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Trummer G, Benk C, Pooth JS, Wengenmayer T, Supady A, Staudacher DL, Damjanovic D, Lunz D, Wiest C, Aubin H, Lichtenberg A, Dünser MW, Szasz J, Dos Reis Miranda D, van Thiel RJ, Gummert J, Kirschning T, Tigges E, Willems S, Beyersdorf F. Treatment of Refractory Cardiac Arrest by Controlled Reperfusion of the Whole Body: A Multicenter, Prospective Observational Study. J Clin Med 2023; 13:56. [PMID: 38202063 PMCID: PMC10780178 DOI: 10.3390/jcm13010056] [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: 11/09/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/12/2024] Open
Abstract
Background: Survival following cardiac arrest (CA) remains poor after conventional cardiopulmonary resuscitation (CCPR) (6-26%), and the outcomes after extracorporeal cardiopulmonary resuscitation (ECPR) are often inconsistent. Poor survival is a consequence of CA, low-flow states during CCPR, multi-organ injury, insufficient monitoring, and delayed treatment of the causative condition. We developed a new strategy to address these issues. Methods: This all-comers, multicenter, prospective observational study (69 patients with in- and out-of-hospital CA (IHCA and OHCA) after prolonged refractory CCPR) focused on extracorporeal cardiopulmonary support, comprehensive monitoring, multi-organ repair, and the potential for out-of-hospital cannulation and treatment. Result: The overall survival rate at hospital discharge was 42.0%, and a favorable neurological outcome (CPC 1+2) at 90 days was achieved for 79.3% of survivors (CPC 1+2 survival 33%). IHCA survival was very favorable (51.7%), as was CPC 1+2 survival at 90 days (41%). Survival of OHCA patients was 35% and CPC 1+2 survival at 90 days was 28%. The subgroup of OHCA patients with pre-hospital cannulation showed a superior survival rate of 57.1%. Conclusions: This new strategy focusing on repairing damage to multiple organs appears to improve outcomes after CA, and these findings should provide a sound basis for further research in this area.
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Affiliation(s)
- Georg Trummer
- Department of Cardiovascular Surgery, University Medical Center Freiburg, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany; (G.T.)
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
| | - Christoph Benk
- Department of Cardiovascular Surgery, University Medical Center Freiburg, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany; (G.T.)
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
| | - Jan-Steffen Pooth
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
- Department of Emergency Medicine, Medical Center—University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Tobias Wengenmayer
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
- Interdisciplinary Medical Intensive Care, Medical Center—University of Freiburg, 79106 Freiburg, Germany
| | - Alexander Supady
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
- Interdisciplinary Medical Intensive Care, Medical Center—University of Freiburg, 79106 Freiburg, Germany
| | - Dawid L. Staudacher
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
- Interdisciplinary Medical Intensive Care, Medical Center—University of Freiburg, 79106 Freiburg, Germany
| | - Domagoj Damjanovic
- Department of Cardiovascular Surgery, University Medical Center Freiburg, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany; (G.T.)
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Medical Center, 93042 Regensburg, Germany;
| | - Clemens Wiest
- Department of Internal Medicine II, University Medical Center, 93042 Regensburg, Germany
| | - Hug Aubin
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany (A.L.)
| | - Artur Lichtenberg
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany (A.L.)
| | - Martin W. Dünser
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020 Linz, Austria
| | - Johannes Szasz
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020 Linz, Austria
| | - Dinis Dos Reis Miranda
- Department of Adult Intensive Care, Erasmus MC University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Robert J. van Thiel
- Department of Adult Intensive Care, Erasmus MC University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Jan Gummert
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, University Hospital of the Ruhr University Bochum, 44791 Bad Oeynhausen, Germany
| | - Thomas Kirschning
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, University Hospital of the Ruhr University Bochum, 44791 Bad Oeynhausen, Germany
| | - Eike Tigges
- Asklepios Klinik St. Georg, Heart and Vascular Center, Department of Cardiology and Intensive Care Medicine, 20099 Hamburg, Germany
| | - Stephan Willems
- Asklepios Klinik St. Georg, Heart and Vascular Center, Department of Cardiology and Intensive Care Medicine, 20099 Hamburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Medical Center Freiburg, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany; (G.T.)
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
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Collins PD, Giosa L, Kathar S, Camarda V, Palmesino F, Eshwar D, Barrett NA, Retter A, Vasques F, Sanderson B, Mak SM, Rose L, Camporota L. Clinical impact of screening computed tomography in extracorporeal membrane oxygenation: a retrospective cohort study. Ann Intensive Care 2023; 13:90. [PMID: 37750928 PMCID: PMC10522559 DOI: 10.1186/s13613-023-01187-w] [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: 06/23/2023] [Accepted: 09/04/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND Data on the prevalence and clinical impact of extrapulmonary findings at screening computed tomography (CT) on initiation of veno-venous extracorporeal membrane oxygenation (V-V ECMO) are limited. We aimed to identify the prevalence of extrapulmonary findings on screening CT following V-V ECMO initiation. We hypothesized that extrapulmonary findings would influence clinical management and outcome. METHODS Retrospective analysis (2011-2021) of admission screening CT including head, abdomen and pelvis with contrast of consecutive patients on initiation of V-V ECMO. CT findings identified by the attending consultant radiologist were extracted. Demographics, admission physiological and laboratory data, clinical decision-making following CT and ECMO ICU mortality were recorded from the electronic medical record. We used multivariable logistic regression and Kaplan-Meier curves to evaluate associations between extrapulmonary findings and ECMO ICU mortality. RESULTS Of the 833 patients receiving V-V ECMO, 761 underwent routine admission CT (91.4%). ECMO ICU length of stay was 19 days (IQR 12-23); ICU mortality at the ECMO centre was 18.9%. An incidental extrapulmonary finding was reported in 227 patients (29.8%), leading to an invasive procedure in 12/227 cases (5.3%) and a change in medical management (mainly in anticoagulation strategy) in 119/227 (52.4%). Extrapulmonary findings associated with mortality were intracranial haemorrhage (OR 2.34 (95% CI 1.31-4.12), cerebral infarction (OR 3.59 (95% CI 1.26-9.86) and colitis (OR 2.80 (95% CI 1.35-5.67). CONCLUSIONS Screening CT frequently identifies extrapulmonary findings of clinical significance. Newly detected intracranial haemorrhage, cerebral infarction and colitis were associated with increased ICU mortality.
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Affiliation(s)
- Patrick D Collins
- Department of Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Lorenzo Giosa
- Department of Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK
| | - Sushil Kathar
- Department of Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Valentina Camarda
- Department of Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Filippo Palmesino
- Department of Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Darshan Eshwar
- Department of Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Nicholas A Barrett
- Department of Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK
| | - Andrew Retter
- Department of Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Francesco Vasques
- Department of Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Barnaby Sanderson
- Department of Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Sze M Mak
- Department of Radiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Luigi Camporota
- Department of Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK.
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK.
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Robba C, Poole D, McNett M, Asehnoune K, Bösel J, Bruder N, Chieregato A, Cinotti R, Duranteau J, Einav S, Ercole A, Ferguson N, Guerin C, Siempos II, Kurtz P, Juffermans NP, Mancebo J, Mascia L, McCredie V, Nin N, Oddo M, Pelosi P, Rabinstein AA, Neto AS, Seder DB, Skrifvars MB, Suarez JI, Taccone FS, van der Jagt M, Citerio G, Stevens RD. Mechanical ventilation in patients with acute brain injury: recommendations of the European Society of Intensive Care Medicine consensus. Intensive Care Med 2020; 46:2397-2410. [PMID: 33175276 PMCID: PMC7655906 DOI: 10.1007/s00134-020-06283-0] [Citation(s) in RCA: 114] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 10/05/2020] [Indexed: 12/29/2022]
Abstract
Purpose To provide clinical practice recommendations and generate a research agenda on mechanical ventilation and respiratory support in patients with acute brain injury (ABI). Methods An international consensus panel was convened including 29 clinician-scientists in intensive care medicine with expertise in acute respiratory failure, neurointensive care, or both, and two non-voting methodologists. The panel was divided into seven subgroups, each addressing a predefined clinical practice domain relevant to patients admitted to the intensive care unit (ICU) with ABI, defined as acute traumatic brain or cerebrovascular injury. The panel conducted systematic searches and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method was used to evaluate evidence and formulate questions. A modified Delphi process was implemented with four rounds of voting in which panellists were asked to respond to questions (rounds 1–3) and then recommendation statements (final round). Strong recommendation, weak recommendation, or no recommendation were defined when > 85%, 75–85%, and < 75% of panellists, respectively, agreed with a statement. Results The GRADE rating was low, very low, or absent across domains. The consensus produced 36 statements (19 strong recommendations, 6 weak recommendations, 11 no recommendation) regarding airway management, non-invasive respiratory support, strategies for mechanical ventilation, rescue interventions for respiratory failure, ventilator liberation, and tracheostomy in brain-injured patients. Several knowledge gaps were identified to inform future research efforts. Conclusions This consensus provides guidance for the care of patients admitted to the ICU with ABI. Evidence was generally insufficient or lacking, and research is needed to demonstrate the feasibility, safety, and efficacy of different management approaches. Electronic supplementary material The online version of this article (10.1007/s00134-020-06283-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Chiara Robba
- San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Daniele Poole
- Anesthesia and Intensive Care Operative Unit, S. Martino Hospital, Belluno, Italy
| | - Molly McNett
- Implementation Science, The Helene Fuld Health Trust National Institute for EBP, College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Karim Asehnoune
- Department of Anaesthesia and Critical Care, Hôtel Dieu, University Hospital of Nantes, Nantes, France
| | - Julian Bösel
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
- Department of Neurology, Klinikum Kassel, Kassel, Germany
| | - Nicolas Bruder
- Anesthesiology-Intensive Care Department, Aix-Marseille University, APHM, CHU Timone, Marseille, France
| | - Arturo Chieregato
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Raphael Cinotti
- Department of Anaesthesia and Critical Care, Hôpital Guillaume et René Laennec, University Hospital of Nantes, Saint-Herblain, France
| | - Jacques Duranteau
- Department of Anesthesiology and Perioperative Intensive Care Medicine, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris, Paris-Saclay University, Paris, France
| | - Sharon Einav
- Faculty of Medicine, Intensive Care Unit of the Shaare Zedek Medical Centre and Hebrew University, Jerusalem, Israel
| | - Ari Ercole
- University of Cambridge Division of Anaesthesia, Addenbrooke's Hospital, Cambridge, UK
| | - Niall Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Physiology, University of Toronto, Toronto, ON, Canada
| | - Claude Guerin
- Medecine Intensive-Réanimation, Hopital Edouard Herriot, University of Lyon, Lyon, France
- INSERM 955, Créteil, France
| | - Ilias I Siempos
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medicine, New York, NY, USA
| | - Pedro Kurtz
- Department of Neurointensive Care, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Olvg Hospital, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Jordi Mancebo
- Servei Medicina Intensiva, Hospital Sant Pau, Barcelona, Spain
| | - Luciana Mascia
- Alma Mater Studiorum, Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | - Victoria McCredie
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Nicolas Nin
- Department of Intensive Care Medicine, Hospital Español, Montevideo, Uruguay
| | - Mauro Oddo
- Department of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Paolo Pelosi
- San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | | | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Critical Care Medicine, Hospital Israelita Alberto Einstein, São Paulo, Brazil
| | - David B Seder
- Department of Critical Care Services, Neuroscience Institute, Maine Medical Center, 22 Bramhall Street, Portland, ME, 04102, USA
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Meilahden sairaala, Haartmaninkatu 4, 00029 HUS, Helsinki, Finland
| | - Jose I Suarez
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Phipps 455, Baltimore, MD, 21287, USA
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fabio Silvio Taccone
- Department of Intensive Care Medicine, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano - Bicocca, Milan, Italy
| | - Robert D Stevens
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Phipps 455, Baltimore, MD, 21287, USA.
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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