
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, United States
| | - Robert W. Neumar
- Departments of Emergency Medicine, University of Michigan, United States
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, United States
| | - Colin F. Greineder
- Departments of Emergency Medicine, University of Michigan, United States
- Pharmacology, University of Michigan, United States
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Holzer M, Poole JE, Lascarrou JB, Fujise K, Nichol G. A Commentary on the Effect of Targeted Temperature Management in Patients Resuscitated from Cardiac Arrest. Ther Hypothermia Temp Manag 2023; 13:102-111. [PMID: 36378270 PMCID: PMC10625468 DOI: 10.1089/ther.2022.0041] [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] [Indexed: 11/16/2022] Open
Abstract
The members of the International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force have written a comprehensive summary of trials of the effectiveness of induced hypothermia (IH) or targeted temperature management (TTM) in comatose patients after cardiac arrest (CA). However, in-depth analysis of these studies is incomplete, especially since there was no significant difference in primary outcome between hypothermia versus normothermia in the recently reported TTM2 trial. We critically appraise trials of IH/TTM versus normothermia to characterize reasons for the lack of treatment effect, based on a previously published framework for what to consider when the primary outcome fails. We found a strong biologic rationale and external clinical evidence that IH treatment is beneficial. Recent TTM trials mainly included unselected patients with a high rate of bystander cardiopulmonary resuscitation. The treatment was not applied as intended, which led to a large delay in achievement of target temperature. While receiving intensive care, sedative drugs were likely used that might have led to increased neurologic damage as were antiplatelet drugs that could be associated with increased acute stent thrombosis in hypothermic patients. It is reasonable to still use or evaluate IH treatment in patients who are comatose after CA as there are multiple plausible reasons why IH compared to normothermia did not significantly improve neurologic outcome in the TTM trials.
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Affiliation(s)
- Michael Holzer
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Jeanne E. Poole
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | | | - Ken Fujise
- Harborview Medical Center, Heart Institute, University of Washington, Seattle, Washington, USA
| | - Graham Nichol
- Departments of Medicine and Emergency Medicine, University of Washington-Harborview Center for Prehospital Emergency Care, University of Washington, Seattle, Washington, USA
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VanZalen JJ, Harvey S, Hála P, Phillips A, Nakashima T, Gok E, Tiba MH, McCracken BM, Hill JE, Liao J, Jung J, Mergos J, Stacey WC, Bartlett RH, Hsu CH, Rojas-Peña A, Neumar RW. Therapeutic Effect of Argatroban During Cardiopulmonary Resuscitation and Streptokinase During Extracorporeal Cardiopulmonary Resuscitation in a Porcine Model of Prolonged Cardiac Arrest. Crit Care Explor 2023; 5:e0902. [PMID: 37181541 PMCID: PMC10174369 DOI: 10.1097/cce.0000000000000902] [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: 05/16/2023] Open
Abstract
Prolonged cardiac arrest (CA) causes microvascular thrombosis which is a potential barrier to organ reperfusion during extracorporeal cardiopulmonary resuscitation (ECPR). The aim of this study was to test the hypothesis that early intra-arrest anticoagulation during cardiopulmonary resuscitation (CPR) and thrombolytic therapy during ECPR improve recovery of brain and heart function in a porcine model of prolonged out-of-hospital CA. DESIGN Randomized interventional trial. SETTING University laboratory. SUBJECTS Swine. INTERVENTIONS In a blinded study, 48 swine were subjected to 8 minutes of ventricular fibrillation CA followed by 30 minutes of goal-directed CPR and 8 hours of ECPR. Animals were randomized into four groups (n = 12) and given either placebo (P) or argatroban (ARG; 350 mg/kg) at minute 12 of CA and either placebo (P) or streptokinase (STK, 1.5 MU) at the onset of ECPR. MEASUREMENTS AND MAIN RESULTS Primary outcomes included recovery of cardiac function measured by cardiac resuscitability score (CRS: range 0-6) and recovery of brain function measured by the recovery of somatosensory-evoked potential (SSEP) cortical response amplitude. There were no significant differences in recovery of cardiac function as measured by CRS between groups (p = 0.16): P + P 2.3 (1.0); ARG + P = 3.4 (2.1); P + STK = 1.6 (2.0); ARG + STK = 2.9 (2.1). There were no significant differences in the maximum recovery of SSEP cortical response relative to baseline between groups (p = 0.73): P + P = 23% (13%); ARG + P = 20% (13%); P + STK = 25% (14%); ARG + STK = 26% (13%). Histologic analysis demonstrated reduced myocardial necrosis and neurodegeneration in the ARG + STK group relative to the P + P group. CONCLUSIONS In this swine model of prolonged CA treated with ECPR, early intra-arrest anticoagulation during goal-directed CPR and thrombolytic therapy during ECPR did not improve initial recovery of heart and brain function but did reduce histologic evidence of ischemic injury. The impact of this therapeutic strategy on the long-term recovery of cardiovascular and neurological function requires further investigation.
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Affiliation(s)
- Jensyn J VanZalen
- Department of Surgery and Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Stephen Harvey
- Department of Surgery and Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Pavel Hála
- Department of Surgery and Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Annie Phillips
- Department of Surgery and Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Takahiro Nakashima
- Department of Surgery and Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI
- Department of Emergency Medicine and The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan Medical School, Ann Arbor, MI
| | - Emre Gok
- Department of Surgery and Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Mohamad Hakam Tiba
- Department of Emergency Medicine and The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan Medical School, Ann Arbor, MI
| | - Brendan M McCracken
- Department of Emergency Medicine and The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan Medical School, Ann Arbor, MI
| | - Joseph E Hill
- Department of Surgery and Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Jinhui Liao
- Department of Emergency Medicine and The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan Medical School, Ann Arbor, MI
| | - Joshua Jung
- Department of Surgery and Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Joshua Mergos
- Movement Science, University of Michigan School of Kinesiology, Ann Arbor, MI
| | - William C Stacey
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI
| | - Robert H Bartlett
- Department of Surgery and Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Cindy H Hsu
- Department of Emergency Medicine and The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan Medical School, Ann Arbor, MI
| | - Alvaro Rojas-Peña
- Department of Surgery and Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI
- Department of Surgery Section of Transplantation, University of Michigan Medical School, Ann Arbor, MI
| | - Robert W Neumar
- Department of Emergency Medicine and The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan Medical School, Ann Arbor, MI
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Early coagulopathy after pediatric out-of-hospital cardiac arrest: secondary analysis of a randomized clinical trial. Thromb J 2022; 20:62. [PMID: 36221135 PMCID: PMC9552408 DOI: 10.1186/s12959-022-00422-x] [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: 07/28/2022] [Accepted: 09/25/2022] [Indexed: 11/22/2022] Open
Abstract
Background To estimate the incidence, risk factors, and impact on mortality and functional outcomes for early coagulopathy after the return of spontaneous circulation (ROSC) in pediatric out-of-hospital cardiac arrest (OHCA) patients. Methods A post hoc analysis of the Therapeutic Hypothermia after Pediatric Cardiac Arrest Out-of-Hospital (THAPCA-OH) trial was conducted. Early coagulopathy was defined as presence of at least one of the following coagulation abnormalities upon admission: international standard ratio (INR), platelets, and age-adjusted activated partial thromboplastin time (APTT) within 6 h after OHCA and before therapeutic hypothermia initiation. The outcomes included 28-day mortality and functional prognosis. Multivariable logistic regression models were used to explore risk factors and association between early coagulopathy and outcomes. Results Of the 227 patients included, 152 (67%) were male and the median age was 2.3 years [interquartile range (IQR), 0.7–8.6 years]. The overall 28-day mortality was 63%. The incidence of early coagulopathy was 46%. Lower age, longer duration of chest compression, lower temperature, and higher white blood cell (WBC) upon admission increased the risk of early coagulopathy. Early coagulopathy [OR, 2.20 (95% CI, 1.12–4.39), P = 0.023] was independently associated with 28-day mortality after adjusting for confounders. Conclusions Early coagulopathy occurred in almost half of pediatric patients with OHCA. Lower age, longer duration of chest compression, lower temperature, and higher WBC increased the risk. The development of early coagulopathy was independently associated with increased mortality. Supplementary Information The online version contains supplementary material available at 10.1186/s12959-022-00422-x.
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Olausson M, Antony D, Travnikova G, Johansson M, Nayakawde NB, Banerjee D, Søfteland JM, Premaratne GU. Novel Ex-Vivo Thrombolytic Reconditioning of Kidneys Retrieved 4 to 5 Hours After Circulatory Death. Transplantation 2022; 106:1577-1588. [PMID: 34974455 PMCID: PMC9311461 DOI: 10.1097/tp.0000000000004037] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 11/09/2021] [Accepted: 11/10/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Due to organ shortage, many patients do not receive donor organs. The present novel thrombolytic technique utilizes organs from donors with uncontrolled donation after circulatory deaths (uDCD), with up to 4-5 h warm ischemia, without advanced cardiopulmonary resuscitation (aCPR) or extracorporeal circulation (EC) after death. METHODS The study group of pigs (n = 21) underwent simulated circulatory death. After 2 h, an ice slush was inserted into the abdomen. Kidneys were retrieved 4.5 h after death. Lys-plasminogen, antithrombin-III (ATIII), and alteplase (tPA) were injected through the renal arteries on the back table. Subsequent ex vivo perfusion at 15 °C was continued for 3 h, followed by 3 h with red blood cells (RBCs) at 32 °C. Perfusion outcome and histology were compared between uDCD kidneys, receiving no thrombolytic treatment (n = 8), and live donor kidneys (n = 7). The study kidneys were then transplanted into pigs as autologous grafts with a single functioning autologous kidney as the only renal support. uDCD control pigs (n = 8), receiving no ex vivo perfusion, served as controls. RESULTS Vascular resistance decreased to <200 mmHg/mL/min ( P < 0.0023) and arterial flow increased to >100 mL/100 g/min ( P < 0.00019) compared to controls. In total 13/21 study pigs survived for >10 days, while all uDCD control pigs died. Histology was preserved after reconditioning, and the creatinine level after 10 days was next to normal. CONCLUSIONS Kidneys from extended uDCD, not receiving aCPR/EC, can be salvaged using thrombolytic treatment to remove fibrin thrombi while preserving histology and enabling transplantation with a clinically acceptable early function.
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Affiliation(s)
- Michael Olausson
- Department of Transplantation, Sahlgrenska Academy, University of Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy at Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
| | - Deepti Antony
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy at Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
| | - Galina Travnikova
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy at Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
| | - Martin Johansson
- Department of Laboratory Medicine, Sahlgrenska Academy, University of Gothenburg, SE-41345 Göteborg, Sweden
| | - Nikhil B. Nayakawde
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy at Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
| | - Debashish Banerjee
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy at Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
| | - John Mackay Søfteland
- Department of Transplantation, Sahlgrenska Academy, University of Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy at Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
| | - Goditha U. Premaratne
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy at Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
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Inhaled nitric oxide improves post-cardiac arrest outcomes via guanylate cyclase-1 in bone marrow-derived cells. Nitric Oxide 2022; 125-126:47-56. [PMID: 35716999 DOI: 10.1016/j.niox.2022.06.005] [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: 05/06/2022] [Revised: 06/10/2022] [Accepted: 06/13/2022] [Indexed: 11/24/2022]
Abstract
RATIONALE Nitric oxide (NO) exerts its biological effects primarily via activation of guanylate cyclase (GC) and production of cyclic guanosine monophosphate. Inhaled NO improves outcomes after cardiac arrest and cardiopulmonary resuscitation (CPR). However, mechanisms of the protective effects of breathing NO after cardiac arrest are incompletely understood. OBJECTIVE To elucidate the mechanisms of beneficial effects of inhaled NO on outcomes after cardiac arrest. METHODS Adult male C57BL/6J wild-type (WT) mice, GC-1 knockout mice, and chimeric WT mice with WT or GC-1 knockout bone marrow were subjected to 8 min of potassium-induced cardiac arrest to determine the role of GC-1 in bone marrow-derived cells. Mice breathed air or 40 parts per million NO for 23 h starting at 1 h after CPR. RESULTS Breathing NO after CPR prevented hypercoagulability, cerebral microvascular occlusion, an increase in circulating polymorphonuclear neutrophils and neutrophil-to-lymphocyte ratio, and right ventricular dysfunction in WT mice, but not in GC-1 knockout mice, after cardiac arrest. The lack of GC-1 in bone marrow-derived cells diminished the beneficial effects of NO breathing after CPR. CONCLUSIONS GC-dependent signaling in bone marrow-derived cells is essential for the beneficial effects of inhaled NO after cardiac arrest and CPR.
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. Postreanimationsbehandlung. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00892-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Activated factor XI-antithrombin complex presenting as an independent predictor of 30-days mortality in out-of-hospital cardiac arrest patients. Thromb Res 2021; 204:1-8. [PMID: 34089982 DOI: 10.1016/j.thromres.2021.05.014] [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: 03/16/2021] [Revised: 05/05/2021] [Accepted: 05/25/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Cardiac arrest and cardiopulmonary resuscitation (CPR) are associated with activated coagulation and microvascular fibrin deposition with subsequent multiorgan failure and adverse outcome. OBJECTIVES Activated Factor XI-antithrombin (FXIa-AT) complex, activated Factor IX-antithrombin (FIXa-AT) complex and thrombin-antithrombin (TAT) complex were measured as markers of coagulation activation, and evaluated as independent prognostic indicators in out-of-hospital cardiac arrest (OHCA) patients. METHODS From February 2007 until December 2010 blood samples were collected in close approximation to CPR from patients with OHCA of assumed cardiac origin. Follow-up samples in survivors were drawn 8-12 h and 24-48 h after hospital admission. All measurements were determined by ELISA. RESULTS Thirty-seven patients presented with asystole and 77 with ventricular fibrillation as first recorded heart rhythm. At 30-days follow-up, 70 patients (61.4%) had died. All patients had elevated levels of FXIa-AT complex, FIXa-AT complex and TAT. Initial levels were significantly higher in non-survivors compared to 30-days survivors. A significant increase in risk of 30-days all-cause mortality was observed through increasing quartiles of all three biomarkers in univariate Cox regression analysis. Compared to the lowest quartile (Q1), only FXIa-AT complex levels in Q3 (HR 3.17, p = 0.011) and Q2 (HR 3.02, p = 0.016) were independently associated with all-cause mortality in the multivariable analysis. FIXa-AT complex and TAT-complex did not behave as independent predictors. CONCLUSIONS Complexes of FXIa-AT were independently associated with 30-days survival in OHCA-patients. CLINICAL TRIAL REGISTRATION ClinicalTrials. gov, NCT02886273.
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care. Intensive Care Med 2021; 47:369-421. [PMID: 33765189 PMCID: PMC7993077 DOI: 10.1007/s00134-021-06368-4] [Citation(s) in RCA: 386] [Impact Index Per Article: 128.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/08/2021] [Indexed: 12/13/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation and organ donation.
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Affiliation(s)
- Jerry P. Nolan
- University of Warwick, Warwick Medical School, Coventry, CV4 7AL UK
- Royal United Hospital, Bath, BA1 3NG UK
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
- Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W. Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC), Université Catholique de Louvain, Brussels, Belgium
- Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Division of Health Sciences, Warwick Medical School, University of Warwick, Room A108, Coventry, CV4 7AL UK
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Véronique R. M. Moulaert
- Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Markus B. Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB UK
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15
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Mariero Olasveengen T, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care. Resuscitation 2021; 161:220-269. [PMID: 33773827 DOI: 10.1016/j.resuscitation.2021.02.012] [Citation(s) in RCA: 315] [Impact Index Per Article: 105.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation, and organ donation.
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Affiliation(s)
- Jerry P Nolan
- University of Warwick, Warwick Medical School, Coventry CV4 7AL, UK; Royal United Hospital, Bath, BA1 3NG, UK.
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy; Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W Böttiger
- University Hospital of Cologne, Kerpener Straße 62, D-50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC) Université Catholique de Louvain, Brussels, Belgium; Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Room A108, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Gisela Lilja
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden
| | - Véronique R M Moulaert
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB, UK
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Relationship between D-dimer level upon emergency room arrival and the duration of cardiac arrest in patients with witnessed out-of-hospital cardiac arrest. Heart Vessels 2021; 36:731-737. [PMID: 33389066 DOI: 10.1007/s00380-020-01745-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/27/2020] [Indexed: 11/27/2022]
Abstract
In patients with out-of-hospital cardiac arrest (OHCA), the probability of resuscitation is strongly influenced by the duration of cardiac arrest, which activates the blood coagulation-fibrinolysis system. Because plasma D-dimer levels reflect activity of blood coagulation and fibrinolysis, they should increase with the duration of cardiac arrest. We evaluated 222 consecutive non-traumatic witnessed OHCA patients who underwent measurement of plasma D-dimer levels on arrival in the emergency room. Return of spontaneous circulation was achieved in 138 patients (62%), but only 42 (19%) were alive 30 days post-OHCA. D-dimer levels were elevated in 217 patients (97.7%). There was a positive correlation between plasma D-dimer levels and duration of cardiac arrest in the 222 patients (r = 0.623, p < 0.001). When the cause of OHCA was limited to cardiovascular disease, the positive correlation between level of D-dimer and the duration of cardiac arrest (r = 0.776, p < 0.001) increased.D-dimer levels were significantly lower in survivors than in non-survivors [9.5 (1.4-17.5) vs 54.2 (34.2-74.3) μg/mL, p = 0.024]. Receiver operating characteristic curve analysis showed that a cutoff value of D-dimer ≤ 10 μg/L led to sensitivity (69.0%) and specificity (72.8%) for 30 day survival (area under curve 0.75). Multivariate logistic regression analysis showed that D-dimer ≤ 10 μg/ml was an independent predictor for 30 day survival (odds ratio 4.39, 95% confidence interval 1.41-13.70; p = 0.01). D-dimer level correlates with duration of cardiac arrest, especially in OHCA patients due to cardiovascular causes, and may help physicians assess the probability of survival in OHCA patients.
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17
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Lederer W. Thrombolysis during CPR. Am J Emerg Med 2020; 46:673. [PMID: 32868141 DOI: 10.1016/j.ajem.2020.08.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 08/09/2020] [Indexed: 11/19/2022] Open
Affiliation(s)
- W Lederer
- Medical University of Innsbruck, Department of Anesthesiology and Critical Care Medicine, Anichstr. 35, 6020 Innsbruck, Austria.
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18
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Zhai Q, Feng L, Zhang H, Wu M, Wang D, Ge H, Li S, Du L, Zheng K, Li H, Liu S, Zhao J, Huai W, Ma Q. Serial disseminated intravascular coagulation score with neuron specific enolase predicts the mortality of cardiac arrest-a pilot study. J Thorac Dis 2020; 12:3573-3581. [PMID: 32802436 PMCID: PMC7399410 DOI: 10.21037/jtd-20-580] [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: 11/06/2022]
Abstract
Background Prognosis in cardiac arrest (CA) patients has been challenging. We sought to investigate prognostic value combining serial disseminated intravascular coagulation (DIC) score and neuron-specific enolase (NSE) in out-of-hospital cardiac arrest (OHCA) patients. Methods Sixty-one consecutive patients successfully resuscitated after CA were included in the analysis. DIC score and NSE levels were serially analyzed after return of spontaneous circulation (ROSC). The outcome measure was death before hospital discharge. Prognostication performance was assessed as the area under the receiver-operating characteristics curve (AUC). Hosmer-Lemeshow test was used for internal validation of predictive models. Calibration curves were drawn to visualize the results of tests. Results The NSE levels continued to increase in the first 72 h in non-survivors. In survivors, the NSE levels decreased after 48 h. Both DIC score at 48 h and NSE level at 48 h were good predictors of outcome. The AUC for predictive mortality in OHCA patients was 0.869 (95% CI, 0.781-0.956) for DIC score at 48 h combining NSE at 24 h, 0.878 (95% CI, 0.791-0.965) for DIC score at 48 h combining NSE at 48 h and 0.882 (95% CI, 0.792-0.972) for DIC score at 48 h combining NSE at 72 h, respectively. Significance of Hosmer-Lemeshow test was 0.488, 0.324, 0.011 for each combination. Conclusions Serial DIC score combined with measurement of NSE levels is a useful and accessible tool for prognostication following OHCA.
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Affiliation(s)
- Qiangrong Zhai
- Department of Emergency, Peking University Third Hospital, Beijing, China
| | - Lu Feng
- Department of Emergency, Peking University Third Hospital, Beijing, China
| | - Hua Zhang
- The Clinical Epidemiology Research Center, Peking University Third Hospital, Beijing, China
| | - Meng Wu
- Department of Emergency, Peking University Third Hospital, Beijing, China
| | - Daidai Wang
- Department of Emergency, Peking University Third Hospital, Beijing, China
| | - Hongxia Ge
- Department of Emergency, Peking University Third Hospital, Beijing, China
| | - Shu Li
- Department of Emergency, Peking University Third Hospital, Beijing, China
| | - Langfang Du
- Department of Emergency, Peking University Third Hospital, Beijing, China
| | - Kang Zheng
- Department of Emergency, Peking University Third Hospital, Beijing, China
| | - Hui Li
- Department of Emergency, Peking University Third Hospital, Beijing, China
| | - Shaoyu Liu
- Department of Emergency, Peking University Third Hospital, Beijing, China
| | - Jingjing Zhao
- Department of Emergency, Peking University Third Hospital, Beijing, China
| | - Wei Huai
- Department of Emergency, Peking University Third Hospital, Beijing, China
| | - Qingbian Ma
- Department of Emergency, Peking University Third Hospital, Beijing, China
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Yu G, Kim YJ, Kim JS, Kim SI, Ryoo SM, Ahn S, Kim WY. Prognostic value of repeated thromboelastography measurement for favorable neurologic outcome during targeted temperature management in out-of-hospital cardiac arrest survivors. Resuscitation 2020; 155:65-73. [PMID: 32755664 DOI: 10.1016/j.resuscitation.2020.07.019] [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: 03/12/2020] [Revised: 05/31/2020] [Accepted: 07/14/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cardiac arrest can activate blood coagulation, which clinically manifests as obstruction of the microcirculation and multiple organ dysfunction. Thromboelastography (TEG) provides a rapid and comprehensive assessment of hemostatic processes, but there are limited data on the use of sequential TEG values during targeted temperature management (TTM) in out-of-hospital cardiac arrest (OHCA) survivors. The aim of this study was to investigate the prognostic value of coagulopathy assessed by repeated TEG to predict neurologically intact survival. METHODS A prospective cohort of consecutive non-trauma OHCA patients who were successfully resuscitated and treated with TTM. Patients with a target temperature of 36 ℃, no TEG data, and who declined appropriate treatment were excluded. TEG was measured at three time points of TTM (initial phase, target phase, and rewarming phase). The primary outcome was 28 day favorable neurologic function, defined as a Cerebral Performance Category of 1 or 2. RESULTS A total of 125 patients (mean age, 61 years; 63.2% male) were analyzed. A favorable neurologic outcome at 28 days was seen in 40 patients (32.0%). TEG values of R and LY30 in the initial phase were significantly lower in the favorable neurologic outcome group than in the unfavorable group (5.8 vs. 8.1 and 0.1 vs. 0.7, respectively; p < 0.01). TEG values of R < 5 or LY30 < 7.5 in the initial phase were more frequently seen in the favorable outcomes group than in the unfavorable group (37.5% vs. 12.9%, p = 0.002 and 95.0% vs. 72.9%, p = 0.004, respectively). However, no significant differences were seen between the two groups in other TEG values (R, K, alpha, and MA) in the target and rewarming phases (p > 0.05 for all). Univariate analysis showed higher D-dimer levels, prothrombin time, and activated partial thromboplastin time in the unfavorable outcome group. In the multivariable analysis, TEG values of combination of R < 5 and LY30 < 7.5 in the initial phase were the only coagulation profiles seen to be independently associated with favorable neurologic outcome (OR, 4.508, 95% CI, 1.254-16.210). CONCLUSION TEG results are available within minutes, and shorted R values or the absence of prolonged LY30 values in the initial phase are an early predictor of neurologically intact survival in successfully resuscitated OHCA patients.
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Affiliation(s)
- Gina Yu
- Department of Emergency Medicine, University of Yonsei College of Medicine, Seoul, Republic of Korea
| | - Youn-Jung Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - June-Sung Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Sang-Il Kim
- Department of Emergency Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Seung Mok Ryoo
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Shin Ahn
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Won Young Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea.
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Meyer ASP, Ostrowski SR, Kjærgaard J, Frydland M, Thomsen JH, Johansson PI, Hassager C. Low dose Iloprost effect on platelet aggregation in comatose out-of-hospital cardiac arrest patients: A predefined sub-study of the ENDO-RCA randomized -phase 2- trial. J Crit Care 2020; 56:197-202. [PMID: 31945586 DOI: 10.1016/j.jcrc.2019.12.025] [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: 08/17/2019] [Revised: 12/27/2019] [Accepted: 12/27/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE This is a predefined sub-study of the Endothelial Dysfunction in Resuscitated Cardiac Arrest (ENDO-RCA) trial. We aim to investigate Iloprost, a prostacyclin analogue, safety by evaluating change in whole blood platelet aggregometry (Multiplate) in out of hospital cardiac arrest (OHCA) patients from baseline to 96-h post randomization. METHODS A randomized, placebo controlled double-blinded trial in 46 OHCA patients. Patients were allocated 1:2 to 48 h Iloprost infusion, (1 ng/kg/min) or placebo (saline infusion). Platelet aggregation was determined by platelet aggregation tests ASPI-test (arachidonic acid); TRAP-test (thrombin-receptor activating peptide (TRAP)-6; RISTO test (Ristocetin); ADP test (adenosin diphosphat). RESULTS There was no significant difference between the iloprost and placebo groups according to ASPI, TRAP, RISTO and ADP platelet aggregation assays. Further, no significant differences regarding risk of bleeding were found between groups (Risk of bleeding: ASPI <40 U; TRAP <92 U; RISTO <35 U; ADP <50 U). CONCLUSIONS In conclusion, the iloprost infusion did not influence platelet aggregation as evaluated by the ASPI, TRAP, RISTO and ADP assays. There was no increased risk of bleeding or transfusion therapy. A decline in platelet aggregation was observed for the ASPI and ADP assays during the initial 96 h after OHCA. TRIAL REGISTRATION Trial registration at clinicaltrials.gov (identifier NCT02685618) on 18-02-2016.
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Affiliation(s)
- A S P Meyer
- Section for Transfusion Medicine, Blood Bank, Rigshospitalet, 2034, Blegdamsvej 9, DK-2100 Copenhagen, Denmark; Dept. of Cardiology, Copenhagen University Rigshospitalet, 2143, Blegdamsvej 9, DK-2100 Copenhagen, Denmark.
| | - S R Ostrowski
- Section for Transfusion Medicine, Blood Bank, Rigshospitalet, 2034, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - J Kjærgaard
- Dept. of Cardiology, Copenhagen University Rigshospitalet, 2143, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - M Frydland
- Dept. of Cardiology, Copenhagen University Rigshospitalet, 2143, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - J H Thomsen
- Dept. of Cardiology, Copenhagen University Rigshospitalet, 2143, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - P I Johansson
- Section for Transfusion Medicine, Blood Bank, Rigshospitalet, 2034, Blegdamsvej 9, DK-2100 Copenhagen, Denmark; Dept. of Surgery, University of Texas Health Medical School, 6410 Fannin Street UPB 1100, Houston, TX 77030, USA
| | - C Hassager
- Dept. of Cardiology, Copenhagen University Rigshospitalet, 2143, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
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Saito T, Hayakawa M, Honma Y, Mizugaki A, Yoshida T, Katabami K, Wada T, Maekawa K. Relationship Between Severity of Fibrinolysis Based on Rotational Thromboelastometry and Conventional Fibrinolysis Markers. Clin Appl Thromb Hemost 2020; 26:1076029620933003. [PMID: 32571089 PMCID: PMC7427038 DOI: 10.1177/1076029620933003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The association between severity of fibrinolysis, ascertained by rotational thromboelastometry to diagnose hyperfibrinolysis in patients with out-of-hospital cardiac arrest (OHCA), and conventional fibrinolysis markers (ie, tissue-plasminogen activator [t-PA], plasminogen, α2-plasmin inhibitor [α2-PI], and plasminogen activator inhibitor [PAI]) with key roles in the fibrinolytic system was investigated. This prospective observational study included 5 healthy volunteers and 35 patients with OHCA from the Hokkaido University Hospital. Blood samples were drawn immediately upon admission to the emergency department. Assessments of the extrinsic pathway using tissue factor activation (EXTEM) and of fibrinolysis by comparison with EXTEM after aprotinin addition (APTEM) were undertaken. Conventional coagulation and fibrinolysis markers were measured in the stored plasma samples. Significant hyperfibrinolysis observed in EXTEM disappeared in APTEM. Patients exhibited significantly higher levels of fibrinogen/fibrin degradation products, plasmin–α2-PI complex, and t-PA but lower levels of fibrinogen, plasminogen, and α2-PI than healthy controls. The PAI level was unchanged. Fibrinolytic parameters of EXTEM correlated with levels of lactate and conventional fibrinolysis markers, especially t-PA. Increased t-PA activity and decreased plasminogen and α2-PI significantly correlated with increased severity of fibrinolysis (hyperfibrinolysis).
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Affiliation(s)
- Tomoyo Saito
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Yoshinori Honma
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Asumi Mizugaki
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Tomonao Yoshida
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Kenichi Katabami
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Takeshi Wada
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Kunihiko Maekawa
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan
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Abstract
OBJECTIVES To evaluate the ramifications of steroid use during postarrest care. DESIGN Retrospective observational population-based study enrolled patients during years 2004-2011 with 1-year follow-up. SETTING Taiwan National Health Insurance Research Database. PATIENTS Adult nontraumatic cardiac arrest patients in the emergency department, who survived to admission. INTERVENTIONS These patients were classified into the steroid and nonsteroid groups based on whether steroid was used or not during hospitalization. A propensity score was used to match patient underlying characteristics, steroid use prior to cardiac arrest, the vasopressors, and shockable rhythm during cardiopulmonary resuscitation, hospital level, and socioeconomic status. MEASUREMENTS AND MAIN RESULTS There were 5,445 patients in each group after propensity score matching. A total of 4,119 patients (75.65%) in the steroid group died during hospitalization, as compared with 4,403 patients (80.86%) in the nonsteroid group (adjusted hazard ratio, 0.74; 95% CI, 0.70-0.77; p < 0.0001). The mortality rate at 1 year was significantly lower in the steroid group than in the nonsteroid group (83.54% vs 87.77%; adjusted hazard ratio, 0.73; 95% CI, 0.70-0.76; p < 0.0001). Steroid use during hospitalization was associated with survival to discharge, regardless of age, gender, underlying diseases (diabetes mellitus, chronic obstructive pulmonary disease, asthma), shockable rhythm, and steroid use prior to cardiac arrest. CONCLUSIONS In this retrospective observational study, postarrest steroid use was associated with better survival to hospital discharge and 1-year survival.
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Perfil de tromboelastometría rotacional (ROTEM) en una cohorte de asistolia no controlada. Med Intensiva 2019; 43:410-415. [DOI: 10.1016/j.medin.2018.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 04/13/2018] [Accepted: 04/22/2018] [Indexed: 01/20/2023]
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Gando S, Wada T. Disseminated intravascular coagulation in cardiac arrest and resuscitation. J Thromb Haemost 2019; 17:1205-1216. [PMID: 31102491 DOI: 10.1111/jth.14480] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 05/02/2019] [Accepted: 05/06/2019] [Indexed: 12/13/2022]
Abstract
The aims of this review are to demonstrate that the changes in coagulation and fibrinolysis observed in cardiac arrest and resuscitation can be recognized as disseminated intravascular coagulation (DIC), and to discuss the probability of DIC being a therapeutic target. The appearance of triggers of DIC, such as damage-associated molecular patterns, inflammatory cytokines, and adrenaline, is associated with platelet activation, marked thrombin generation and fibrin formation, insufficient anticoagulation pathways, and increased fibrinolysis by tissue-type plasminogen activator, followed by the suppression of fibrinolysis by plasminogen activator inhibitor-1, in patients with cardiac arrest and resuscitation. Simultaneous neutrophil activation and endothelial injury associated with glycocalyx perturbation have been observed in these patients. The degree of these changes is more severe in patients with prolonged precardiac arrest hypoxia and long no-flow and low-flow times, patients without return of spontaneous circulation, and non-survivors. Animal and clinical studies have confirmed decreased cerebral blood flow and microvascular fibrin thrombosis in vital organs, including the brain. The clinical diagnosis of DIC in patients with cardiac arrest and resuscitation is associated with multiple organ dysfunction, as assessed with the sequential organ failure assessment score, and increased mortality. This review confirms that the coagulofibrinolytic changes in cardiac arrest and resuscitation meet the definition of DIC proposed by the ISTH, and that DIC is associated with organ dysfunction and poor patient outcomes. This evidence implies that established DIC should be considered to be one of the main therapeutic targets in post-cardiac arrest syndrome.
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Affiliation(s)
- Satoshi Gando
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
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Storm C, Behringer W, Wolfrum S, Michels G, Fink K, Kill C, Arrich J, Leithner C, Ploner C, Busch HJ. [Postcardiac arrest treatment guide]. Med Klin Intensivmed Notfmed 2019; 115:573-584. [PMID: 31197420 DOI: 10.1007/s00063-019-0591-6] [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: 01/17/2019] [Revised: 03/28/2019] [Accepted: 05/06/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Treatment after cardiac arrest has become more complex and interdisciplinary over the last few years. Thus, the clinically active intensive and emergency care physician not only has to carry out the immediate care and acute diagnostics, but also has to prognosticate the neurological outcome. AIM The different, most important steps are presented by leading experts in the area, taking into account the interdisciplinarity and the currently valid guidelines. MATERIALS AND METHODS Attention was paid to a concise, practice-oriented presentation. RESULTS AND DISCUSSION The practical guide contains all important steps from the acute care to the neurological prognosis generation that are relevant for the clinically active intensive care physician.
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Affiliation(s)
- C Storm
- Medizinische Klinik mit Schwerpunkt Nephrologie und Internistische Intensivmedizin, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland.
| | - W Behringer
- Zentrum für Notfallmedizin, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland.
| | - S Wolfrum
- Interdisziplinäre Notaufnahme, Universitätsklinikum Lübeck, Lübeck, Deutschland
| | - G Michels
- Klinik III für Innere Medizin, Herzzentrum, Universität zu Köln, Köln, Deutschland
| | - K Fink
- Universitäts-Notfallzentrum, Universitätsklinikum Freiburg, Sir-Hans-A.-Krebs-Straße, 79106, Freiburg Breisgau, Deutschland
| | - C Kill
- Zentrum für Notfallmedizin, Universitätsklinikum Essen, Essen, Deutschland
| | - J Arrich
- Zentrum für Notfallmedizin, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland
| | - C Leithner
- Klinik für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - C Ploner
- Klinik für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - H-J Busch
- Universitäts-Notfallzentrum, Universitätsklinikum Freiburg, Sir-Hans-A.-Krebs-Straße, 79106, Freiburg Breisgau, Deutschland.
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On-the-Scene Hyaluronan and Syndecan-1 Serum Concentrations and Outcome after Cardiac Arrest and Resuscitation. Mediators Inflamm 2019; 2019:8071619. [PMID: 31148947 PMCID: PMC6501212 DOI: 10.1155/2019/8071619] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 01/18/2019] [Accepted: 03/03/2019] [Indexed: 11/18/2022] Open
Abstract
Background It is not predictable which patients will develop a severe inflammatory response after successful cardiopulmonary resuscitation (CPR), also known as “postcardiac arrest syndrome.” This pathology affects only a subgroup of cardiac arrest victims. Whole body ischemia/reperfusion and prolonged shock states after return of spontaneous circulation (ROSC) may both contribute to this devastating condition. The vascular endothelium with its glycocalyx is especially susceptible to initial ischemic damage and may play a detrimental role in the initiation of postischemic inflammatory reactions. It is not known to date if an immediate early damage to the endothelial glycocalyx, detected by on-the-scene blood sampling and measurement of soluble components (hyaluronan and syndecan-1), precedes and predicts multiple organ failure (MOF) and survival after ROSC. Methods 15 patients after prehospital resuscitation were included in the study. Serum samples were collected on the scene immediately after ROSC and after 6 h, 12 h, 24 h, and 48 h. Hyaluronan and syndecan-1 were measured by ELISA. We associated the development of multiple organ failure and 30-day survival rates with these serum markers of early glycocalyx damage. Results Immediate serum hyaluronan concentrations show significant differences depending on 30-day survival. Further, the hyaluronan level is significantly higher in patients developing MOF during the initial and intermediate resuscitation period. Also, the syndecan-1 levels are significantly different according to MOF occurrence. Conclusion Serum markers of glycocalyx shedding taken immediately on the scene after ROSC can predict the occurrence of multiple organ failure and adverse clinical outcome in patients after cardiac arrest.
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27
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Johnson NJ, Caldwell E, Carlbom DJ, Gaieski DF, Prekker ME, Rea TD, Sayre M, Hough CL. The acute respiratory distress syndrome after out-of-hospital cardiac arrest: Incidence, risk factors, and outcomes. Resuscitation 2019; 135:37-44. [PMID: 30654012 DOI: 10.1016/j.resuscitation.2019.01.009] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 10/25/2018] [Accepted: 01/02/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To define the incidence of the acute respiratory distress syndrome (ARDS) following out-of-hospital cardiac arrest (OHCA) and characterize its impact on outcome. METHODS This was a retrospective cohort study conducted at two urban, tertiary, academic hospitals from 2007 to 2014. We included adults with non-traumatic OHCA and survived for ≥48 h. Patients who received mechanical ventilation for ≥24 h, had 2 consecutive arterial blood gases with a ratio of the partial pressure of oxygen to the fraction of inspired oxygen ≤300, and bilateral radiographic opacities within 48 h of hospital admission were defined as having ARDS. We examined the associations between ARDS and outcome using multivariable analyses and performed sensitivity analyses excluding patients with evidence of cardiac dysfunction. RESULTS Of 978 OHCA patients transported to the study hospitals, 600 were mechanically ventilated and survived ≥48 h. A total of 287 (48%, 95% CI 44-52%) met criteria for ARDS within 48 h of admission. There were no differences in demographics, OHCA etiology, or cardiac rhythm according to ARDS status. Patients with ARDS had higher hospital mortality, longer ICU stays, more ventilator days, and were less likely to survive with full neurologic recovery. Upon excluding patients with cardiac dysfunction, the incidence of ARDS was unchanged. CONCLUSION Nearly half of initial OHCA survivors develop ARDS within 48 h of hospital admission. ARDS was associated with poor outcome and increased resource utilization. OHCA should be considered among the traditional ARDS risk factors.
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Affiliation(s)
- Nicholas J Johnson
- Department of Emergency Medicine, University of Washington, Seattle, WA, United States; Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA, United States.
| | - Ellen Caldwell
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA, United States
| | - David J Carlbom
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA, United States
| | - David F Gaieski
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Matthew E Prekker
- Department of Emergency Medicine & Division Pulmonary and Critical Care Medicine, Hennepin County Medical Center, Minneapolis, MN, United States
| | - Thomas D Rea
- Division of General Internal Medicine, University of Washington, Seattle, WA, United States; King County Medic One, WA, United States
| | - Michael Sayre
- Department of Emergency Medicine, University of Washington, Seattle, WA, United States; Seattle Medic One, WA, United States
| | - Catherine L Hough
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA, United States
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28
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Abstract
The post-cardiac arrest syndrome is a highly inflammatory state characterized by organ dysfunction, systemic ischemia and reperfusion injury, and persistent precipitating pathology. Early critical care should focus on identifying and treating arrest etiology and minimizing further injury to the brain and other organs by optimizing perfusion, oxygenation, ventilation, and temperature. Patients should be treated with targeted temperature management, although the exact temperature goal is not clear. No earlier than 72 hours after rewarming, prognostication using a multimodal approach should inform discussions with families regarding likely neurologic outcome.
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Affiliation(s)
- Amy C Walker
- Department of Emergency Medicine, University of Washington, Harborview Medical Center, 325 9th Avenue, Box 359702, Seattle, WA 98104, USA
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington, Harborview Medical Center, 325 9th Avenue, Box 359702, Seattle, WA 98104, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Harborview Medical Center, 325 9th Avenue, Box 359702, Seattle, WA 98104, USA.
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29
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Buchtele N, Schober A, Schoergenhofer C, Spiel AO, Mauracher L, Weiser C, Sterz F, Jilma B, Schwameis M. Added value of the DIC score and of D-dimer to predict outcome after successfully resuscitated out-of-hospital cardiac arrest. Eur J Intern Med 2018; 57:44-48. [PMID: 29958747 DOI: 10.1016/j.ejim.2018.06.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 05/28/2018] [Accepted: 06/19/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Recent Korean data suggest a high prevalence of overt disseminated intravascular coagulation (DIC) and a good predictive performance of the ISTH DIC score in successfully resuscitated out-of-hospital cardiac arrest. OBJECTIVES We hypothesised that in a European cohort of resuscitated out-of-hospital cardiac arrest patients the prevalence of DIC is substantially lower. Furthermore, the determination of D-dimer levels at admission, but not the DIC score, could improve mortality prediction above traditional predictors. PATIENTS/METHODS Data were extracted from a prospective cardiac arrest registry including patients admitted between 2006 and 2015, who achieved return of spontaneous circulation and had parameters for DIC score calculation available. The primary outcome was the prevalence of overt DIC at admission. Secondary outcomes included the association of overt DIC with 30-day mortality and the contribution of the DIC score and D-dimer levels to 30-day mortality prediction using logistic regression. Three stepwise models were evaluated by receiver-operating-characteristic analysis. RESULTS Out of 1179 patients 388 were included in the study. Overt DIC was present in 8% of patients and associated with substantial 30-day mortality (83% vs. 39%). The AUC for model 1, including traditional mortality predictors, was 0.83. The inclusion of D-dimer levels significantly improved prognostication above traditional predictors (model 3, AUC 0.89), whereas the inclusion of the DIC Score had no effect on mortality prediction (model 2, AUC 0.83). CONCLUSION Overt DIC was rare in a European cohort of out-of-hospital cardiac arrest patients. D-dimer levels improved 30-day mortality prediction and provided added value to assess early mortality risk after successful resuscitation.
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Affiliation(s)
- N Buchtele
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - A Schober
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - C Schoergenhofer
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - A O Spiel
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - L Mauracher
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - C Weiser
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - F Sterz
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - B Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - M Schwameis
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
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Anderson RJ, Jinadasa SP, Hsu L, Ghafouri TB, Tyagi S, Joshua J, Mueller A, Talmor D, Sell RE, Beitler JR. Shock subtypes by left ventricular ejection fraction following out-of-hospital cardiac arrest. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:162. [PMID: 29907120 PMCID: PMC6003130 DOI: 10.1186/s13054-018-2078-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 05/21/2018] [Indexed: 12/14/2022]
Abstract
Background Post-resuscitation hemodynamic instability following out-of-hospital cardiac arrest (OHCA) may occur from myocardial dysfunction underlying cardiogenic shock and/or inflammation-mediated distributive shock. Distinguishing the predominant shock subtype with widely available clinical metrics may have prognostic and therapeutic value. Methods A two-hospital cohort was assembled of patients in shock following OHCA. Left ventricular ejection fraction (LVEF) was assessed via echocardiography or cardiac ventriculography within 1 day post arrest and used to delineate shock physiology. The study evaluated whether higher LVEF, indicating distributive-predominant shock physiology, was associated with neurocognitive outcome (primary endpoint), survival, and duration of multiple organ failures. The study also investigated whether volume resuscitation exhibited a subtype-specific association with outcome. Results Of 162 patients with post-resuscitation shock, 48% had normal LVEF (> 40%), consistent with distributive shock physiology. Higher LVEF was associated with less favorable neurocognitive outcome (OR 0.74, 95% CI 0.58–0.94 per 10% increase in LVEF; p = 0.01). Higher LVEF also was associated with worse survival (OR 0.81, 95% CI 0.67–0.97; p = 0.02) and fewer organ failure-free days (β = – 0.67, 95% CI – 1.28 to − 0.06; p = 0.03). Only 51% of patients received a volume challenge of at least 30 ml/kg body weight in the first 6 h post arrest, and the volume received did not differ by LVEF. Greater volume resuscitation in the first 6 h post arrest was associated with favorable neurocognitive outcome (OR 1.59, 95% CI 0.99–2.55 per liter; p = 0.03) and survival (OR 1.44, 95% CI 1.02–2.04; p = 0.02) among patients with normal LVEF but not low LVEF. Conclusions In post-resuscitation shock, higher LVEF—indicating distributive shock physiology—was associated with less favorable neurocognitive outcome, fewer days without organ failure, and higher mortality. Greater early volume resuscitation was associated with more favorable neurocognitive outcome and survival in patients with this shock subtype. Additional studies with repeated measures of complementary hemodynamic parameters are warranted to validate the clinical utility for subtyping post-resuscitation shock. Electronic supplementary material The online version of this article (10.1186/s13054-018-2078-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ryan J Anderson
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA, USA
| | - Sayuri P Jinadasa
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Leeyen Hsu
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Tiffany Bita Ghafouri
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA, USA
| | - Sanjeev Tyagi
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Jisha Joshua
- Division of Pulmonary and Critical Care Medicine, University of California San Diego, San Diego, CA, USA
| | - Ariel Mueller
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Daniel Talmor
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Rebecca E Sell
- Division of Pulmonary and Critical Care Medicine, University of California San Diego, San Diego, CA, USA
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians & Surgeons, 622 W. 168th Street, 8E101, New York, NY, 10032, USA.
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Cha KC, Kim HI, Kim OH, Cha YS, Kim H, Lee KH, Hwang SO. Echocardiographic patterns of postresuscitation myocardial dysfunction. Resuscitation 2018; 124:90-95. [DOI: 10.1016/j.resuscitation.2018.01.019] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 12/23/2017] [Accepted: 01/10/2018] [Indexed: 10/18/2022]
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32
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Endovascular cooling versus standard femoral catheters and intravascular complications: A propensity-matched cohort study. Resuscitation 2018; 124:1-6. [DOI: 10.1016/j.resuscitation.2017.12.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 12/07/2017] [Accepted: 12/11/2017] [Indexed: 11/21/2022]
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Robel R, Caroccio P, Maze M. Methods for Defining the Neuroprotective Properties of Xenon. Methods Enzymol 2018; 602:273-288. [PMID: 29588034 DOI: 10.1016/bs.mie.2018.01.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Xenon has features that make it an ideal general anesthetic agent; cost and scarcity mitigate xenon's widespread use in the operating room. Discovery of xenon's cytoprotective properties resulted in its application to thwart ongoing acute neurologic injury, an unmet clinical need. The discovery that xenon's neuroprotective effect interacts synergistically with targeted temperature management (TTM) led to its investigation in clinical settings, including in the management of the postcardiac arrest syndrome, in which TTM is indicated. Following successful demonstration of xenon's efficacy in combination with TTM in a preclinical model of porcine cardiac arrest, xenon plus TTM was shown to significantly decrease an imaging biomarker of brain injury for out of hospital cardiac arrest victims that had been successfully resuscitated. With the development of an efficient delivery system the stage is now set to investigate whether xenon improves survival, with good clinical outcome, for successfully resuscitated victims of a cardiac arrest.
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Affiliation(s)
| | | | - Mervyn Maze
- University of California San Francisco, San Francisco, CA, United States.
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Abstract
Introduction In recent years, thrombolysis has emerged as a potentially promising treatment for cardiac arrest. Patients with cardiac arrests from myocardial infarction or pulmonary embolism, as well as out-of-hospital cardiac arrests, were reported to have improvement in both survival and neurologic outcome after being treated with thrombolysis. This paper aims to review the available literature on the use of thrombolysis in cardiac arrest. Method Study of papers from PubMed literature search for all articles with terms related to thrombolysis and cardiac arrest in title or abstract. Results Thrombolytics are thought to act by lysing both macroscopic clots and microthrombi, particularly in the cerebral microcirculation, thus alleviating or reversing post-arrest cerebral no-reflow. Their use in cardiac arrest has been restrained by concerns over their safety after cardiopulmonary resuscitation, in particular bleeding-related complications, although these concerns seem to have been misplaced. Conclusions Thrombolysis for cardiac arrest is likely to be most efficacious in a pre-hospital environment, and future research should be directed to this setting.
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Johnson NJ, Carlbom DJ, Gaieski DF. Ventilator Management and Respiratory Care After Cardiac Arrest: Oxygenation, Ventilation, Infection, and Injury. Chest 2017; 153:1466-1477. [PMID: 29175085 DOI: 10.1016/j.chest.2017.11.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 10/16/2017] [Accepted: 11/10/2017] [Indexed: 01/14/2023] Open
Abstract
Return of spontaneous circulation after cardiac arrest results in a systemic inflammatory state called the post-cardiac arrest syndrome, which is characterized by oxidative stress, coagulopathy, neuronal injury, and organ dysfunction. Perturbations in oxygenation and ventilation may exacerbate secondary injury after cardiac arrest and have been shown to be associated with poor outcome. Further, patients who experience cardiac arrest are at risk for a number of other pulmonary complications. Up to 70% of patients experience early infection after cardiac arrest, and the respiratory tract is the most common source. Vigilance for early-onset pneumonia, as well as aggressive diagnosis and early antimicrobial agent administration are important components of critical care in this population. Patients who experience cardiac arrest are at risk for the development of ARDS. Risk factors include aspiration, pulmonary contusions (from chest compressions), systemic inflammation, and reperfusion injury. Early evidence suggests that they may benefit from ventilation with low tidal volumes. Meticulous attention to mechanical ventilation, early assessment and optimization of respiratory gas exchange, and therapies targeted at potential pulmonary complications may improve outcomes after cardiac arrest.
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Affiliation(s)
- Nicholas J Johnson
- Department of Emergency Medicine, University of Washington, Seattle, WA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA.
| | - David J Carlbom
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA
| | - David F Gaieski
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
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Disseminated intravascular coagulation is associated with the neurologic outcome of cardiac arrest survivors. Am J Emerg Med 2017; 35:1617-1623. [DOI: 10.1016/j.ajem.2017.04.077] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 04/17/2017] [Accepted: 04/30/2017] [Indexed: 01/31/2023] Open
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Wada T. Coagulofibrinolytic Changes in Patients with Post-cardiac Arrest Syndrome. Front Med (Lausanne) 2017; 4:156. [PMID: 29034235 PMCID: PMC5626829 DOI: 10.3389/fmed.2017.00156] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 09/11/2017] [Indexed: 01/08/2023] Open
Abstract
Whole-body ischemia and reperfusion due to cardiac arrest and subsequent return of spontaneous circulation constitute post-cardiac arrest syndrome (PCAS), which consists of four syndromes including systemic ischemia/reperfusion responses and post-cardiac arrest brain injury. The major pathophysiologies underlying systemic ischemia/reperfusion responses are systemic inflammatory response syndrome and increased coagulation, leading to disseminated intravascular coagulation (DIC), which clinically manifests as obstruction of microcirculation and multiple organ dysfunction. In particular, thrombotic occlusion in the brain due to DIC, referred to as the "no-reflow phenomenon," may be deeply involved in post-cardiac arrest brain injury, which is the leading cause of mortality in patients with PCAS. Coagulofibrinolytic changes in patients with PCAS are characterized by tissue factor-dependent coagulation, which is accelerated by impaired anticoagulant mechanisms, including antithrombin, protein C, thrombomodulin, and tissue factor pathway inhibitor. Damage-associated molecular patterns (DAMPs) accelerate not only tissue factor-dependent coagulation but also the factor XII- and factor XI-dependent activation of coagulation. Inflammatory cytokines are also involved in these changes via the expression of tissue factor on endothelial cells and monocytes, the inhibition of anticoagulant systems, and the release of neutrophil elastase from neutrophils activated by inflammatory cytokines. Hyperfibrinolysis in the early phase of PCAS is followed by inadequate endogenous fibrinolysis and fibrinolytic shutdown by plasminogen activator inhibitor-1. Moreover, cell-free DNA, which is also a DAMP, plays a pivotal role in the inhibition of fibrinolysis. DIC diagnosis criteria or fibrinolysis markers, including d-dimer and fibrin/fibrinogen degradation products, which are commonly tested in patients and easily accessible, can be used to predict the mortality or neurological outcome of PCAS patients with high accuracy. A number of studies have explored therapy for this unique pathophysiology since the first report on "no-reflow phenomenon" was published roughly 50 years ago. However, the optimum therapeutic strategy focusing on the coagulofibrinolytic changes in cardiac arrest or PCAS patients has not yet been established. The elucidation of more precise pathomechanisms of coagulofibrinolytic changes in PCAS may aid in the development of novel therapeutic targets, leading to an improvement in the outcomes of PCAS patients.
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Affiliation(s)
- Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Postreanimationsbehandlung. Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0331-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Jeppesen AN, Hvas AM, Duez CHV, Grejs AM, Ilkjær S, Kirkegaard H. Prolonged targeted temperature management compromises thrombin generation: A randomised clinical trial. Resuscitation 2017; 118:126-132. [PMID: 28602694 DOI: 10.1016/j.resuscitation.2017.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 05/26/2017] [Accepted: 06/05/2017] [Indexed: 11/16/2022]
Abstract
AIM To investigate whether prolonged compared with standard duration of targeted temperature management (TTM) compromises coagulation. METHODS Comatose survivors after out-of-hospital cardiac arrest (n=82) were randomised to standard (24h) or prolonged (48h) duration of TTM at 33±1°C. Blood samples were drawn 22, 46 and 70h after attaining the target temperature. Samples were analysed for rotational thromboelastometry (ROTEM® (EXTEM®, INTEM®, FIBTEM® and HEPTEM®)) and thrombin generation using the Calibrated Automated Thrombogram® assay. RESULTS With the 22-h sample, we revealed no difference between groups in the ROTEM® and thrombin generation results beside a slightly higher EXTEM® and INTEM® maximum velocity in the prolonged group (p-values≤0.04). With the 46-h sample, ROTEM® showed no differences when using EXTEM®; however, 11% (p<0.01) longer clotting time and 12% (p<0.01) longer time to maximum velocity were evident in the prolonged group than in the standard group when using INTEM®. The prolonged group had reduced thrombin generation compared with the standard group as indicated by 30% longer lag time (p=0.04), 106nM decreased peak concentration (p<0.001), 36% longer time to peak (p=0.01) and 411 nM*minute decreased endogenous thrombin potential (p<0.001). With the 70-h sample, no differences in ROTEM® results were found between groups. However, the prolonged group had reduced thrombin generation indicated by longer lag time, decreased peak concentration and longer time to peak (all p-values≤0.02) compared with the standard group. CONCLUSION Prolonged TTM in post-cardiac arrest patients impairs thrombin generation. ClinicalTrials.gov identifier: NCT02258360.
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Affiliation(s)
- Anni Nørgaard Jeppesen
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Research Centre for Emergency Medicine, Aarhus University Hospital, Nørrebrogade 44, Building 30, 8000 Aarhus C, Denmark.
| | - Anne-Mette Hvas
- Centre for Haemophilia and Thrombosis, Department of Clinical Biochemistry, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Christophe Henri Valdemar Duez
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Research Centre for Emergency Medicine, Aarhus University Hospital, Nørrebrogade 44, Building 30, 8000 Aarhus C, Denmark
| | - Anders Morten Grejs
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Research Centre for Emergency Medicine, Aarhus University Hospital, Nørrebrogade 44, Building 30, 8000 Aarhus C, Denmark
| | - Susanne Ilkjær
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Hans Kirkegaard
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Research Centre for Emergency Medicine, Aarhus University Hospital, Nørrebrogade 44, Building 30, 8000 Aarhus C, Denmark; Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
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Luiz T, Wilhelms A, Madler C, Pollach G, Haaff B, Grüttner J, Viergutz T. Outcome of out-of-hospital cardiac arrest after fibrinolysis with reteplase in comparison to the return of spontaneous circulation after cardiac arrest score in a geographic region without emergency coronary intervention. Exp Ther Med 2017; 13:1598-1603. [PMID: 28413515 DOI: 10.3892/etm.2017.4155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 12/01/2016] [Indexed: 11/05/2022] Open
Abstract
Coronary occlusion and pulmonary embolism are responsible for the majority of cases of out-of-hospital cardiac arrest (OHCA). Despite previous favourable results of pre-hospital fibrinolysis in cases of OHCA, the benefit could not be confirmed in a large controlled study using the fibrinolytic tenecteplase. For reteplase (r-PA), there are hardly any data regarding pre-hospital fibrinolysis during ongoing resuscitation. The present study reported results using r-PA therapy in a German physician-supported Emergency Medical Services system. The data of OHCA patients who received pre-hospital fibrinolytic treatment with r-PA after an individual risk/benefit assessment were retrospectively analysed. To assess the effectiveness of this approach, the rate of patients with a return of spontaneous circulation (ROSC) was compared with the corresponding figure that was calculated with the help of the RACA (ROSC after cardiac arrest) score. The RACA algorithm predicts the probability of ROSC based on data from the German Resuscitation Registry. Further outcome data comprised hospital discharge rate and neurologic status at discharge. From 2001 to 2009, 43 patients (mean age, 58.5 years; 65.1% male; 58.1% ventricular fibrillation) received r-PA. Of these, 20 patients (46.5%) achieved ROSC, compared to a probability of 49.8% according to the RACA score (P=0.58). A total of 8 patients (18.6%) were discharged alive, including 5 (11.2%) with a good neurological outcome. For the analysed small patient collective, pre-hospital r-PA did not offer any benefits with regard to the ROSC rate. Further analyses of larger patient numbers on a nationwide registry basis are recommended.
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Affiliation(s)
- Thomas Luiz
- Clinic for Anaesthesiology, Intensive Care and Emergency Medicine, Westpfalz Hospital GmbH, D-67655 Kaiserslautern, Rhineland-Palatinate, Germany
| | - Alexander Wilhelms
- Clinic for Anaesthesiology, Intensive Care and Emergency Medicine, Westpfalz Hospital GmbH, D-67655 Kaiserslautern, Rhineland-Palatinate, Germany
| | - Christian Madler
- Clinic for Anaesthesiology, Intensive Care and Emergency Medicine, Westpfalz Hospital GmbH, D-67655 Kaiserslautern, Rhineland-Palatinate, Germany
| | - Gregor Pollach
- Clinic for Anaesthesiology, Intensive Care and Emergency Medicine, Westpfalz Hospital GmbH, D-67655 Kaiserslautern, Rhineland-Palatinate, Germany
| | - Bernd Haaff
- Outpatient Department, Clinic for Internal Medicine II, Cardiology, Pulmonology, Angiology and Intensive Care, Westpfalz Hospital GmbH, D-67655 Kaiserslautern, Rhineland-Palatinate, Germany
| | - Joachim Grüttner
- Emergency Department, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, D-68167 Mannheim, Baden-Wuerttemberg, Germany
| | - Tim Viergutz
- Clinic for Anesthesiology and Operative Intensive Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, D-68167 Mannheim, Baden-Wuerttemberg, Germany
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Koami H, Sakamoto Y, Sakurai R, Ohta M, Imahase H, Yahata M, Umeka M, Miike T, Nagashima F, Iwamura T, Yamada KC, Inoue S. Thromboelastometric analysis of the risk factors for return of spontaneous circulation in adult patients with out-of-hospital cardiac arrest. PLoS One 2017; 12:e0175257. [PMID: 28380019 PMCID: PMC5381924 DOI: 10.1371/journal.pone.0175257] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 03/22/2017] [Indexed: 11/18/2022] Open
Abstract
It is well known that coagulopathy is observed in patients with out-of-hospital cardiac arrest (OHCA). Thrombolytic therapy for those patients has been controversial until now. The purpose of this study was to identify a significant predictor for return of spontaneous circulation (ROSC) of OHCA patients in the emergency department (ED) using whole blood viscoelastic testing. Adult non-trauma OHCA patients transported to our hospital that underwent thromboelastometry (ROTEM) during cardiopulmonary resuscitation between January 2013 and December 2015 were enrolled in this study. We divided patients into two groups based on the presence or absence of ROSC, and performed statistical analysis utilizing patient characteristics, prehospital data, laboratory data, and ROTEM data. Seventy-five patients were enrolled. The ROSC group and non-ROSC group included 23 and 52 patients, respectively. The logistic regression analysis, utilizing significant parameters by univariate analysis, demonstrated that lactate level [odds ratio (OR) 0.880, 95% confidence interval (CI) 0.785-0.986, p = 0.028] and A30 of EXTEM test [OR 1.039, 95% CI 1.010-1.070, p = 0.009] were independent risk factors for ROSC. The cut-off values of lactate and A30 in EXTEM were 12.0 mmol/L and A 48.0 mm, respectively. We defined a positive prediction for ROSC if the patient presented lower lactate level (<12.0 mmol/L) and higher A30 of EXTEM (≥48.0 mm) with high specificity (94.7%) and accuracy (75.0%). The present study showed that lactate level and ROTEM parameter of clot firmness were reliable predictors of ROSC in the ED for adult patients with OHCA.
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Affiliation(s)
- Hiroyuki Koami
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Saga University, Saga, Japan
- * E-mail:
| | - Yuichiro Sakamoto
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Ryota Sakurai
- Advanced Emergency Care Center, Saga University Hospital, Saga, Japan
| | - Miho Ohta
- Advanced Emergency Care Center, Saga University Hospital, Saga, Japan
| | - Hisashi Imahase
- Advanced Emergency Care Center, Saga University Hospital, Saga, Japan
| | - Mayuko Yahata
- Advanced Emergency Care Center, Saga University Hospital, Saga, Japan
| | - Mitsuru Umeka
- Advanced Emergency Care Center, Saga University Hospital, Saga, Japan
| | - Toru Miike
- Advanced Emergency Care Center, Saga University Hospital, Saga, Japan
| | - Futoshi Nagashima
- Advanced Emergency Care Center, Saga University Hospital, Saga, Japan
| | - Takashi Iwamura
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | | | - Satoshi Inoue
- Division of Trauma Surgery and Surgical Critical Care, Faculty of Medicine, Saga University, Saga, Japan
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Chung SP, Yune HY, Park YS, You JS, Hong JH, Kong T, Park JW, Chung HS, Park I. Usefulness of mean platelet volume as a marker for clinical outcomes after out-of-hospital cardiac arrest: a retrospective cohort study. J Thromb Haemost 2016; 14:2036-2044. [PMID: 27437641 DOI: 10.1111/jth.13421] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Accepted: 06/27/2016] [Indexed: 01/06/2023]
Abstract
Essentials It is unknown whether mean platelet volume (MPV) estimates outcomes after cardiac arrest (CA). We investigated whether MPV was associated with 30-day neurologic outcome and mortality after CA. Elevated MPV at admission was associated with poor neurological outcomes and mortality at 30 days. Identifying levels of MPV is helpful for estimating disease severity among resuscitated patients. SUMMARY Background Whole-body ischemia followed by reperfusion during cardiac arrest and after return of spontaneous circulation (ROSC) triggers systemic sterile inflammatory responses, inducing a sepsis-like state during post-cardiac arrest syndrome. Activated platelets are enlarged, and contain vasoactive and prothrombic factors that aggravate systemic inflammation and endothelial dysfunction. Objectives To investigate whether mean platelet volume (MPV) is useful as a marker for early mortality and neurologic outcomes in patients who achieve ROSC after out-of-hospital cardiac arrest (OHCA). Methods OHCA records from the Emergency Department Cardiac Arrest Registry were retrospectively analyzed. Patients who survived for > 24 h after ROSC were included. We evaluated mortality and cerebral performance category scores after 30 days. Results We analyzed records from 184 patients with OHCA. Increased 30-day mortality among patients who achieved ROSC after OHCA was associated with MPV at admission (hazard ratio [HR] 1.36; 95% confidence interval [CI] 1.06-1.75). An elevated MPV at admission was also associated with poor neurologic outcomes (HR 1.28; 95% CI 1.06-1.55). Conclusions An elevated MPV was independently associated with increased 30-day mortality, with the highest discriminative value being obtained upon admission after OHCA. An elevated MPV on admission was associated with poor neurologic outcomes. High MPVs are helpful for estimating 30-day mortality and neurologic outcomes among patients who achieve ROSC after OHCA.
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Affiliation(s)
- S P Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - H Y Yune
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Y S Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - J S You
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea.
| | - J H Hong
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - T Kong
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - J W Park
- Department of Emergency Medicine, Kosin University College of Medicine, Busan, Korea
| | - H S Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - I Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
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Nolan JP, Soar J, Cariou A, Cronberg T, Moulaert VRM, Deakin CD, Bottiger BW, Friberg H, Sunde K, Sandroni C. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines for Post-resuscitation Care 2015: Section 5 of the European Resuscitation Council Guidelines for Resuscitation 2015. Resuscitation 2016; 95:202-22. [PMID: 26477702 DOI: 10.1016/j.resuscitation.2015.07.018] [Citation(s) in RCA: 734] [Impact Index Per Article: 91.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jerry P Nolan
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, UK.
| | - Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK
| | - Alain Cariou
- Cochin University Hospital (APHP) and Paris Descartes University, Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Division of Neurology, Lund University, Lund, Sweden
| | - Véronique R M Moulaert
- Adelante, Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands
| | - Charles D Deakin
- Cardiac Anaesthesia and Cardiac Intensive Care and NIHR Southampton Respiratory Biomedical Research Unit, University Hospital, Southampton, UK
| | - Bernd W Bottiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Hans Friberg
- Department of Clinical Sciences, Division of Anesthesia and Intensive Care Medicine, Lund University, Lund, Sweden
| | - Kjetil Sunde
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
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Meyer ASP, Ostrowski SR, Kjaergaard J, Johansson PI, Hassager C. Endothelial Dysfunction in Resuscitated Cardiac Arrest (ENDO-RCA): safety and efficacy of low-dose prostacyclin administration and blood pressure target in addition to standard therapy, as compared to standard therapy alone, in post-cardiac arrest syndrome patients: study protocol for a randomized controlled trial. Trials 2016; 17:378. [PMID: 27484224 PMCID: PMC4969682 DOI: 10.1186/s13063-016-1477-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 07/05/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Morbidity and mortality following initial survival of cardiac arrest remain high despite great efforts to improve resuscitation techniques and post-resuscitation care, in part due to the ischemia-reperfusion injury secondary to the restoration of the blood circulation. Patients resuscitated from cardiac arrest display evidence of endothelial injury and coagulopathy (hypocoagulability, hyperfibrinolysis), which in associated with poor outcome. Recent randomized controlled trials have revealed that treatment with infusion of prostacyclin reduces endothelial damage after major surgery and AMI. Thus, a study is pertinent to investigate if prostacyclin infusion as a therapeutic intervention reduces endothelial damage without compromising, or even improving, the hemostatic competence in resuscitated cardiac arrest patients. Post-cardiac arrest patients frequently have a need for vasopressor therapy (catecholamines) to achieve the guideline-supported blood pressure goals. To evaluate a possible catecholamine interaction with the primary endpoints of this study, included patients will be randomized into two different blood pressure goals within guideline-recommended targets. METHODS/DESIGN A randomized, placebo-controlled, double-blind investigator-initiated pilot trial in 40 out-of-hospital-cardiac-arrest (OHCA) patients will be conducted. Patients will be randomly assigned to either the active treatment group (48 hours of active study drug (iloprost, 1 ng/kg/min) or to the control group [placebo (saline) infusion]. Target mean blood pressure levels will be allocated 1:1 to 65 mmHg or approximately 75 mmHg, which gives four different permutations, namely: (i) iloprost/65 mHg, (ii) iloprost/75 mmHg, (iii) placebo/65 mmHg, and (iv) placebo/75 mmHg. All randomized patients will be treated in accordance with state-of-the art therapy including targeted temperature management. The primary endpoint of this study is change in biomarkers indicative of endothelial activation and damage, [soluble thrombomodulin (sTM), sE-selectin, syndecan-1, soluble vascular endothelial growth factor (sVEGF), nucleosomes] and sympathoadrenal over activation (epinephrine/norepinephrine) from baseline to 48 hours post-randomization. The secondary endpoints of this trial will include: (1) the hemostatic profile [change in functional hemostatic blood test (thrombelastography (TEG) and whole blood platelet aggregometry (multiplate)) blood cell and endothelial cell-derived microparticles]; (2) feasibility of blood pressure target intervention (target 90 %); (3) interaction of primary endpoints and blood pressure target; (4) levels of neuron-specific enolase at 48 hours post-inclusion according to blood pressure targets. DISCUSSION The ENDO-RCA study is a pilot study trial that investigates safety and efficacy of low-dose infusion of prostacyclin administration as compared to standard therapy in post-cardiac arrest syndrome patients. TRIAL REGISTRATION Trial registration at ClinicalTrials.gov (identifier NCT02685618 ) on 18 February 2016.
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Affiliation(s)
- Anna Sina P Meyer
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, 2034, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Sisse R Ostrowski
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, 2034, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, Rigshospitalet, 2143, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Pär I Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, 2034, Blegdamsvej 9, 2100, Copenhagen, Denmark.,Department of Surgery, University of Texas Health Medical School, 6410 Fannin Street UPB 1100, Houston, TX, 77030, USA
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet, 2143, Blegdamsvej 9, 2100, Copenhagen, Denmark
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Deng Y, He L, Yang J, Wang J. Serum D-dimer as an indicator of immediate mortality in patients with in-hospital cardiac arrest. Thromb Res 2016; 143:161-5. [DOI: 10.1016/j.thromres.2016.03.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 02/19/2016] [Accepted: 03/01/2016] [Indexed: 01/08/2023]
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46
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Which comes first? The chicken or the egg: The association of d-dimer with return of spontaneous circulation following in-hospital cardiac arrest. Thromb Res 2016; 143:159-60. [DOI: 10.1016/j.thromres.2016.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Revised: 04/19/2016] [Accepted: 04/19/2016] [Indexed: 11/19/2022]
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47
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Thrombolytic-Enhanced Extracorporeal Cardiopulmonary Resuscitation After Prolonged Cardiac Arrest. Crit Care Med 2016; 44:e58-69. [PMID: 26488218 DOI: 10.1097/ccm.0000000000001305] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To investigate the effects of the combination of extracorporeal cardiopulmonary resuscitation and thrombolytic therapy on the recovery of vital organ function after prolonged cardiac arrest. DESIGN Laboratory investigation. SETTING University laboratory. SUBJECTS Pigs. INTERVENTIONS Animals underwent 30-minute untreated ventricular fibrillation cardiac arrest followed by extracorporeal cardiopulmonary resuscitation for 6 hours. Animals were allocated into two experimental groups: t-extracorporeal cardiopulmonary resuscitation (t-ECPR) group, which received streptokinase 1 million units, and control extracorporeal cardiopulmonary resuscitation (c-ECPR), which did not receive streptokinase. In both groups, the resuscitation protocol included the following physiologic targets: mean arterial pressure greater than 70 mm Hg, cerebral perfusion pressure greater than 50 mm Hg, PaO2 150 ± 50 torr (20 ± 7 kPa), PaCO2 40 ± 5 torr (5 ± 1 kPa), and core temperature 33°C ± 1°C. Defibrillation was attempted after 30 minutes of extracorporeal cardiopulmonary resuscitation. MEASUREMENTS AND MAIN RESULTS A cardiac resuscitability score was assessed on the basis of success of defibrillation, return of spontaneous heart beat, weanability from extracorporeal cardiopulmonary resuscitation, and left ventricular systolic function after weaning. The addition of thrombolytic to extracorporeal cardiopulmonary resuscitation significantly improved cardiac resuscitability (3.7 ± 1.6 in t-ECPR vs 1.0 ± 1.5 in c-ECPR). Arterial lactate clearance was higher in t-ECPR than in c-ECPR (40% ± 15% vs 18% ± 21%). At the end of the experiment, the intracranial pressure was significantly higher in c-ECPR than in t-ECPR. Recovery of brain electrical activity, as assessed by quantitative analysis of electroencephalogram signal, and ischemic neuronal injury on histopathologic examination did not differ between groups. Animals in t-ECPR group did not have increased bleeding complications, including intracerebral hemorrhages. CONCLUSIONS In a porcine model of prolonged cardiac arrest, t-ECPR improved cardiac resuscitability and reduced brain edema, without increasing bleeding complications. However, early electroencephalogram recovery and ischemic neuronal injury were not improved.
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Uchino H, Ogihara Y, Fukui H, Chijiiwa M, Sekine S, Hara N, Elmér E. Brain injury following cardiac arrest: pathophysiology for neurocritical care. J Intensive Care 2016; 4:31. [PMID: 27123307 PMCID: PMC4847238 DOI: 10.1186/s40560-016-0140-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 02/04/2016] [Indexed: 11/27/2022] Open
Abstract
Cardiac arrest induces the cessation of cerebral blood flow, which can result in brain damage. The primary intervention to salvage the brain under such a pathological condition is to restore the cerebral blood flow to the ischemic region. Ischemia is defined as a reduction in blood flow to a level that is sufficient to alter normal cellular function. Brain tissue is highly sensitive to ischemia, such that even brief ischemic periods in neurons can initiate a complex sequence of events that may ultimately culminate in cell death. However, paradoxically, restoration of blood flow can cause additional damage and exacerbate the neurocognitive deficits in patients who suffered a brain ischemic event, which is a phenomenon referred to as “reperfusion injury.” Transient brain ischemia following cardiac arrest results from the complex interplay of multiple pathways including excitotoxicity, acidotoxicity, ionic imbalance, peri-infarct depolarization, oxidative and nitrative stress, inflammation, and apoptosis. The pathophysiology of post-cardiac arrest brain injury involves a complex cascade of molecular events, most of which remain unknown. Many lines of evidence have shown that mitochondria suffer severe damage in response to ischemic injury. Mitochondrial dysfunction based on the mitochondrial permeability transition after reperfusion, particularly involving the calcineurin/immunophilin signal transduction pathway, appears to play a pivotal role in the induction of neuronal cell death. The aim of this article is to discuss the underlying pathophysiology of brain damage, which is a devastating pathological condition, and highlight the central signal transduction pathway involved in brain damage, which reveals potential targets for therapeutic intervention.
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Affiliation(s)
- Hiroyuki Uchino
- Department of Anesthesiology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023 Japan
| | - Yukihiko Ogihara
- Department of Anesthesiology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023 Japan
| | - Hidekimi Fukui
- Department of Anesthesiology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023 Japan
| | - Miyuki Chijiiwa
- Department of Anesthesiology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023 Japan
| | - Shusuke Sekine
- Department of Anesthesiology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023 Japan
| | - Naomi Hara
- Department of Anesthesiology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023 Japan
| | - Eskil Elmér
- Mitochondrial Pathophysiology Unit, Department of Clinical Sciences, Lund University, Box 117, 221 00 Lund, Sweden
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Madathil RJ, Hira RS, Stoeckl M, Sterz F, Elrod JB, Nichol G. Ischemia reperfusion injury as a modifiable therapeutic target for cardioprotection or neuroprotection in patients undergoing cardiopulmonary resuscitation. Resuscitation 2016; 105:85-91. [PMID: 27131843 DOI: 10.1016/j.resuscitation.2016.04.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 04/07/2016] [Accepted: 04/13/2016] [Indexed: 12/13/2022]
Abstract
AIMS We sought to review cellular changes that occur with reperfusion to try to understand whether ischemia-reperfusion injury (RI) is a potentially modifiable therapeutic target for cardioprotection or neuroprotection in patients undergoing cardiopulmonary resuscitation. DATA SOURCES Articles written in English and published in PubMed. RESULTS Remote ischemic conditioning (RIC) involves brief episodes of non-lethal ischemia and reperfusion applied to an organ or limb distal to the heart and brain. Induction of hypothermia involves cooling an ischemic organ or body. Both have pluripotent effects that reduce the potential harm associated with RI in the heart and brain by reduced opening of the mitochondrial permeability transition pore. Recent trials of RIC and induced hypothermia did not demonstrate these treatments to be effective. Assessment of the effect of these interventions in humans to date may have been modified by use of concurrent medications including propofol. CONCLUSIONS Ongoing research is necessary to assess whether reduction of RI improves patient outcomes.
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Affiliation(s)
| | - Ravi S Hira
- University of Washington, Seattle, WA, United States
| | | | - Fritz Sterz
- Medical University of Vienna, Vienna, Austria
| | | | - Graham Nichol
- University of Washington, Seattle, WA, United States.
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Evaluation of cyclosporine a as a cardio- and neuroprotective agent after cardiopulmonary resuscitation in a rat model. Shock 2016; 43:576-81. [PMID: 25705861 DOI: 10.1097/shk.0000000000000357] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The immunosuppressant drug cyclosporine A (CsA) is a direct inhibitor of the mitochondrial permeability transition pore, which is the common end point of many pathways of ischemic preconditioning and postconditioning. We studied the neuroprotective and cardioprotective effect of CsA after cardiac arrest (CA) in a rat model of cardiopulmonary resuscitation. After institutional approval by the Governmental Animal Care Committee, 83 rats were subjected to 6 min of CA and were randomly and investigator-blinded allocated either to placebo (n = 15) or interventional group (n = 15; 10-mg/kg body weight CsA intravenously) after restoration of spontaneous circulation (ROSC). Before CA (baseline) as well as 1 h and 3 h after ROSC, continuous measurement of stroke volume, left ventricular ejection fraction, preload adjusted maximum power, and end diastolic volume was performed using a conductance catheter. One day, 3 days, and 7 days after ROSC, neurological outcome was evaluated by a tape removal test. After 7 days of reperfusion, coronal brain sections were analyzed by counting Nissl-positive (i.e., viable) neurons and terminal deoxynucleotidyl transferase dUTP nick end labeling positive (i.e., apoptotic) cells. Animals treated with CsA had a higher stroke volume (96 [93; 107] μL vs. 78 [73; 94] μL; P = 0.02), higher ejection fraction (58% [51%; 63%] vs. 42% [35%; 51%]; P = 0.002), and higher preload adjusted maximum power (4.8 [3.9; 6.1] vs. 2.3 [2.0; 2.6] mW/μL; P < 0.001). End diastolic volume remained stable in the CsA group 3 h after ROSC in comparison to baseline (160 [143; 181] μL vs. 157 [148; 192] μL; P = 0.56), whereas it increased in the placebo group (169 [153; 221] μL vs. 156 [138; 166] μL, P = 0.05). More neurons survived after administration of CsA (2.5 [1.6; 4.9] vs. 0.7 [0.4; 1.4]; P = 0.005). Compared to placebo-treated animals, the time in the tape removal test 7 days after ROSC was reduced by half in the CsA group without reaching statistical significance (26 [22; 51] vs. placebo 53 [38; 56] s; P = 0.13). Cyclosporine A treatment neither affected the number of terminal deoxynucleotidyl transferase dUTP nick end labeling-positive cells nor the survival rate. Pharmacological postconditioning with CsA after successful cardiopulmonary resuscitation attenuates myocardial dysfunction and reduces neuronal damage.
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