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Zhang F, Ye Z, Ran Y, Liu C, Zhang M, Xu X, Song F, Yao L. Ruthenium red alleviates post-resuscitation myocardial dysfunction by upregulating mitophagy through inhibition of USP33 in a cardiac arrest rat model. Eur J Pharmacol 2024; 974:176633. [PMID: 38703975 DOI: 10.1016/j.ejphar.2024.176633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 04/30/2024] [Accepted: 04/30/2024] [Indexed: 05/06/2024]
Abstract
Cardiac arrest (CA) remains a leading cause of death, with suboptimal survival rates despite efforts involving cardiopulmonary resuscitation and advanced life-support technology. Post-resuscitation myocardial dysfunction (PRMD) is an important determinant of patient outcomes. Myocardial ischemia/reperfusion injury underlies this dysfunction. Previous reports have shown that ruthenium red (RR) has a protective effect against cardiac ischemia-reperfusion injury; however, its precise mechanism of action in PRMD remains unclear. This study investigated the effects of RR on PRMD and analyzed its underlying mechanisms. Ventricular fibrillation was induced in rats, which were then subjected to cardiopulmonary resuscitation to establish an experimental CA model. At the onset of return of spontaneous circulation, RR (2.5 mg/kg) was administered intraperitoneally. Our study showed that RR improved myocardial function and reduced the production of oxidative stress markers such as malondialdehyde (MDA), glutathione peroxidase (GSSG), and reactive oxygen species (ROS) production. RR also helped maintain mitochondrial structure and increased ATP and GTP levels. Additionally, RR effectively attenuated myocardial apoptosis. Furthermore, we observed downregulation of proteins closely related to mitophagy, including ubiquitin-specific protease 33 (USP33) and P62, whereas LC3B (microtubule-associated protein light chain 3B) was upregulated. The upregulation of mitophagy may play a critical role in reducing myocardial injury. These results demonstrate that RR may attenuate PRMD by promoting mitophagy through the inhibition of USP33. These effects are likely mediated through diverse mechanisms, including antioxidant activity, apoptosis suppression, and preservation of mitochondrial integrity and energy metabolism. Consequently, RR has emerged as a promising therapeutic approach for addressing post-resuscitation myocardial dysfunction.
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Affiliation(s)
- Fan Zhang
- Department of Emergency Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, 519000, China; Institute of Cardiopulmonary Cerebral Resuscitation, Sun Yat-sen University, Guangzhou, 510000, China
| | - Zhou Ye
- Department of Emergency Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, 519000, China; Institute of Cardiopulmonary Cerebral Resuscitation, Sun Yat-sen University, Guangzhou, 510000, China
| | - Yingqi Ran
- Department of Emergency Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, 519000, China
| | - Cong Liu
- Department of Emergency Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, 519000, China
| | - Mingtao Zhang
- Department of Emergency Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, 519000, China
| | - Xiangchang Xu
- Department of Emergency Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, 519000, China
| | - Fengqing Song
- Department of Emergency Medicine, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, China; Institute of Cardiopulmonary Cerebral Resuscitation, Sun Yat-sen University, Guangzhou, 510000, China.
| | - Lan Yao
- Department of Emergency Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, 519000, China.
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Liu R, Majumdar T, Gardner MM, Burnett R, Graham K, Beaulieu F, Sutton RM, Nadkarni VM, Berg RA, Morgan RW, Topjian AA, Kirschen MP. Association of Postarrest Hypotension Burden With Unfavorable Neurologic Outcome After Pediatric Cardiac Arrest. Crit Care Med 2024:00003246-990000000-00342. [PMID: 38832829 DOI: 10.1097/ccm.0000000000006339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
OBJECTIVE Quantify hypotension burden using high-resolution continuous arterial blood pressure (ABP) data and determine its association with outcome after pediatric cardiac arrest. DESIGN Retrospective observational study. SETTING Academic PICU. PATIENTS Children 18 years old or younger admitted with in-of-hospital or out-of-hospital cardiac arrest who had invasive ABP monitoring during postcardiac arrest care. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS High-resolution continuous ABP was analyzed up to 24 hours after the return of circulation (ROC). Hypotension burden was the time-normalized integral area between mean arterial pressure (MAP) and fifth percentile MAP for age. The primary outcome was unfavorable neurologic status (pediatric cerebral performance category ≥ 3 with change from baseline) at hospital discharge. Mann-Whitney U tests compared hypotension burden, duration, and magnitude between favorable and unfavorable patients. Multivariable logistic regression determined the association of unfavorable outcomes with hypotension burden, duration, and magnitude at various percentile thresholds from the 5th through 50th percentile for age. Of 140 patients (median age 53 [interquartile range 11-146] mo, 61% male); 63% had unfavorable outcomes. Monitoring duration was 21 (7-24) hours. Using a MAP threshold at the fifth percentile for age, the median hypotension burden was 0.01 (0-0.11) mm Hg-hours per hour, greater for patients with unfavorable compared with favorable outcomes (0 [0-0.02] vs. 0.02 [0-0.27] mm Hg-hr per hour, p < 0.001). Hypotension duration and magnitude were greater for unfavorable compared with favorable patients (0.03 [0-0.77] vs. 0.71 [0-5.01]%, p = 0.003; and 0.16 [0-1.99] vs. 2 [0-4.02] mm Hg, p = 0.001). On logistic regression, a 1-point increase in hypotension burden below the fifth percentile for age (equivalent to 1 mm Hg-hr of burden per hour of recording) was associated with increased odds of unfavorable outcome (adjusted odds ratio [aOR] 14.8; 95% CI, 1.1-200; p = 0.040). At MAP thresholds of 10th-50th percentiles for age, MAP burden below the threshold was greater in unfavorable compared with favorable patients in a dose-dependent manner. CONCLUSIONS High-resolution continuous ABP data can be used to quantify hypotension burden after pediatric cardiac arrest. The burden, duration, and magnitude of hypotension are associated with unfavorable neurologic outcomes.
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Affiliation(s)
- Raymond Liu
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Tanmay Majumdar
- Department of Medicine, Drexel University College of Medicine, Philadelphia, PA
| | - Monique M Gardner
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Ryan Burnett
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Forrest Beaulieu
- Department of Anesthesiology, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Robert M Sutton
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Vinay M Nadkarni
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Robert A Berg
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Ryan W Morgan
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Alexis A Topjian
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Matthew P Kirschen
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Pirouzram A, Wikström M, Larzon T, Tamás É, Nilsson KF. Induced Moderate Hypothermia in Aortic Rupture With Retroperitoneal Bleeding: A Randomized Porcine Study. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2024:15569845241253234. [PMID: 38828939 DOI: 10.1177/15569845241253234] [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: 06/05/2024]
Abstract
OBJECTIVE Induced hypothermia improves outcome in aortic arch surgery, neonatal neurointensive care, and transplant surgery for example. In contrast, spontaneous hypothermia has been associated with worse outcomes in patients suffering from hemorrhagic shock, mostly explained by its adverse effects on the coagulation system. We investigated if induced hypothermia would impair short-term survival in experimental aortic rupture with retroperitoneal bleeding. METHODS Anesthetized pigs were randomized into 2 groups: hypothermia by peritoneal lavage of ice-cold Ringer's acetate and external cooling (n = 10) and normothermia (n = 10). Aortic rupture with retroperitoneal bleeding was induced by endovascular means creating a 6 mm hole in the retroperitoneal portion of abdominal aorta. Survival (primary outcome), hemodynamics, and arterial blood gases including lactate were collected and analyzed up to 180 min after aortic rupture. RESULTS The body temperature (mean ± standard deviation) in the hypothermic group was 31.5 ± 1.0 °C and 38.7 ± 0.4 °C in the normothermic group at the time for aortic rupture. Survival up to 180 min after the retroperitoneal bleeding was significantly higher in the hypothermic compared with the normothermic group (P = 0.023). CONCLUSIONS Induced hypothermia did not impair survival in this experimental retroperitoneal aortic bleeding model in anesthetized pigs. This finding may indicate a minor role for the coagulation system in this type of bleeding.
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Affiliation(s)
- Artai Pirouzram
- Department of Cardiothoracic and Vascular Surgery, and Department of Health, Medicine and Caring Sciences, Linköping University, Sweden
| | - Maria Wikström
- Department of General Surgery, Central Hospital in Karlstad, Sweden
- School of Medical Sciences, Örebro University, Sweden
| | - Thomas Larzon
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Sweden
| | - Éva Tamás
- Department of Cardiothoracic and Vascular Surgery, and Department of Health, Medicine and Caring Sciences, Linköping University, Sweden
| | - Kristofer F Nilsson
- School of Medical Sciences, Örebro University, Sweden
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Sweden
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Shellen S, Parnia S, Huppert EL, Gonzales AM, Pollard K. Integrating rSO 2 and EEG monitoring in cardiopulmonary resuscitation: A novel methodology. Resusc Plus 2024; 18:100644. [PMID: 38708064 PMCID: PMC11066545 DOI: 10.1016/j.resplu.2024.100644] [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: 05/07/2024] Open
Abstract
Despite improvements in cardiopulmonary resuscitation (CPR), survival and neurologic recovery after cardiac arrest remain poor due to ischemia and subsequent reperfusion injury. As the likelihood of survival and favorable neurologic outcome decreases with increasing severity of ischemia during CPR, developing methods to measure the magnitude of ischemia during resuscitation is critical for improving overall outcomes. Cerebral oximetry, which measures regional cerebral oxygen saturation (rSO2) by near-infrared spectroscopy, has emerged as a potentially beneficial marker of cerebral ischemia during CPR. In numerous preclinical and clinical studies, higher rSO2 during CPR has been associated with improved cardiac arrest survival and neurologic outcome. There is also emerging evidence that this can be integrated with electroencephalogram (EEG) monitoring to provide a bimodal system of brain monitoring during CPR. In this method's review, we discuss the feasibility, application, and implications of this integrated monitoring approach, highlighting its significance for improving clinical outcomes in cardiac arrest management and guiding future research directions.
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Affiliation(s)
- Samantha Shellen
- Critical Care and Resuscitation Research Program, New York University Grossman School of Medicine, NYU Langone Health, New York, NY, USA
| | - Sam Parnia
- Critical Care and Resuscitation Research Program, New York University Grossman School of Medicine, NYU Langone Health, New York, NY, USA
- Division of Pulmonary, Critical Care & Sleep Medicine, New York University Grossman School of Medicine, NYU Langone Health, New York, NY, USA
| | - Elise L. Huppert
- Critical Care and Resuscitation Research Program, New York University Grossman School of Medicine, NYU Langone Health, New York, NY, USA
| | - Anelly M. Gonzales
- Critical Care and Resuscitation Research Program, New York University Grossman School of Medicine, NYU Langone Health, New York, NY, USA
| | - Kenna Pollard
- Critical Care and Resuscitation Research Program, New York University Grossman School of Medicine, NYU Langone Health, New York, NY, USA
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Johnson NJ, Moskowitz A. Norepinephrine or just more epinephrine: Which is the best vasopressor for post-arrest shock? Resuscitation 2024; 198:110215. [PMID: 38609064 DOI: 10.1016/j.resuscitation.2024.110215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 04/05/2024] [Indexed: 04/14/2024]
Affiliation(s)
- Nicholas J Johnson
- Department of Emergency Medicine & Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, United States.
| | - Ari Moskowitz
- Division of Pulmonary Medicine, Division of Critical Care, Montefiore Medical Center, the Bronx, NY, USA
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Livesey JA, Lone N, Black E, Broome R, Syme A, Keating S, Elliott L, McCahill C, Simpson G, Grant H, Auld F, Garrioch S, Hay A, Craven TH. Neurological outcome following out of hospital cardiac arrest: Evaluation of performance of existing risk prediction models in a UK cohort. J Intensive Care Soc 2024; 25:131-139. [PMID: 38737314 PMCID: PMC11086724 DOI: 10.1177/17511437231214146] [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] Open
Abstract
Introduction Out of hospital cardiac arrest (OHCA) is a common problem. Rates of survival are low and a proportion of survivors are left with an unfavourable neurological outcome. Four models have been developed to predict risk of unfavourable outcome at the time of critical care admission - the Cardiac Arrest Hospital Prognosis (CAHP), MIRACLE2, Out of Hospital Cardiac Arrest (OHCA), and Targeted Temperature Management (TTM) models. This evaluation evaluates the performance of these four models in a United Kingdom population and provides comparison to performance of the Acute Physiology and Chronic Health Evaluation II (APACHE-II) score. Methods A retrospective evaluation of the performance of the models was conducted over a 43-month period in 414 adult, non-pregnant patients presenting consecutively following non-traumatic OHCA to the five units in our regional critical care network. Scores were generated for each model for where patients had complete data (CAHP = 347, MIRACLE2 = 375, OHCA = 356, TTM = 385). Cerebral Performance Category (CPC) outcome was calculated for each patient at last documented follow up and an unfavourable outcome defined as CPC ⩾ 3. Performance for discrimination of unfavourable outcome was tested by generating receiver operating characteristic (ROC) curves for each model and comparing the area under the curve (AUC). Results Best performance for discrimination of unfavourable outcome was demonstrated by the high risk group of the CAHP score with an AUC of 0.87 [95% CI 0.83-0.91], specificity of 97.1% [95% CI 93.8-100] and positive predictive value (PPV) of 96.3% [95% CI 92.2-100]. The high risk group of the MIRACLE2 model, which is significantly easier to calculate, had an AUC of 0.81 [95% CI 0.76-0.86], specificity of 92.3% [95% CI 87.2-97.4] and PPV of 95.2% [95% CI 91.9-98.4]. Conclusion The CAHP, MIRACLE2, OHCA and TTM scores all perform comparably in a UK population to the original development and validation cohorts. All four scores outperform APACHE-II in a population of patients resuscitated from OHCA. CAHP and TTM perform best but are more complex to calculate than MIRACLE2, which displays inferior performance.
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Affiliation(s)
- John A Livesey
- Edinburgh Critical Care Research Group, Department of Critical Care, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Nazir Lone
- Edinburgh Critical Care Research Group, Department of Critical Care, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Emily Black
- Department of Critical Care, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Richard Broome
- Department of Critical Care, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Alastair Syme
- Department of Critical Care, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Sean Keating
- Department of Critical Care, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Laura Elliott
- Department of Critical Care, Victoria Hospital Kirkcaldy, Kirkcaldy, UK
| | - Cara McCahill
- Department of Critical Care, Victoria Hospital Kirkcaldy, Kirkcaldy, UK
| | - Gavin Simpson
- Department of Critical Care, Victoria Hospital Kirkcaldy, Kirkcaldy, UK
| | - Helen Grant
- Department of Critical Care, St John’s Hospital, Livingston, UK
| | - Fiona Auld
- Department of Critical Care, Western General Hospital, Edinburgh, UK
| | - Sweyn Garrioch
- Department of Critical Care, Borders General Hospital, Melrose, UK
| | - Alasdair Hay
- Edinburgh Critical Care Research Group, Department of Critical Care, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Thomas H Craven
- Edinburgh Critical Care Research Group, Department of Critical Care, Royal Infirmary of Edinburgh, Edinburgh, UK
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Jansen G, Latka E, Bernhard M, Deicke M, Fischer D, Hoyer A, Keller Y, Kobiella A, Linder S, Strickmann B, Strototte LM, Thies KC, Johanning K, von Dossow V, Hinkelbein J. Midazolam for Post-Arrest Sedation in Pre-Hospital Emergency Care. DEUTSCHES ARZTEBLATT INTERNATIONAL 2024; 121:214-221. [PMID: 38260968 DOI: 10.3238/arztebl.m2023.0277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 12/15/2023] [Accepted: 12/15/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND An out-of-hospital cardiac arrest (OHCA) with return of spontaneous circulation (ROSC) may need to be treated with airway management, emergency ventilation, invasive interventions, and post-arrest sedation. We investigated the influence of the use of midazolam for post-arrest sedation on achieving postresuscitation care targets and the associated risk of hemodynamic complications. METHODS All emergency rescue missions of the Dresden, Gütersloh, and Lippe medical rescue services in the years 2019-2021 were reviewed to identify adult patients who had OHCA, unconsciousness, and sustained ROSC with spontaneous circulation until arrival at the hospital; the findings were supplemented with data from the German Resuscitation Registry. Patients who received midazolam (alone or in combination with other anesthetic agents) for post-arrest sedation were compared with those who did not. The endpoints were the regaining of a systolic blood pressure ≥ 100 mmHg, end-tidal pCO2 35-45 mmHg, and oxygen saturation (SpO2) 94-98%. A propensity score analysis was used to adjust for age, sex, and variables potentially affecting hemodynamic status or the targets for oxygenation and ventilation. RESULTS There were 2335 cases of OHCA among 391 305 emer - gency rescue missions. 571 patients had ROSC before arrival in the hospital (24.5%; female, 33.6%; age, 68 ± 14 years). Of the 395 among them (69.2%) who were treated with postarrest sedation, 249 (63.0%) received midazolam. Patients who received midazolam reached the guideline- recommended targets for oxygenation, ventilation, and blood pressure more frequently than those who were not sedated: the respective odds ratios and 95% confidence intervals were 2.00 [1.20; 3.34], 1.57 [0.99; 2.48], and 1.41 [0.89; 2.21]. CONCLUSION The pre-hospital administration of midazolam leads to more frequent pre-hospital attainment of the oxygenation and ventilation targets in post-resuscitation care, without any evidence of an elevated risk of hemodynamic complications.
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Affiliation(s)
- Gerrit Jansen
- University Department of Anesthesiology, Intensive Care Medicine and Emergency Medicine, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany; Medical School OWL, Bielefeld University, Bielefeld, Germany; Department of Medical and Emergency Services, Study Institute Westfalen-Lippe, Bielefeld, Germany; Emergency Department, University Hospital of Düsseldorf, Düsseldorf, Germany; Medical Director of Rescue Service, Osnabrück District, Germany; Department of Anesthesiology and Operative Intensive Care Medicine, Hochschule Osnabrück - University of Applied Sciences, Osnabrück, Germany; Rescue Service Lippe District, Germany; Biostatistics and Medical Biometry, Medical School OWL, Bielefeld University, Bielefeld, Germany; Rescue Service, Integrated Regional Control Center Dresden, Dresden, Germany; Rescue Service, Gütersloh District, Germany; Skillslab, Medical School OWL, Bielefeld University, Bielefeld, Germany; University Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine, Transfusion Medicine, and Pain Therapy, Evangelisches Klinikum Bethel, University Hospital OWL, Bielefeld University, Bielefeld, Germany; Department of Anesthesiology, Operative Intensive Care Medicine, Emergency Medicine and Pain Therapy, Municipal Hospital of Bielefeld, Bielefeld, Germany; Institute of Anesthesiology and Pain Therapy, Heart and Diabetes Center NRW, University Hospital of the Ruhr-University Bochum, Bad Oeynhausen, Germany
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Combes A, Price S, Levy B. What's new in VA-ECMO for acute myocardial infarction-related cardiogenic shock. Intensive Care Med 2024; 50:590-592. [PMID: 38498163 DOI: 10.1007/s00134-024-07356-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 02/10/2024] [Indexed: 03/20/2024]
Affiliation(s)
- Alain Combes
- Sorbonne Université, Institute of Cardiometabolism and Nutrition, Paris, France.
- Service de Médecine Intensive-Réanimation, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, 47, Boulevard de L'Hôpital, 75013, Paris, France.
| | - Susanna Price
- Cardiology and Critical Care, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
- National Heart and Lung Institute, Imperial College, London, UK
| | - Bruno Levy
- Université de Lorraine, CHRU de Nancy, Institut Lorrain du Cœur Et Des Vaisseaux, Service de Médecine Intensive-Réanimation, U1116, FCRIN-INICRCT, Nancy, France
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El-Menyar A, Wahlen BM. Cardiac arrest, stony heart, and cardiopulmonary resuscitation: An updated revisit. World J Cardiol 2024; 16:126-136. [PMID: 38576519 PMCID: PMC10989225 DOI: 10.4330/wjc.v16.i3.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/17/2024] [Accepted: 02/26/2024] [Indexed: 03/21/2024] Open
Abstract
The post-resuscitation period is recognized as the main predictor of cardiopulmonary resuscitation (CPR) outcomes. The first description of post-resuscitation syndrome and stony heart was published over 50 years ago. Major manifestations may include but are not limited to, persistent precipitating pathology, systemic ischemia/reperfusion response, post-cardiac arrest brain injury, and finally, post-cardiac arrest myocardial dysfunction (PAMD) after successful resuscitation. Why do some patients initially survive successful resuscitation, and others do not? Also, why does the myocardium response vary after resuscitation? These questions have kept scientists busy for several decades since the first successful resuscitation was described. By modifying the conventional modalities of resuscitation together with new promising agents, rescuers will be able to salvage the jeopardized post-resuscitation myocardium and prevent its progression to a dismal, stony heart. Community awareness and staff education are crucial for shortening the resuscitation time and improving short- and long-term outcomes. Awareness of these components before and early after the restoration of circulation will enhance the resuscitation outcomes. This review extensively addresses the underlying pathophysiology, management, and outcomes of post-resuscitation syndrome. The pattern, management, and outcome of PAMD and post-cardiac arrest shock are different based on many factors, including in-hospital cardiac arrest vs out-of-hospital cardiac arrest (OHCA), witnessed vs unwitnessed cardiac arrest, the underlying cause of arrest, the duration, and protocol used for CPR. Although restoring spontaneous circulation is a vital sign, it should not be the end of the game or lone primary outcome; it calls for better understanding and aggressive multi-disciplinary interventions and care. The development of stony heart post-CPR and OHCA remain the main challenges in emergency and critical care medicine.
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Affiliation(s)
- Ayman El-Menyar
- Department of Trauma and Vascular Surgery, Clinical Research, Hamad Medical Corporation, Doha 3050, Qatar
- Department of Clinical Medicine, Weill Cornell Medical College, Doha 24144, Qatar.
| | - Bianca M Wahlen
- Department of Anesthesiology, Hamad Medical Corporation, Doha 3050, Qatar
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Pansiritanachot W, Vathanavalun O, Chakorn T. Early post-resuscitation outcomes in patients receiving norepinephrine versus epinephrine for post-resuscitation shock in a non-trauma emergency department: A parallel-group, open-label, feasibility randomized controlled trial. Resusc Plus 2024; 17:100551. [PMID: 38313404 PMCID: PMC10834978 DOI: 10.1016/j.resplu.2024.100551] [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: 10/24/2023] [Revised: 12/22/2023] [Accepted: 01/08/2024] [Indexed: 02/06/2024] Open
Abstract
Background Post-resuscitation shock is the main cause of early death in post-cardiac arrest patients. To date, no randomized trial compares the efficacy between norepinephrine and epinephrine in post-resuscitation shock patients. Objectives This study aimed to assess the feasibility of the study protocol, and explore potential differences in efficacy and adverse events between norepinephrine and epinephrine in post-resuscitation shock patients. Methods This single-center, parallel-group, open-label, feasibility randomized controlled trial included adult non-traumatic cardiac arrest patients who had post-resuscitation shock within one hour after successful resuscitation. Patients were randomized to receive norepinephrine or epinephrine in a 1:1 ratio. Feasibility outcomes were reported descriptively and narratively. Exploratory analyses were performed to compare the efficacy and adverse events. Results A total of 40 patients were equally allocated. Most feasibility goals were achieved. All patients received the allocated intervention with no withdrawals. Ten (50%) patients in the norepinephrine group and 15 (75%) patients in the epinephrine group achieved the target blood pressure by the protocol with a median time of 42 and 39 min, respectively. However, the protocol deviated in 10 (25%) patients and the recruitment rate did not reach the acceptable threshold. The vasopressor dose to achieve the target blood pressure was significantly lower in the norepinephrine group. No significant differences in mortality rates and adverse outcomes were observed in the exploratory analyses. Conclusion It is feasible to conduct the definitive trial comparing early post-resuscitation outcomes in patients receiving NE versus EPI for post-resuscitation shock. Some protocol modifications are necessary.
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Affiliation(s)
- Wasin Pansiritanachot
- Department of Emergency Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Siriraj, Bangkoknoi, Bangkok 10700, Thailand
| | - Orapim Vathanavalun
- Department of Emergency Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Siriraj, Bangkoknoi, Bangkok 10700, Thailand
| | - Tipa Chakorn
- Department of Emergency Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Siriraj, Bangkoknoi, Bangkok 10700, Thailand
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Doğan NÖ. Initial Vasopressor Dosing After Return of Spontaneous Circulation: Which Drug, Which Dose? J Emerg Med 2024; 66:e391-e392. [PMID: 38499403 DOI: 10.1016/j.jemermed.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/31/2023] [Accepted: 11/04/2023] [Indexed: 03/20/2024]
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12
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Lawson CK, Faine BA, Rech MA, Childs CA, Brown CS, Slocum GW, Acquisto NM, Ray L. Norepinephrine versus epinephrine for hemodynamic support in post-cardiac arrest shock: A systematic review. Am J Emerg Med 2024; 77:158-163. [PMID: 38150986 DOI: 10.1016/j.ajem.2023.12.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 12/17/2023] [Indexed: 12/29/2023] Open
Abstract
PURPOSE The preferred vasopressor in post-cardiac arrest shock has not been established with robust clinical outcomes data. Our goal was to perform a systematic review and meta-analysis comparing rates of in-hospital mortality, refractory shock, and hemodynamic parameters in post-cardiac arrest patients who received either norepinephrine or epinephrine as primary vasopressor support. METHODS We conducted a search of PubMed, Cochrane Library, and CINAHL from 2000 to 2022. Included studies were prospective, retrospective, or published abstracts comparing norepinephrine and epinephrine in adults with post-cardiac arrest shock or with cardiogenic shock and extractable post-cardiac arrest data. The primary outcome of interest was in-hospital mortality. Other outcomes included incidence of arrhythmias or refractory shock. RESULTS The database search returned 2646 studies. Two studies involving 853 participants were included in the systematic review. The proposed meta-analysis was deferred due to low yield. Crude incidence of in-hospital mortality was numerically higher in the epinephrine group compared with norepinephrine in both studies, but only statistically significant in one. Risk of bias was moderate to severe for in-hospital mortality. Additional outcomes were reported differently between studies, minimizing direct comparison. CONCLUSION The vasopressor with the best mortality and hemodynamic outcomes in post-cardiac arrest shock remains unclear. Randomized studies are crucial to remedy this.
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Affiliation(s)
- Christine K Lawson
- Department of Pharmacy, Rhode Island Hospital, 593 Eddy St, Providence, RI 02903, USA.
| | - Brett A Faine
- Department of Pharmacy and Department of Emergency Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Dr., Iowa City, IA 52242, USA
| | - Megan A Rech
- Department of Veteran Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, 5000 5th Ave., Hines, IL 60141, USA
| | - Christopher A Childs
- Hardin Library for the Health Sciences, University of Iowa, 600 Newton Rd., Iowa City, IA 52242, USA
| | - Caitlin S Brown
- Department of Emergency Medicine and Department of Pharmacy, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Giles W Slocum
- Department of Emergency Medicine and Department of Pharmacy, Rush University Medical Center, 1653 W. Congress Parkway, Chicago, IL 60612, USA
| | - Nicole M Acquisto
- Department of Emergency Medicine and Department of Pharmacy, University of Rochester Medical Center, 601 Elmwood Ave, Box 638, Rochester, NY 14642, USA
| | - Lance Ray
- Department of Pharmacy, Denver Health and Hospital Authority, 790 Delaware St., MC 0056, Denver, CO 80204, USA; Department of Emergency Medicine, University of Colorado, 13001 E 17th Pl., Aurora, CO 80045, USA
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13
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Hirsch KG, Abella BS, Amorim E, Bader MK, Barletta JF, Berg K, Callaway CW, Friberg H, Gilmore EJ, Greer DM, Kern KB, Livesay S, May TL, Neumar RW, Nolan JP, Oddo M, Peberdy MA, Poloyac SM, Seder D, Taccone FS, Uzendu A, Walsh B, Zimmerman JL, Geocadin RG. Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement from the American Heart Association and Neurocritical Care Society. Neurocrit Care 2024; 40:1-37. [PMID: 38040992 PMCID: PMC10861627 DOI: 10.1007/s12028-023-01871-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 06/08/2023] [Indexed: 12/03/2023]
Abstract
The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.
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Affiliation(s)
| | | | - Edilberto Amorim
- San Francisco-Weill Institute for Neurosciences, University of California, San Francisco, USA
| | - Mary Kay Bader
- Providence Mission Hospital Nursing Center of Excellence/Critical Care Services, Mission Viejo, USA
| | | | | | | | | | | | | | - Karl B Kern
- Sarver Heart Center, University of Arizona, Tucson, USA
| | | | | | | | - Jerry P Nolan
- Warwick Medical School, University of Warwick, Coventry, UK
- Royal United Hospital, Bath, UK
| | - Mauro Oddo
- CHUV-Lausanne University Hospital, Lausanne, Switzerland
| | | | | | | | | | - Anezi Uzendu
- St. Luke's Mid America Heart Institute, Kansas City, USA
| | - Brian Walsh
- University of Texas Medical Branch School of Health Sciences, Galveston, USA
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14
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Nikolovski SS, Lazic AD, Fiser ZZ, Obradovic IA, Tijanic JZ, Raffay V. Recovery and Survival of Patients After Out-of-Hospital Cardiac Arrest: A Literature Review Showcasing the Big Picture of Intensive Care Unit-Related Factors. Cureus 2024; 16:e54827. [PMID: 38529434 PMCID: PMC10962929 DOI: 10.7759/cureus.54827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2024] [Indexed: 03/27/2024] Open
Abstract
As an important public health issue, out-of-hospital cardiac arrest (OHCA) requires several stages of high quality medical care, both on-field and after hospital admission. Post-cardiac arrest shock can lead to severe neurological injury, resulting in poor recovery outcome and increased risk of death. These characteristics make this condition one of the most important issues to deal with in post-OHCA patients hospitalized in intensive care units (ICUs). Also, the majority of initial post-resuscitation survivors have underlying coronary diseases making revascularization procedure another crucial step in early management of these patients. Besides keeping myocardial blood flow at a satisfactory level, other tissues must not be neglected as well, and maintaining mean arterial pressure within optimal range is also preferable. All these procedures can be simplified to a certain level along with using targeted temperature management methods in order to decrease metabolic demands in ICU-hospitalized post-OHCA patients. Additionally, withdrawal of life-sustaining therapy as a controversial ethical topic is under constant re-evaluation due to its possible influence on overall mortality rates in patients initially surviving OHCA. Focusing on all of these important points in process of managing ICU patients is an imperative towards better survival and complete recovery rates.
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Affiliation(s)
- Srdjan S Nikolovski
- Pathology and Laboratory Medicine, Cardiovascular Research Institute, Loyola University Chicago Health Science Campus, Maywood, USA
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Aleksandra D Lazic
- Emergency Center, Clinical Center of Vojvodina, Novi Sad, SRB
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Zoran Z Fiser
- Emergency Medicine, Department of Emergency Medicine, Novi Sad, SRB
| | - Ivana A Obradovic
- Anesthesiology, Resuscitation, and Intensive Care, Sveti Vračevi Hospital, Bijeljina, BIH
| | - Jelena Z Tijanic
- Emergency Medicine, Municipal Institute of Emergency Medicine, Kragujevac, SRB
| | - Violetta Raffay
- School of Medicine, European University Cyprus, Nicosia, CYP
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
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15
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Tamis-Holland JE, Menon V, Johnson NJ, Kern KB, Lemor A, Mason PJ, Rodgers M, Serrao GW, Yannopoulos D. Cardiac Catheterization Laboratory Management of the Comatose Adult Patient With an Out-of-Hospital Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation 2024; 149:e274-e295. [PMID: 38112086 DOI: 10.1161/cir.0000000000001199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
Out-of-hospital cardiac arrest is a leading cause of death, accounting for ≈50% of all cardiovascular deaths. The prognosis of such individuals is poor, with <10% surviving to hospital discharge. Survival with a favorable neurologic outcome is highest among individuals who present with a witnessed shockable rhythm, received bystander cardiopulmonary resuscitation, achieve return of spontaneous circulation within 15 minutes of arrest, and have evidence of ST-segment elevation on initial ECG after return of spontaneous circulation. The cardiac catheterization laboratory plays an important role in the coordinated Chain of Survival for patients with out-of-hospital cardiac arrest. The catheterization laboratory can be used to provide diagnostic, therapeutic, and resuscitative support after sudden cardiac arrest from many different cardiac causes, but it has a unique importance in the treatment of cardiac arrest resulting from underlying coronary artery disease. Over the past few years, numerous trials have clarified the role of the cardiac catheterization laboratory in the management of resuscitated patients or those with ongoing cardiac arrest. This scientific statement provides an update on the contemporary approach to managing resuscitated patients or those with ongoing cardiac arrest.
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16
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Hirsch KG, Abella BS, Amorim E, Bader MK, Barletta JF, Berg K, Callaway CW, Friberg H, Gilmore EJ, Greer DM, Kern KB, Livesay S, May TL, Neumar RW, Nolan JP, Oddo M, Peberdy MA, Poloyac SM, Seder D, Taccone FS, Uzendu A, Walsh B, Zimmerman JL, Geocadin RG. Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement From the American Heart Association and Neurocritical Care Society. Circulation 2024; 149:e168-e200. [PMID: 38014539 PMCID: PMC10775969 DOI: 10.1161/cir.0000000000001163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.
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17
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Zhou FW, Liu C, Li DZ, Zhang Y, Zhou FC. Efficacy and safety of corticosteroid therapy in patients with cardiac arrest: A meta-analysis of randomized controlled trials. Am J Emerg Med 2024; 75:111-118. [PMID: 37939521 DOI: 10.1016/j.ajem.2023.10.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 10/05/2023] [Accepted: 10/19/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND The clinical benefits of steroid therapy during cardiac arrest (CA) are unclear. Several recent clinical trials have shown that administering corticosteroid therapy during CA may improve patient outcomes. The purpose of the present study was to determine whether providing corticosteroids improves outcomes for patients following CA. METHODS We searched the PubMed, Embase, Cochrane Library, Web of Science and CNKI databases for randomized controlled trials comparing corticosteroid therapy to placebo during CA. RESULTS Eleven relevant studies involving a total of 2273 patients were included in the meta-analysis. The statistical analysis showed that corticosteroid treatment during CA was significantly associated with an increased rate of sustained return of spontaneous circulation (ROSC) (OR: 2.05, 95% CI: 1.24 to 3.37, P < 0.01). Corticosteroid treatment during CA did not show a significant benefit in favorable neurological outcomes (OR: 1.13, 95% CI: 0.81 to 1.58, P = 0.49) or overall survival rate at hospital discharge (OR: 1.29, 95% CI: 0.74 to 2.26, P = 0.38). However, in the subgroup analysis, we found that patients had a significantly increased survival rate and ROSC if the dose of corticosteroid therapy above 100 mg methylprednisolone. The statistical analysis revealed no significant differences in adverse events. CONCLUSION High-dose corticosteroid treatment (above 100 mg methylprednisolone) is associated with better overall survival rate at hospital discharge and ROSC outcomes. However, there is uncertainty regarding whether this treatment results in a benefit or harm to the favorable neurological outcomes at hospital discharge.
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Affiliation(s)
- Fa-Wei Zhou
- Department of Emergency, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Department of Emergency, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi, China
| | - Chang Liu
- Department of Emergency, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - De-Zhong Li
- Department of Emergency, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi, China
| | - Yong Zhang
- Department of Nephrology, Jianli People's Hospital, Jianli, China.
| | - Fa-Chun Zhou
- Department of Emergency, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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18
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Javaudin F, Bougouin W, Fanet L, Diehl JL, Jost D, Beganton F, Empana JP, Jouven X, Adnet F, Lamhaut L, Lascarrou JB, Cariou A, Dumas F. Cumulative dose of epinephrine and mode of death after non-shockable out-of-hospital cardiac arrest: a registry-based study. Crit Care 2023; 27:496. [PMID: 38124126 PMCID: PMC10734153 DOI: 10.1186/s13054-023-04776-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 12/11/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Epinephrine increases the chances of return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest (OHCA), especially when the initial rhythm is non-shockable. However, this drug could also worsen the post-resuscitation syndrome (PRS). We assessed the association between epinephrine use during cardiopulmonary resuscitation (CPR) and subsequent intensive care unit (ICU) mortality in patients with ROSC after non-shockable OHCA. METHODS We used data prospectively collected in the Sudden Death Expertise Center (SDEC) registry (capturing OHCA data located in the Greater Paris area, France) between May 2011 and December 2021. All adults with ROSC after medical, cardiac and non-cardiac causes, non-shockable OHCA admitted to an ICU were included. The mode of death in the ICU was categorized as cardiocirculatory, neurological, or other. RESULTS Of the 2,792 patients analyzed, there were 242 (8.7%) survivors at hospital discharge, 1,004 (35.9%) deaths from cardiocirculatory causes, 1,233 (44.2%) deaths from neurological causes, and 313 (11.2%) deaths from other etiologies. The cardiocirculatory death group received more epinephrine (4.6 ± 3.8 mg versus 1.7 ± 2.8 mg, 3.2 ± 2.6 mg, and 3.5 ± 3.6 mg for survivors, neurological deaths, and other deaths, respectively; p < 0.001). The proportion of cardiocirculatory death increased linearly (R2 = 0.92, p < 0.001) with cumulative epinephrine doses during CPR (17.7% in subjects who did not receive epinephrine and 62.5% in those who received > 10 mg). In multivariable analysis, a cumulative dose of epinephrine was strongly associated with cardiocirculatory death (adjusted odds ratio of 3.45, 95% CI [2.01-5.92] for 1 mg of epinephrine; 12.28, 95% CI [7.52-20.06] for 2-5 mg; and 23.71, 95% CI [11.02-50.97] for > 5 mg; reference 0 mg; population reference: alive at hospital discharge), even after adjustment on duration of resuscitation. The other modes of death (neurological and other causes) were also associated with epinephrine use, but to a lesser extent. CONCLUSIONS In non-shockable OHCA with ROSC, the dose of epinephrine used during CPR is strongly associated with early cardiocirculatory death. Further clinical studies aimed at limiting the dose of epinephrine during CPR seem warranted. Moreover, strategies for the prevention and management of PRS should take this dose of epinephrine into consideration for future trials.
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Affiliation(s)
- François Javaudin
- Paris Sudden Death Expertise Center, 75015, Paris, France.
- Emergency Department, Nantes University Hospital, 44000, Nantes, France.
- SAMU, 1 Quai Moncousu, 44093, Nantes Cedex1, France.
| | - Wulfran Bougouin
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Université Paris Cité, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Medical Intensive Care Unit, Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300, Massy, France
- AfterROSC Network, Paris, France
| | - Lucie Fanet
- Paris Sudden Death Expertise Center, 75015, Paris, France
| | - Jean-Luc Diehl
- Medical Intensive Care Unit, AP-HP, European Georges Pompidou Hospital, 75015, Paris, France
- Innovative Therapies in Hemostasis, INSERM 1140, Université Paris Cité, 75006, Paris, France
| | - Daniel Jost
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Université Paris Cité, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- BSPP (Paris Fire-Brigade Emergency-Medicine Department), 1 Place Jules Renard, 75017, Paris, France
| | - Frankie Beganton
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Université Paris Cité, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
| | - Jean-Philippe Empana
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Université Paris Cité, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
| | - Xavier Jouven
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Université Paris Cité, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Cardiology Department, AP-HP, European Georges Pompidou Hospital, 75015, Paris, France
| | - Frédéric Adnet
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Université Paris Cité, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- SAMU de Paris, Necker University Hospital, Assistance Publique-Hôpitaux de Paris, 75015, Paris, France
| | - Lionel Lamhaut
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Université Paris Cité, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- SAMU de Paris, Necker University Hospital, Assistance Publique-Hôpitaux de Paris, 75015, Paris, France
| | - Jean-Baptiste Lascarrou
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Université Paris Cité, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- AfterROSC Network, Paris, France
- Medecine Intensive Reanimation, Nantes University Hospital, 44000, Nantes, France
| | - Alain Cariou
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Université Paris Cité, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- AfterROSC Network, Paris, France
- Medical Intensive Care Unit, AP-HP, Cochin Hospital, 75014, Paris, France
| | - Florence Dumas
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Université Paris Cité, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Emergency Department, AP-HP, Cochin-Hotel-Dieu Hospital, 75014, Paris, France
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Langeslag J, Onland W, Visser D, Groenendaal F, de Vries L, van Kaam AH, de Haan TR. Predictive performance of multiple organ dysfunction in asphyxiated newborns treated with therapeutic hypothermia on 24-month outcome: a cohort study. Arch Dis Child Fetal Neonatal Ed 2023; 109:41-45. [PMID: 37369599 DOI: 10.1136/archdischild-2023-325585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Perinatal asphyxia may be followed by multiple organ dysfunction (MOD) and is often included in prognostication of the individual patient, but evidence of discriminating accuracy is lacking. The aim of this study was to assess whether MOD in asphyxiated neonates during therapeutic hypothermia (TH) predicts mortality or neurodevelopmental impairment (NDI) at 24 months of age and which peripartum variables are associated with the onset of MOD. METHODS A retrospective analysis of a prospective cohort study of asphyxiated newborns undergoing TH was performed. MOD was defined as dysfunction of the brain (encephalopathy) combined with two or more organ systems. Outcome was routinely assessed by standardised developmental testing at the age of 24 months. The predictive accuracy of MOD on the combined outcome and its components (death and NDI) was expressed as areas under the receiver operating characteristic curves (AUROCs). The associations of peripartum variables and development of MOD were expressed as ORs and their CIs. RESULTS 189 infants (median gestation 40 (range 36-42 weeks) with moderate to severe hypoxic ischaemic encephalopathy were included. 47% developed MOD. The prediction of the combined 24-month outcome or its components showed AUROCs <0.70. Associated with MOD were pH at birth (OR 0.97, CI 0.95 to 0.99), lactate at birth (OR 1.09, CI 1.04 to 1.15), Base Excess (BE) at birth (OR 0.94, CI 0.90 to 0.99) and epinephrine administration during resuscitation (OR 2.09, CI 1.02 to 4.40). CONCLUSION MOD has a low discriminating accuracy in predicting mortality or NDI at 24 months age and might not be useful for prognostication. Signs of acid-base disturbance and adrenalin use at birth are associated with the development of MOD.
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Affiliation(s)
- Juliette Langeslag
- Department of Neonatology, Amsterdam UMC Locatie University of Amsterdam, Emma Children's Hospital, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
| | - Wes Onland
- Department of Neonatology, Amsterdam UMC Locatie University of Amsterdam, Emma Children's Hospital, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
| | - Douwe Visser
- Department of Neonatology, Amsterdam UMC Locatie University of Amsterdam, Emma Children's Hospital, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
| | - Floris Groenendaal
- Department of Neonatology, Whilhelmina Children's Hospital, University Medical Center Utrecht, and Brain Center, Utrecht, The Netherlands
| | - Linda de Vries
- Department of Neonatology, Whilhelmina Children's Hospital, University Medical Center Utrecht, and Brain Center, Utrecht, The Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Amsterdam UMC Locatie University of Amsterdam, Emma Children's Hospital, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
| | - T R de Haan
- Department of Neonatology, Amsterdam UMC Locatie University of Amsterdam, Emma Children's Hospital, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
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20
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Lascarrou JB, Ermel C, Cariou A, Laitio T, Kirkegaard H, Søreide E, Grejs AM, Reinikainen M, Colin G, Taccone FS, Le Gouge A, Skrifvars MB. Dysnatremia at ICU admission and functional outcome of cardiac arrest: insights from four randomised controlled trials. Crit Care 2023; 27:472. [PMID: 38041177 PMCID: PMC10693108 DOI: 10.1186/s13054-023-04715-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 10/30/2023] [Indexed: 12/03/2023] Open
Abstract
PURPOSE To evaluate the potential association between early dysnatremia and 6-month functional outcome after cardiac arrest. METHODS We pooled data from four randomised clinical trials in post-cardiac-arrest patients admitted to the ICU with coma after stable return of spontaneous circulation (ROSC). Admission natremia was categorised as normal (135-145 mmol/L), low, or high. We analysed associations between natremia category and Cerebral Performance Category (CPC) 1 or 2 at 6 months, with and without adjustment on the modified Cardiac Arrest Hospital Prognosis Score (mCAHP). RESULTS We included 1163 patients (581 from HYPERION, 352 from TTH48, 120 from COMACARE, and 110 from Xe-HYPOTHECA) with a mean age of 63 ± 13 years and a predominance of males (72.5%). A cardiac cause was identified in 63.6% of cases. Median time from collapse to ROSC was 20 [15-29] minutes. Overall, mean natremia on ICU admission was 137.5 ± 4.7 mmol/L; 211 (18.6%) and 31 (2.7%) patients had hyponatremia and hypernatremia, respectively. By univariate analysis, CPC 1 or 2 at 6 months was significantly less common in the group with hyponatremia (50/211 [24%] vs. 363/893 [41%]; P = 0.001); the mCAHP-adjusted odds ratio was 0.45 (95%CI 0.26-0.79, p = 0.005). The number of patients with hypernatremia was too small for a meaningful multivariable analysis. CONCLUSIONS Early hyponatremia was common in patients with ROSC after cardiac arrest and was associated with a poorer 6-month functional outcome. The mechanisms underlying this association remain to be elucidated in order to determine whether interventions targeting hyponatremia are worth investigating. Registration ClinicalTrial.gov, NCT01994772, November 2013, 21.
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Affiliation(s)
- Jean Baptiste Lascarrou
- Nantes Université, CHU Nantes, Movement - Interactions - Performance, MIP, UR 4334, 44000, Nantes, France.
- Médecine Intensive Reanimation, University Hospital Centre, Nantes, France.
- AfterROSC Network, Nantes, France.
- Service de Médecine Intensive Reanimation, CHU Nantes, 30 Boulevard Jean Monet, 44093, Nantes Cedex 9, France.
| | - Cyrielle Ermel
- Médecine Intensive Reanimation, University Hospital Centre, Nantes, France
| | - Alain Cariou
- AfterROSC Network, Nantes, France
- Université de Paris Cité, INSERM, Paris Cardiovascular Research Centre, Paris, France
- Médecine Intensive Reanimation, AP-HP, CHU Cochin, Paris, France
| | - Timo Laitio
- Division of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital, University of Turku, Turku, Finland
| | - Hans Kirkegaard
- Research Centre for Emergency Medicine and Anaesthesiology and Intensive Care, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Eldar Søreide
- Intensive Care Unit, Department of Anaesthesiology, Stavanger University Hospital and Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Anders M Grejs
- Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Matti Reinikainen
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital, Kuopio, Finland
- University of Eastern Finland, Kuopio, Finland
| | - Gwenhael Colin
- AfterROSC Network, Nantes, France
- Médecine Intensive Reanimation, CHD Vendee, La Roche Sur Yon, France
| | - Fabio Silvio Taccone
- AfterROSC Network, Nantes, France
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | | | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Mohnke K, Conzelmann P, Renz M, Riedel J, Rissel R, Urmann A, Hain J, Duenges B, Ziebart A, Ruemmler R. Ultra-low tidal volume ventilation during cardiopulmonary resuscitation shows no mitigating effect on pulmonary end-organ damage compared to standard ventilation: insights from a porcine model. Intensive Care Med Exp 2023; 11:81. [PMID: 38006467 PMCID: PMC10676323 DOI: 10.1186/s40635-023-00568-6] [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: 07/30/2023] [Accepted: 11/17/2023] [Indexed: 11/27/2023] Open
Abstract
OBJECTIVE This study aimed to determine whether ultra-low tidal volume ventilation (ULTVV) applied during cardiopulmonary resuscitation (CPR) compared with standard ventilation (intermittent positive pressure ventilation, IPPV) can reduce pulmonary end-organ damage in the post-resuscitation period. METHODS A prospective, randomized trial was conducted using a porcine model (n = 45). The animals were divided into three groups: IPPV, ULTVV, and a sham control group. Juvenile male pigs underwent CPR after inducing ventricular fibrillation and received the designated ventilation intervention [IPPV: tidal volume 6-8 ml per kilogram body weight (ml/kg BW), respiratory rate 10/min, FiO2 1.0; ULTVV: tidal volume 2-3 ml/kg BW, respiratory rate 50/min, FiO2 1.0]. A 20-h observation period followed if return of spontaneous circulation was achieved. Histopathological examination using the diffuse alveolar damage scoring system was performed on postmortem lung tissue samples. Arterial and venous blood gas analyses and ventilation/perfusion measurements via multiple inert gas elimination technique (MIGET) were repeatedly recorded during the experiment. RESULTS Out of the 45 experiments conducted, 28 animals were excluded based on predefined criteria. Histopathological analysis showed no significant differences in lung damage between the ULTVV and IPPV groups. ULTVV demonstrated adequate oxygenation and decarboxylation. MIGET measurements during and after resuscitation revealed no significant differences between the intervention groups. CONCLUSION In the short-term follow-up phase, ULTVV demonstrated similar histopathological changes and functional pulmonary parameters compared to standard ventilation. Further research is needed to investigate the long-term effects and clinical implications of ULTVV in resuscitation settings.
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Affiliation(s)
- Katja Mohnke
- Department of Anesthesiology, Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany.
| | - Philipp Conzelmann
- Department of Anesthesiology, Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Miriam Renz
- Department of Anesthesiology, Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Julian Riedel
- Department of Anesthesiology, Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - René Rissel
- Department of Anesthesiology, Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Andrea Urmann
- Department of Anesthesiology, Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Johanna Hain
- Department of Anesthesiology, Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Bastian Duenges
- Department of Anesthesiology, Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Alexander Ziebart
- Department of Anesthesiology, Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Robert Ruemmler
- Department of Anesthesiology, Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
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Laurikkala J, Ameloot K, Reinikainen M, Palmers PJ, De Deyne C, Bert F, Dupont M, Janssens S, Dens J, Hästbacka J, Jakkula P, Loisa P, Birkelund T, Wilkman E, Vaara ST, Skrifvars MB. The effect of higher or lower mean arterial pressure on kidney function after cardiac arrest: a post hoc analysis of the COMACARE and NEUROPROTECT trials. Ann Intensive Care 2023; 13:113. [PMID: 37987871 PMCID: PMC10663425 DOI: 10.1186/s13613-023-01210-0] [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: 06/25/2023] [Accepted: 11/06/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND We aimed to study the incidence of acute kidney injury (AKI) in out-of-hospital cardiac arrest (OHCA) patients treated according to low-normal or high-normal mean arterial pressure (MAP) targets. METHODS A post hoc analysis of the COMACARE (NCT02698917) and Neuroprotect (NCT02541591) trials that randomized patients to lower or higher targets for the first 36 h of intensive care. Kidney function was defined using the Kidney Disease Improving Global Outcome (KDIGO) classification. We used Cox regression analysis to identify factors associated with AKI after OHCA. RESULTS A total of 227 patients were included: 115 in the high-normal MAP group and 112 in the low-normal MAP group. Eighty-six (38%) patients developed AKI during the first five days; 40 in the high-normal MAP group and 46 in the low-normal MAP group (p = 0.51). The median creatinine and daily urine output were 85 μmol/l and 1730 mL/day in the high-normal MAP group and 87 μmol/l and 1560 mL/day in the low-normal MAP group. In a Cox regression model, independent AKI predictors were no bystander cardiopulmonary resuscitation (p < 0.01), non-shockable rhythm (p < 0.01), chronic hypertension (p = 0.03), and time to the return of spontaneous circulation (p < 0.01), whereas MAP target was not an independent predictor (p = 0.29). CONCLUSION Any AKI occurred in four out of ten OHCA patients. We found no difference in the incidence of AKI between the patients treated with lower and those treated with higher MAP after CA. Higher age, non-shockable initial rhythm, and longer time to ROSC were associated with shorter time to AKI. CLINICAL TRIAL REGISTRATION COMACARE (NCT02698917), NEUROPROTECT (NCT02541591).
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Affiliation(s)
- Johanna Laurikkala
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 9, 00290 HUS, Helsinki, Finland.
| | - Koen Ameloot
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Departement de Cardiologie/Soins Intensifs Adultes, CHC-Montlégia, Liège, Belgique
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
- Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
| | - Matti Reinikainen
- Department of Anaesthesiology and Intensive Care, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
| | - Pieter-Jan Palmers
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Departement de Cardiologie/Soins Intensifs Adultes, CHC-Montlégia, Liège, Belgique
| | - Cathy De Deyne
- Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
- Department of Anesthesiology and Critical Care Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Ferdinande Bert
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Departement de Cardiologie/Soins Intensifs Adultes, CHC-Montlégia, Liège, Belgique
| | - Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Departement de Cardiologie/Soins Intensifs Adultes, CHC-Montlégia, Liège, Belgique
| | - Stefan Janssens
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Joseph Dens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Departement de Cardiologie/Soins Intensifs Adultes, CHC-Montlégia, Liège, Belgique
- Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
| | - Johanna Hästbacka
- Department of Anesthesia and Intensive Care, Tampere University Hospital and Tampere University, Tampere, Finland
| | - Pekka Jakkula
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 9, 00290 HUS, Helsinki, Finland
| | - Pekka Loisa
- Department of Intensive Care, Päijät-Häme Central Hospital, Lahti, Finland
| | | | - Erika Wilkman
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 9, 00290 HUS, Helsinki, Finland
| | - Suvi T Vaara
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 9, 00290 HUS, Helsinki, Finland
| | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Katzenschlager S, Obermaier M, Kuhner M, Spöttl W, Dietrich M, Weigand MA, Weilbacher F, Popp E. [Focus emergency medicine 2022/2023-Summary of selected studies in emergency medicine]. DIE ANAESTHESIOLOGIE 2023; 72:809-820. [PMID: 37725144 DOI: 10.1007/s00101-023-01330-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/02/2023] [Indexed: 09/21/2023]
Affiliation(s)
- S Katzenschlager
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland.
| | - M Obermaier
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M Kuhner
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - W Spöttl
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - F Weilbacher
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - E Popp
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
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Kruit N, Hambly J, Ong A, French J, Bowcock E, Kushwaha V, Jain P, Dennis M. Protocolised Management of Cardiogenic Shock and Shock Teams: A Narrative Review. Heart Lung Circ 2023; 32:1148-1157. [PMID: 37813747 DOI: 10.1016/j.hlc.2023.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 07/30/2023] [Accepted: 08/22/2023] [Indexed: 10/11/2023]
Abstract
Despite advances in therapy, the incidence of cardiogenic shock continues to increase, with significant mortality that has improved minimally over time. Treatment options for cardiogenic shock are complex and time-, resource-, and case volume-dependent, and involve multiple medical specialties. To provide early, more equitable, and standardised access to cardiogenic shock expertise with advanced therapies, cardiogenic shock teams with a protocolised treatment approach have been proposed. These processes have been applied across hospitals into integrated cardiogenic shock networks. This narrative review evaluates the role of cardiogenic shock teams, protocolised and regionalised shock networks, and the main individual components of protocolised shock management approaches.
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Affiliation(s)
- Natalie Kruit
- Westmead Hospital, Sydney, NSW, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - James Hambly
- Westmead Hospital, Sydney, NSW, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Andrew Ong
- Westmead Hospital, Sydney, NSW, Australia
| | - John French
- Liverpool Hospital, Sydney, NSW, Australia; University of New South Wales, Sydney, NSW, Australia
| | - Emma Bowcock
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Nepean Hospital, Sydney, NSW, Australia
| | - Virag Kushwaha
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Prince of Wales Hospital, Sydney, NSW, Australia
| | - Pankaj Jain
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Mark Dennis
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Royal Prince Alfred Hospital, Sydney, NSW, Australia.
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25
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Wender ER, Counts CR, Van Dyke M, Sayre MR, Maynard C, Johnson NJ. Prehospital Administration of Norepinephrine and Epinephrine for Shock after Resuscitation from Cardiac Arrest. PREHOSP EMERG CARE 2023; 28:453-458. [PMID: 37642521 DOI: 10.1080/10903127.2023.2252500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 08/18/2023] [Accepted: 08/23/2023] [Indexed: 08/31/2023]
Abstract
INTRODUCTION Shock after resuscitation from out-of-hospital cardiac arrest (OHCA) is often treated with vasopressors. We examined whether infusion of epinephrine versus norepinephrine was associated with prehospital rearrest and neurologically favorable survival among OHCA patients. METHODS This retrospective study included OHCA cases in Seattle, Washington from 2014-2021 who had return of spontaneous circulation (ROSC) followed by vasopressor infusion. Our primary exposure was infusion of epinephrine or norepinephrine. Our primary outcome was prehospital rearrest. Secondary outcomes included survival and neurologically favorable outcome (Cerebral Performance Category score of 1 or 2). We used multivariable logistic regression to test associations between exposures and outcomes adjusting for key covariates. RESULTS Of 451 OHCA patients with ROSC followed by vasopressor infusion, 253 (56%) received norepinephrine and 198 (44%) received epinephrine infusions. Those who received epinephrine were older (median 66 [interquartile ranges {IQR} 53-79] vs 63 [IQR 47-75] years), but otherwise had similar baseline characteristics. Patients who received epinephrine were twice as likely to rearrest (55% vs 25%). After adjustment, the difference in rearrest rates between epinephrine and norepinephrine persisted (OR 3.28, 95%CI 2.25-5.08), and the odds of pulses at hospital arrival were lower in the epinephrine group (OR 0.52 95%CI 0.32-0.83). After adjustment, there was no difference in neurologically favorable survival, survival to hospital admission, or survival to discharge. CONCLUSION Patients who received epinephrine infusions after ROSC suffered prehospital rearrest more frequently than those who received norepinephrine. Survival and neurological status at hospital discharge were similar. Future trials should examine the optimal approach to hemodynamic management for post-OHCA shock.
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Affiliation(s)
- Emma R Wender
- Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Catherine R Counts
- Department of Emergency Medicine, University of Washington, Seattle, Washington
- Seattle Fire Department, Seattle, Washington
| | - Molly Van Dyke
- Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Michael R Sayre
- Department of Emergency Medicine, University of Washington, Seattle, Washington
- Seattle Fire Department, Seattle, Washington
| | - Charles Maynard
- Department of Health Systems and Population Health, University of Washington, Seattle, Washington
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington, Seattle, Washington
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Huang YH, Lin YS, Wu CH, How CK, Chen CT. Prognostic value of neutrophil-lymphocyte ratio in out-of-hospital cardiac arrest patients receiving targeted temperature management: An observational cohort study. J Formos Med Assoc 2023; 122:890-898. [PMID: 36739232 DOI: 10.1016/j.jfma.2023.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/26/2022] [Accepted: 01/12/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Out-hospital cardiac arrest (OHCA) is a major cause of mortality and morbidity worldwide. The magnitude of the post-resuscitation inflammatory response is closely related to the severity of the circulatory dysfunction. Currently, targeted temperature management (TTM) has become an essential part of the post-resuscitation care for unconscious OHCA survivors. Some novel prognostic inflammatory markers may help predict outcomes of OHCA patients after TTM. METHODS A retrospective observational cohort study of 65 OHCA patients treated with TTM was conducted in a tertiary hospital in Taiwan. The primary outcome measure was in-hospital mortality. Baseline and post-TTM neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte (PLR), and the systemic immune inflammation index (SII) were identified as potential predictors. RESULTS These patients had a mean age of 62.2 ± 17.0 years. Among the total sample, 53.8% had an initial shockable rhythm and 61.5% had a presumed cardiac etiology. The median resuscitation duration was 20 min (IQR 13.5-28.5) and 60% received subsequent percutaneous coronary intervention. The mean baseline NLR, PLR and SII were 7.5 ± 16.7, 118 ± 207, 1395 ± 3004, and the mean post-TTM NLR, PLR and SII were 15.0 ± 11.6, 206 ± 124, 2369 ± 2569, respectively. Using multiple logistic regression analysis, post-TTM NLR was one of the independent factors which predicted in-hospital mortality (adjusted odds ratio (aOR): 1.249, 95% confidence interval (CI): 1.040-1.501, p = 0.017). CONCLUSION Post-TTM NLR is a predictor of in-hospital mortality in OHCA patients who underwent TTM.
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Affiliation(s)
- Yung-Huai Huang
- Emergency Department, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yu-Shan Lin
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Cheng-Hsueh Wu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan; Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chorng-Kuang How
- Emergency Department, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Chung-Ting Chen
- Emergency Department, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan; Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan.
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27
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Lender O. What caused this patient's cardiac arrest? JAAPA 2023; 36:46-49. [PMID: 37368854 DOI: 10.1097/01.jaa.0000937268.14398.1e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Affiliation(s)
- Olga Lender
- Olga Lender practices in cardiac surgery at Cleveland Clinic's Heart, Vascular and Thoracic Institute in Abu Dhabi, United Arab Emirates. The author has disclosed no potential conflicts of interest, financial or otherwise
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Binois Y, Renaudier M, Dumas F, Youssfi Y, Beganton F, Jost D, Lamhaut L, Marijon E, Jouven X, Cariou A, Bougouin W. Factors associated with circulatory death after out-of-hospital cardiac arrest: a population-based cluster analysis. Ann Intensive Care 2023; 13:49. [PMID: 37294400 DOI: 10.1186/s13613-023-01143-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 05/25/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Out-of-hospital cardiac arrest (OHCA) is a common cause of death. Early circulatory failure is the most common reason for death within the first 48 h. This study in intensive care unit (ICU) patients with OHCA was designed to identify and characterize clusters based on clinical features and to determine the frequency of death from refractory postresuscitation shock (RPRS) in each cluster. METHODS We retrospectively identified adults admitted alive to ICUs after OHCA in 2011-2018 and recorded in a prospective registry for the Paris region (France). We identified patient clusters by performing an unsupervised hierarchical cluster analysis (without mode of death among the variables) based on Utstein clinical and laboratory variables. For each cluster, we estimated the hazard ratio (HRs) for RPRS. RESULTS Of the 4445 included patients, 1468 (33%) were discharged alive from the ICU and 2977 (67%) died in the ICU. We identified four clusters: initial shockable rhythm with short low-flow time (cluster 1), initial non-shockable rhythm with usual absence of ST-segment elevation (cluster 2), initial non-shockable rhythm with long no-flow time (cluster 3), and long low-flow time with high epinephrine dose (cluster 4). RPRS was significantly associated with this last cluster (HR, 5.51; 95% confidence interval 4.51-6.74). CONCLUSIONS We identified patient clusters based on Utstein criteria, and one cluster was strongly associated with RPRS. This result may help to make decisions about using specific treatments after OHCA.
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Affiliation(s)
- Yannick Binois
- Université de Paris, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Paris Sudden Death Expertise Center, 75015, Paris, France
| | - Marie Renaudier
- Université de Paris, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Paris Sudden Death Expertise Center, 75015, Paris, France
| | - Florence Dumas
- Université de Paris, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Emergency Department, AP-HP, Cochin-Hotel-Dieu Hospital, 75014, Paris, France
| | - Younès Youssfi
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Center for Research in Economics and Statistics, 91120, Palaiseau, France
| | - Frankie Beganton
- Université de Paris, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Paris Sudden Death Expertise Center, 75015, Paris, France
| | - Daniel Jost
- Université de Paris, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Paris Sudden Death Expertise Center, 75015, Paris, France
- BSPP (Paris Fire-Brigade Emergency-Medicine Department), 1 Place Jules Renard, 75017, Paris, France
| | - Lionel Lamhaut
- Université de Paris, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Intensive Care Unit and SAMU 75, Necker Enfants-Malades Hospital, 75014, Paris, France
| | - Eloi Marijon
- Université de Paris, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Cardiology Department, AP-HP, European Georges Pompidou Hospital, 75015, Paris, France
| | - Xavier Jouven
- Université de Paris, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Paris Sudden Death Expertise Center, 75015, Paris, France
- Cardiology Department, AP-HP, European Georges Pompidou Hospital, 75015, Paris, France
| | - Alain Cariou
- Université de Paris, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France
- Medical Intensive Care Unit, AP-HP, Cochin Hospital, 75014, Paris, France
- Paris Sudden Death Expertise Center, 75015, Paris, France
- AfterROSC network, Paris, France
| | - Wulfran Bougouin
- Université de Paris, INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 75015, Paris, France.
- Paris Sudden Death Expertise Center, 75015, Paris, France.
- Medical Intensive Care Unit, Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300, Massy, France.
- AfterROSC network, Paris, France.
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Gao Y, Liu H, Zhou J, Guo M, Sun J, Duan M. THE PROTECTIVE EFFECT OF C23 IN A RAT MODEL OF CARDIAC ARREST AND RESUSCITATION. Shock 2023; 59:892-901. [PMID: 36930651 DOI: 10.1097/shk.0000000000002113] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
ABSTRACT Background : Systemic inflammation acts as a contributor to neurologic deficits after cardiac arrest (CA) and cardiopulmonary resuscitation (CPR). Extracellular cold-inducible RNA-binding, protein (CIRP) has been demonstrated to be responsible in part for the inflammation through binding to toll-like receptor 4 (TLR4) after cerebral ischemia. The short peptide C23 derived from CIRP has a high affinity for TLR4, we hypothesize that C23 reduces systemic inflammation after CA/CPR by blocking the binding of CIRP to TLR4. Methods : Adult male SD rats in experimental groups were subjected to 5 min of CA followed by resuscitation. C23 peptide (8 mg/kg) or normal saline was injected intraperitoneally at the beginning of the return of spontaneous circulation (ROSC). Results : The expressions of CIRP, TNF-α, IL-6, and IL-1β in serum and brain tissues were significantly increased at 24 h after ROSC ( P < 0.05). C23 treatment could markedly decrease the expressions of TNF-α, IL-6, and IL-1β in serum ( P < 0.05). Besides, it can decrease the expressions of TLR4, TNF-α, IL-6, and IL-1β in the cortex and hippocampus and inhibit the colocalization of CIRP and TLR4 ( P < 0.05). In addition, C23 treatment can reduce the apoptosis of hippocampus neurons ( P < 0.05). Finally, the rats in the C23 group have improved survival rate and neurological prognosis ( P < 0.05). Conclusions: These findings suggest that C23 can reduce systemic inflammation and it has the potential to be developed into a possible therapy for post-CA syndrome.
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Affiliation(s)
- Yu Gao
- Department of anesthesiology, Zhongda Hospital Southeast University, Nanjing 210000, Jiangsu, China
| | - Haoxin Liu
- Department of anesthesiology, Nanjing Maternity and Child Health Care Hospital, Women's Hospital of Nanjing Medical University, Nanjing 210000, Jiangsu, China
| | - Jiejie Zhou
- Department of Anesthesiology, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing 210000, Jiangsu, China
| | - Min Guo
- Department of anesthesiology, Changzhi People's Hospital Affiliated to Changzhi Medical College, Changzhi 046000, Shanxi, China
| | - Jie Sun
- Department of anesthesiology, Zhongda Hospital Southeast University, Nanjing 210000, Jiangsu, China
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Merdji H, Levy B, Jung C, Ince C, Siegemund M, Meziani F. Microcirculatory dysfunction in cardiogenic shock. Ann Intensive Care 2023; 13:38. [PMID: 37148451 PMCID: PMC10164225 DOI: 10.1186/s13613-023-01130-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/13/2023] [Indexed: 05/08/2023] Open
Abstract
Cardiogenic shock is usually defined as primary cardiac dysfunction with low cardiac output leading to critical organ hypoperfusion, and tissue hypoxia, resulting in high mortality rate between 40% and 50% despite recent advances. Many studies have now evidenced that cardiogenic shock not only involves systemic macrocirculation, such as blood pressure, left ventricular ejection fraction, or cardiac output, but also involves significant systemic microcirculatory abnormalities which seem strongly associated with the outcome. Although microcirculation has been widely studied in the context of septic shock showing heterogeneous alterations with clear evidence of macro and microcirculation uncoupling, there is now a growing body of literature focusing on cardiogenic shock states. Even if there is currently no consensus regarding the treatment of microcirculatory disturbances in cardiogenic shock, some treatments seem to show a benefit. Furthermore, a better understanding of the underlying pathophysiology may provide hypotheses for future studies aiming to improve cardiogenic shock prognosis.
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Affiliation(s)
- Hamid Merdji
- Intensive Care Unit, Department of Acute Medicine, University Hospital, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Bruno Levy
- Institut Lorrain du Cœur et des Vaisseaux, Medical Intensive Care Unit Brabois, Université de Lorraine, CHRU de Nancy, INSERM U1116, Nancy, France
| | - Christian Jung
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, 40225, Düsseldorf, Germany
| | - Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Martin Siegemund
- Intensive Care Unit, Department of Acute Medicine, University Hospital, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Ferhat Meziani
- Faculté de Médecine, Université de Strasbourg (UNISTRA), Strasbourg, France.
- Service de Médecine Intensive-Réanimation, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, 1, Place de L'Hôpital, 67091, Strasbourg Cedex, France.
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France.
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Duse DA, Voß F, Heyng L, Wolff G, Quast C, Scheiber D, Horn P, Kelm M, Westenfeld R, Jung C, Erkens R. Lactate versus Phosphate as Biomarkers to Aid Mechanical Circulatory Support Decisions in Patients with Out-of-Hospital Cardiac Arrest and Return of Spontaneous Circulation. Diagnostics (Basel) 2023; 13:diagnostics13091523. [PMID: 37174915 PMCID: PMC10177342 DOI: 10.3390/diagnostics13091523] [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: 03/16/2023] [Revised: 04/17/2023] [Accepted: 04/21/2023] [Indexed: 05/15/2023] Open
Abstract
AIMS Identifying patients who may benefit from mechanical circulatory support (MCS) after out-of-hospital cardiac arrest (OHCA) and return of spontaneous circulation (ROSC) remains challenging; thus, a search for helpful biomarkers is warranted. We aimed to evaluate phosphate and lactate levels on admission regarding their associations with survival with and without MCS. METHODS In 224 OHCA patients who achieved ROSC, the initial phosphate and lactate levels were investigated to discriminate in-hospital mortality by receiver operating characteristic (ROC) curves. According to the Youden Index (YI) from the respective ROC, the groups were risk stratified by both biomarkers, and 30-day mortality was analyzed in patients with and without MCS. RESULTS Within the entire collective, MCS was not associated with a better chance of survival. Both phosphate and lactate level elevations showed good yet comparable discriminations to predict mortality (areas under the curve: 0.80 vs. 0.79, p = 0.74). In patients with initial phosphate values > 2.2 mmol/L (>YI), 30-day mortality within the MCS cohort was lower (HR 2.3, 95% CI: 1.4-3.7; p = 0.0037). In patients with lower phosphate levels and groups stratified by lactate, 30-day mortality was similar in patients with and without MCS. CONCLUSIONS We found a significant association between survival and MCS therapy in patients with phosphate levels above 2.2 mmol/L (Youden Index), and a similar discrimination of patient overall survival by lactate and phosphate. Prospective studies should assess the possible independent prognostic value of phosphate and its clearance for MCS efficiency.
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Affiliation(s)
- Dragos Andrei Duse
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty, Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Fabian Voß
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty, Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Laura Heyng
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty, Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Georg Wolff
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty, Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Christine Quast
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty, Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Daniel Scheiber
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty, Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Patrick Horn
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty, Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty, Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
- Cardiovascular Research Institute Düsseldorf (CARID), University Hospital Düsseldorf, Medical Faculty, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Ralf Westenfeld
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty, Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
- Abiomed Europe GmbH Europe, Neunhofer Weg 3, 52074 Aachen, Germany
| | - Christian Jung
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty, Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Ralf Erkens
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty, Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
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Bang HJ, Oh SH, Jeong WJ, Cha K, Park KN, Youn CS, Kim HJ, Lim JY, Kim HJ, Song H. A novel cardiac arrest severity score for the early prediction of hypoxic-ischemic brain injury and in-hospital death. Am J Emerg Med 2023; 66:22-30. [PMID: 36669440 DOI: 10.1016/j.ajem.2023.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 11/27/2022] [Accepted: 01/02/2023] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Out-of-hospital cardiac arrest (OHCA) outcomes are unsatisfactory despite postcardiac arrest care. Early prediction of prognoses might help stratify patients and provide tailored therapy. In this study, we derived and validated a novel scoring system to predict hypoxic-ischemic brain injury (HIBI) and in-hospital death (IHD). METHODS We retrospectively analyzed Korean Hypothermia Network prospective registry data collected from in Korea between 2015 and 2018. Patients without neuroprognostication data were excluded, and the remaining patients were randomly divided into derivation and validation cohorts. HIBI was defined when at least one prognostication predicted a poor outcome. IHD meant all deaths regardless of cause. In the derivation cohort, stepwise multivariate logistic regression was conducted for the HIBI and IHD scores, and model performance was assessed. We then classified the patients into four categories and analyzed the associations between the categories and cerebral performance categories (CPCs) at hospital discharge. Finally, we validated our models in an internal validation cohort. RESULTS Among 1373 patients, 240 were excluded, and 1133 were randomized into the derivation (n = 754) and validation cohorts (n = 379). In the derivation cohort, 7 and 8 predictors were selected for HIBI (0-8) and IHD scores (0-11), respectively, and the area under the curves (AUC) were 0.85 (95% CI 0.82-0.87) and 0.80 (95% CI 0.77-0.82), respectively. Applying optimum cutoff values of ≥6 points for HIBI and ≥7 points for IHD, the patients were classified as follows: HIBI (-)/IHD (-), Category 1 (n = 424); HIBI (-)/IHD (+), Category 2 (n = 100); HIBI (+)/IHD (-), Category 3 (n = 21); and HIBI (+)/IHD (+), Category 4 (n = 209). The CPCs at discharge were significantly different in each category (p < 0.001). In the validation cohort, the model showed moderate discrimination (AUC 0.83, 95% CI 0.79-0.87 for HIBI and AUC 0.77, 95% CI 0.72-0.81 for IHD) with good calibration. Each category of the validation cohort showed a significant difference in discharge outcomes (p < 0.001) and a similar trend to the derivation cohort. CONCLUSIONS We presented a novel approach for assessing illness severity after OHCA. Although external prospective studies are warranted, risk stratification for HIBI and IHD could help provide OHCA patients with appropriate treatment.
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Affiliation(s)
- Hyo Jin Bang
- Department of Emergency Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea.
| | - Sang Hoon Oh
- Department of Emergency Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea.
| | - Won Jung Jeong
- Department of Emergency Medicine, Suwon St. Vincent Hospital, College of Medicine, The Catholic University of Korea, Suwon 16247, Republic of Korea.
| | - Kyungman Cha
- Department of Emergency Medicine, Suwon St. Vincent Hospital, College of Medicine, The Catholic University of Korea, Suwon 16247, Republic of Korea.
| | - Kyu Nam Park
- Department of Emergency Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea.
| | - Chun Song Youn
- Department of Emergency Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea.
| | - Han Joon Kim
- Department of Emergency Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea.
| | - Jee Yong Lim
- Department of Emergency Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea.
| | - Hyo Joon Kim
- Department of Emergency Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Hwan Song
- Department of Emergency Medicine, Suwon St. Vincent Hospital, College of Medicine, The Catholic University of Korea, Suwon 16247, Republic of Korea
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Kasahara T, Sakakura K, Hori N, Jinnouchi H, Taniguchi Y, Tsukui T, Watanabe Y, Yamamoto K, Seguchi M, Wada H, Fujita H. Comparison of in-hospital outcomes of acute myocardial infarction between patients with cardiogenic shock and with cardiac arrest. Heart Vessels 2023; 38:139-146. [PMID: 35904576 DOI: 10.1007/s00380-022-02145-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 07/15/2022] [Indexed: 01/10/2023]
Abstract
In-hospital mortality of acute myocardial infarction (AMI) complicated with cardiogenic shock (CS) remains high. Also, in-hospital mortality of AMI complicated with cardiac arrest (CA) has been reported to be highest among any AMI. However, there were few reports that compared in-hospital mortality directly between AMI complicated with CS and complicated with CA. The purpose of this study was to compare in-hospital outcomes between AMI complicated with CS and complicated with CA. We retrospectively included 195 AMI patients complicated by CS or CA, and divided those into the CA group (n = 109) and the CS group (n = 86). We also subdivided the CA group into CA with persistent CS (n = 83) and CA without persistent CS (n = 26). One-third of the study population died during the index admission. In-hospital death was more frequently observed in the CA group (45.0%) than in the CS group (20.9%) (p < 0.001). In-hospital mortality was highest in the CA with persistent CS group (68.7%), followed by the CS group (20.9%), and least in the CA without persistent CS group (11.5%) (p < 0.001). Favorable neurological function was more frequently observed in the CA without persistent CS group (76.9%) and the CS group (74.4%) than in the CA with persistent CS group (27.7%) (p < 0.001). In conclusion, in-hospital mortality was higher in AMI patients with CA than in those with CS. However, when we divided AMI patients with CA into those with and without persistent CS, in-hospital mortality was lowest in CA without persistent CS, followed by CS, and highest in CA with persistent CS.
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Affiliation(s)
- Taku Kasahara
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma, Omiya, Saitama City, 330-8503, Japan
| | - Kenichi Sakakura
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma, Omiya, Saitama City, 330-8503, Japan.
| | - Nanase Hori
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma, Omiya, Saitama City, 330-8503, Japan
| | - Hiroyuki Jinnouchi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma, Omiya, Saitama City, 330-8503, Japan
| | - Yousuke Taniguchi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma, Omiya, Saitama City, 330-8503, Japan
| | - Takunori Tsukui
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma, Omiya, Saitama City, 330-8503, Japan
| | - Yusuke Watanabe
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma, Omiya, Saitama City, 330-8503, Japan
| | - Kei Yamamoto
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma, Omiya, Saitama City, 330-8503, Japan
| | - Masaru Seguchi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma, Omiya, Saitama City, 330-8503, Japan
| | - Hiroshi Wada
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma, Omiya, Saitama City, 330-8503, Japan
| | - Hideo Fujita
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma, Omiya, Saitama City, 330-8503, Japan
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Clinical characteristics and evolution of patients with cardiogenic shock in Argentina in the context of an acute myocardial infarction with ST segment elevation. Data from the nationwide ARGEN-IAM-ST Registry. Curr Probl Cardiol 2023; 48:101468. [PMID: 36261099 DOI: 10.1016/j.cpcardiol.2022.101468] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 01/04/2023]
Abstract
Cardiogenic Shock is one of the main causes of death in ST segment Elevation Myocardial Infarction. To know the clinical characteristics, in-hospital evolution and mortality of patients with Cardiogenic Shock. Patients enrolled in the ARGEN-IAM-ST Registry were analyzed. Predictors of Cardiogenic Shock and death during hospital stay were established. A total of 6122 patients were admitted between 2015 and 2022. Cardiogenic Shock was present in 10.75% of cases. Patients with CS were older (64.5 vs 60 years), more females (41% vs 36%), with more antecedents of infarction and a higher prevalence of anterior location of infarction and multivessel disease. They were also less revascularized (88.5% vs 91.5%) and had a higher incidence of failed angioplasty (15.7% vs 2.7%). They also evidenced a higher occurrence of mechanical complications (6.8% vs 0.4%), ischemic recurrence (7.4% vs 3.4%) and cardiac arrest on admission (44.8% vs 2.6%). All the differences described showed statistical significance with P < 0.05. Overall mortality was 58% in contrast to 2.77% in patients without Cardiogenic Shock (P < 0.001). Only age, DBT, and early cardiac arrest were independent predictors of shock on admission whereas age, female gender, cardiac arrest on admission and failed angioplasty were independent predictors of death. One out of 10 patients with ST Elevation Myocardial Infarction presented cardiogenic shock. Its clinical characteristics were similar to those described more than 20 years ago. Despite a high use of reperfusion strategy cardiogenic shock continues to have a very high mortality Argentina.
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Zhang C, Zhan H, Zhou D, Li T, Zhang Q, Liu C, Wei H, Hu C. Establishment of a nonshockable rhythm cardiac arrest model caused by asphyxia. BMC Cardiovasc Disord 2022; 22:573. [PMID: 36581829 PMCID: PMC9798662 DOI: 10.1186/s12872-022-02996-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 12/06/2022] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE Cardiac arrest (CA) is caused by a nonshockable rhythm with a low success rate of return of spontaneous circulation (ROSC) and a poor prognosis. This study intended to establish a nonshockable rhythm CA model caused by asphyxia. MATERIALS AND METHODS Healthy adult male Wistar rats were injected with vecuronium bromide to induce CA. After the CA duration reached the target time point, cardiopulmonary resuscitation was performed. The survival status and neurological and cardiac function were evaluated after ROSC. Brain histopathology, including hematoxylin staining, Nissl staining and Terminal dUTP nick-end labeling (TUNEL) staining, was performed to evaluate the surviving cells and apoptotic cells. Apoptosis-related proteins after ROSC for 72 h were analyzed by western blot. RESULTS CA was successfully induced in all animals. The time for the three groups of animals to PEA was 320 ± 22 s in the CA-8 group, 322 ± 28 s in the CA-12 group and 320 ± 18 s in the CA-15 group. The time to asystole was 436 ± 54 s in the CA-8 group, 438 ± 62 s in the CA-12 group and 433 ± 56 s in the CA-15 group. The NDS of rats in the CA group was significantly decreased after ROSC for 24 h. The NDS in the CA-15 group was 5-16 points, while it was 58-67 points and 15-43 points in the CA-8 and CA-12 groups, respectively. The cardiac function of animals in the CA group was impaired after ROSC, and the ejection fraction, fractional shortening, stroke volume and cardiac output, were all significantly decreased. Brain histopathology showed that the number of surviving neurons was decreased, and the number of apoptotic cells was increased in CA group, the longer the CA duration, the more apoptotic cells increased. The expression of the proapoptotic protein Bax and the apoptotic executive protein caspase3 in the hippocampus of CA rats was significantly increased, while the expression of the antiapoptotic protein Bcl-2 was significantly reduced. CONCLUSIONS The use of vecuronium can successfully induce CA caused by nonshockable rhythm in rats, which will help to further study the pathophysiological changes after CA by nonshockable rhythm.
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Affiliation(s)
- Chenyu Zhang
- grid.412615.50000 0004 1803 6239Department of Emergency Medicine, The First Affiliated Hospital of Sun Yat-sen University, The 58 Zhongshan Er Rd, Guangzhou, 510080 People’s Republic of China ,grid.412615.50000 0004 1803 6239Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, The 58 Zhongshan Er Rd, Guangzhou, 510080 People’s Republic of China ,grid.12981.330000 0001 2360 039XNHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, 510080 People’s Republic of China
| | - Haohong Zhan
- grid.412615.50000 0004 1803 6239Department of Emergency Medicine, The First Affiliated Hospital of Sun Yat-sen University, The 58 Zhongshan Er Rd, Guangzhou, 510080 People’s Republic of China ,grid.12981.330000 0001 2360 039XNHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, 510080 People’s Republic of China
| | - Dawang Zhou
- grid.12981.330000 0001 2360 039XNHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, 510080 People’s Republic of China ,grid.511083.e0000 0004 7671 2506Department of Emergency Medicine, The Seventh affiliated hospital of Sun Yat-sen University, 628, Zhenyuan Rd, Guangming (New) Dist, Shenzhen, 518107 People’s Republic of China
| | - Tian Li
- grid.233520.50000 0004 1761 4404School of Basic Medicine, Fourth Military Medical University, 169 Changle West Rd, Xi’an, 710032 People’s Republic of China
| | - Qiang Zhang
- grid.12981.330000 0001 2360 039XNHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, 510080 People’s Republic of China ,grid.511083.e0000 0004 7671 2506Department of Emergency Medicine, The Seventh affiliated hospital of Sun Yat-sen University, 628, Zhenyuan Rd, Guangming (New) Dist, Shenzhen, 518107 People’s Republic of China
| | - Cong Liu
- grid.12981.330000 0001 2360 039XNHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, 510080 People’s Republic of China ,grid.511083.e0000 0004 7671 2506Department of Emergency Medicine, The Seventh affiliated hospital of Sun Yat-sen University, 628, Zhenyuan Rd, Guangming (New) Dist, Shenzhen, 518107 People’s Republic of China
| | - Hongyan Wei
- grid.412615.50000 0004 1803 6239Department of Emergency Medicine, The First Affiliated Hospital of Sun Yat-sen University, The 58 Zhongshan Er Rd, Guangzhou, 510080 People’s Republic of China ,grid.12981.330000 0001 2360 039XNHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, 510080 People’s Republic of China
| | - Chunlin Hu
- grid.412615.50000 0004 1803 6239Department of Emergency Medicine, The First Affiliated Hospital of Sun Yat-sen University, The 58 Zhongshan Er Rd, Guangzhou, 510080 People’s Republic of China ,grid.12981.330000 0001 2360 039XNHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, 510080 People’s Republic of China
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Lazzarin T, Tonon CR, Martins D, Fávero EL, Baumgratz TD, Pereira FWL, Pinheiro VR, Ballarin RS, Queiroz DAR, Azevedo PS, Polegato BF, Okoshi MP, Zornoff L, Rupp de Paiva SA, Minicucci MF. Post-Cardiac Arrest: Mechanisms, Management, and Future Perspectives. J Clin Med 2022; 12:jcm12010259. [PMID: 36615059 PMCID: PMC9820907 DOI: 10.3390/jcm12010259] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 12/22/2022] [Accepted: 12/23/2022] [Indexed: 12/31/2022] Open
Abstract
Cardiac arrest is an important public health issue, with a survival rate of approximately 15 to 22%. A great proportion of these deaths occur after resuscitation due to post-cardiac arrest syndrome, which is characterized by the ischemia-reperfusion injury that affects the role body. Understanding physiopathology is mandatory to discover new treatment strategies and obtain better results. Besides improvements in cardiopulmonary resuscitation maneuvers, the great increase in survival rates observed in recent decades is due to new approaches to post-cardiac arrest care. In this review, we will discuss physiopathology, etiologies, and post-resuscitation care, emphasizing targeted temperature management, early coronary angiography, and rehabilitation.
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Persic V, Jerman A, Malgaj Vrecko M, Berden J, Gorjup V, Stecher A, Lukic M, Jereb M, Taleska Stupica G, Gubensek J. Effect of CytoSorb Coupled with Hemodialysis on Interleukin-6 and Hemodynamic Parameters in Patients with Systemic Inflammatory Response Syndrome: A Retrospective Cohort Study. J Clin Med 2022; 11:jcm11247500. [PMID: 36556116 PMCID: PMC9788171 DOI: 10.3390/jcm11247500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 12/11/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Excessive release of cytokines during systemic inflammatory response syndrome (SIRS) often leads to refractory hypotension and multiple organ failure with high mortality. Cytokine removal with hemoadsorption has emerged as a possible adjuvant therapy, but data on interleukin-6 (IL-6) reduction and outcomes in clinical practice are scarce. We aimed to evaluate the effect of CytoSorb hemoadsorption on laboratory and clinical outcomes in shocked patients with SIRS. We designed a retrospective analysis of all patients with SIRS treated with CytoSorb in intensive care units (ICU). IL-6, laboratory and hemodynamic parameters were analyzed at approximate time intervals during CytoSorb treatment in the whole cohort and in a subgroup with septic shock. Observed and predicted mortality rates were compared. We included 118 patients with various etiologies of SIRS (septic shock 69%, post-resuscitation shock 16%, SIRS with acute pancreatitis 6%, other 9%); in all but one patient, CytoSorb was coupled with renal replacement therapy. A statistically significant decrease in IL-6 and vasopressor index with an increase in pH and mean arterial pressure was observed from 6 h onward. The reduction of lactate became significant at 48 h. Results were similar in a subgroup of patients with septic shock. Observed ICU and in-hospital mortalities were lower than predicted by Sequential Organ Failure Assessment (SOFA) (61% vs. 79%, p = 0.005) and Acute Physiology and Chronic Health Evaluation (APACHE) II (64% vs. 78%, p = 0.031) scores. To conclude, hemoadsorption in shocked patients with SIRS was associated with a rapid decrease in IL-6 and hemodynamic improvement, with improved observed vs. predicted survival. These results need to be confirmed in a randomized study.
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Affiliation(s)
- Vanja Persic
- Center for Acute and Complicated Dialysis and Vascular Access, Department of Nephrology, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Alexander Jerman
- Center for Acute and Complicated Dialysis and Vascular Access, Department of Nephrology, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia
| | - Marija Malgaj Vrecko
- Center for Acute and Complicated Dialysis and Vascular Access, Department of Nephrology, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Jernej Berden
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
- Center of Intensive Internal Medicine, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia
| | - Vojka Gorjup
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
- Center of Intensive Internal Medicine, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia
| | - Adela Stecher
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
- Department of Anesthesiology and Surgical Intensive Therapy, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia
| | - Milica Lukic
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
- Department of Infectious Diseases, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia
| | - Matjaz Jereb
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
- Department of Infectious Diseases, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia
| | - Gordana Taleska Stupica
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
- Department of Anesthesiology and Surgical Intensive Therapy, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia
| | - Jakob Gubensek
- Center for Acute and Complicated Dialysis and Vascular Access, Department of Nephrology, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
- Correspondence: ; Tel.: +386-1-522-31-21
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38
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Brennan KA, Bhutiani M, Kingeter MA, McEvoy MD. Updates in the Management of Perioperative Vasoplegic Syndrome. Adv Anesth 2022; 40:71-92. [PMID: 36333053 DOI: 10.1016/j.aan.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Vasoplegic syndrome occurs relatively frequently in cardiac surgery, liver transplant, major noncardiac surgery, in post-return of spontaneous circulation situations, and in pateints with sepsis. It is paramount for the anesthesiologist to understand both the pathophysiology of vasoplegia and the different treatment strategies available for rescuing a patient from life-threatening hypotension.
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Affiliation(s)
- Kaitlyn A Brennan
- Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Avenue South, MAB 422, Nashville, TN 37212, USA
| | - Monica Bhutiani
- Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Avenue South, VUH 4107, Nashville, TN 37212, USA
| | - Meredith A Kingeter
- Anesthesia Residency, Vanderbilt University Medical Center, 1215 21st Avenue South, Suite 5160 MCE NT, Nashville, TN 37212, USA
| | - Matthew D McEvoy
- VUMC Enhanced Recovery Programs, Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN 37232, USA.
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39
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Vallabhajosyula S, Verghese D, Henry TD, Katz JN, Nicholson WJ, Jaber WA, Jentzer JC. Contemporary Management of Concomitant Cardiac Arrest and Cardiogenic Shock Complicating Myocardial Infarction. Mayo Clin Proc 2022; 97:2333-2354. [PMID: 36464466 DOI: 10.1016/j.mayocp.2022.06.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 06/08/2022] [Accepted: 06/24/2022] [Indexed: 12/03/2022]
Abstract
Cardiogenic shock (CS) and cardiac arrest (CA) are the most life-threatening complications of acute myocardial infarction. Although there is a significant overlap in the pathophysiology with approximately half the patients with CS experiencing a CA and approximately two-thirds of patients with CA developing CS, comprehensive guideline recommendations for management of CA + CS are lacking. This paper summarizes the current evidence on the incidence, pathophysiology, and short- and long-term outcomes of patients with acute myocardial infarction complicated by concomitant CA + CS. We discuss the hemodynamic factors and unique challenges that need to be accounted for while developing treatment strategies for these patients. A summary of expert-based step-by-step recommendations to the approach and treatment of these patients, both in the field before admission and in-hospital management, are presented.
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Affiliation(s)
- Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Dhiran Verghese
- Section of Advanced Cardiac Imaging, Division of Cardiovascular Medicine, Department of Medicine, Harbor UCLA Medical Center, Torrance, CA, USA; Department of Cardiovascular Medicine, NCH Heart Institute, Naples, FL, USA
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education at the Christ Hospital Health Network, Cincinnati, OH, USA
| | - Jason N Katz
- Divisions of Cardiovascular Diseases and Pulmonary and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - William J Nicholson
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Wissam A Jaber
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
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40
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Dupont V, Bonnet-Lebrun AS, Boileve A, Charpentier J, Mira JP, Geri G, Cariou A, Jozwiak M. Impact of early mean arterial pressure level on severe acute kidney injury occurrence after out-of-hospital cardiac arrest. Ann Intensive Care 2022; 12:69. [PMID: 35843964 PMCID: PMC9288937 DOI: 10.1186/s13613-022-01045-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 07/04/2022] [Indexed: 11/20/2022] Open
Abstract
Background The optimal early mean arterial pressure (MAP) level in terms of renal function remains to be established in patients with out-of-hospital cardiac arrest (OHCA). We aimed to evaluate the association between early MAP level and severe acute kidney injury (AKI) occurrence in patients with OHCA. Results In 568 consecutive patients, the percentage time spent below a predefined MAP threshold and the corresponding area below threshold (ABT) were calculated from continuous MAP measurement. Both MAP-derived variables were calculated for different MAP thresholds (65, 75 and 85 mmHg) and time periods (the first 6 and 12 after ICU admission). 274 (48%) patients developed severe AKI defined as stage 3 of KDIGO. Both ABT and percentage time were independently associated with severe AKI, regardless of the MAP threshold and time period considered. Highest adjusted odds ratios for developing severe AKI were observed while considering the first 6 h period. Within the first 6 h, every 100 mmHg-h increase in ABT under MAP thresholds of 65, 75 and 85 mmHg increased severe AKI risk by 69% (OR = 1.69; 95% CI 1.26–2.26; p < 0.01), 13% (OR = 1.13; 95% CI 1.07–1.20; p < 0.01) and 4% (OR = 1.04; 95% CI 1.02–1.06; p < 0.01), respectively. Every 10% increase in percentage time spent under MAP thresholds of 65, 75 and 85 mmHg increased severe AKI risk by 19% (OR = 1.19; 95% CI 1.06–1.33; p < 0.01), 12% (OR = 1.12; 95% CI 1.04–1.19; p < 0.01) and 8% (OR = 1.08; 95% CI 1.02–1.14; p < 0.01), respectively. Conclusions Both severity and duration of early arterial hypotension after ICU admission remained associated with severe AKI occurrence while considering a MAP threshold as high as 85 mmHg after OHCA. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01045-1.
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Affiliation(s)
- Vincent Dupont
- Centre Hospitalier Universitaire de Reims, University Hospital of Reims, Reims, France. .,French Clinical Research Infrastructure Network, Investigation Network Initiative - Cardiovascular and Renal Clinical Trialists (F-CRIN INI-CRCT), Reims, France.
| | | | - Alice Boileve
- Département de Médecine Oncologique, Gustave Roussy, 94805, Villejuif, France
| | - Julien Charpentier
- Assistance Publique - Hôpitaux de Paris, Hôpitaux Universitaires Paris-Centre, Hôpital Cochin, Service de Médecine Intensive Réanimation, 27, Rue du Faubourg Saint Jacques, Paris, France
| | - Jean-Paul Mira
- Assistance Publique - Hôpitaux de Paris, Hôpitaux Universitaires Paris-Centre, Hôpital Cochin, Service de Médecine Intensive Réanimation, 27, Rue du Faubourg Saint Jacques, Paris, France.,Université de Paris, Paris, France
| | - Guillaume Geri
- Service de Médecine Intensive et Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Ambroise Paré, Boulogne-Billancourt, France.,Université Paris-Saclay, Gif-sur-Yvette, France.,INSERM, UMR1018, Centre de Recherche en Epidémiologie et Santé des Populations, Villejuif, France
| | - Alain Cariou
- Assistance Publique - Hôpitaux de Paris, Hôpitaux Universitaires Paris-Centre, Hôpital Cochin, Service de Médecine Intensive Réanimation, 27, Rue du Faubourg Saint Jacques, Paris, France.,Université de Paris, Paris, France.,INSERM U970, Paris-Cardiovascular-Research-Center, Paris, France.,Paris Sudden-Death-Expertise-Centre, Paris, France.,AfterROSC Network Group, Paris, France
| | - Mathieu Jozwiak
- Centre Hospitalier Universitaire l'Archet 1, Service de Médecine Intensive Réanimation, Nice, France.,Equipe 2 CARRES, UR2CA Unité de Recherche Clinique Université Côte d'Azur, Université Côte d'Azur, Nice, France
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41
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Renaudier M, Binois Y, Dumas F, Lamhaut L, Beganton F, Jost D, Charpentier J, Lesieur O, Marijon E, Jouven X, Cariou A, Bougouin W. Organ donation after out-of-hospital cardiac arrest: a population-based study of data from the Paris Sudden Death Expertise Center. Ann Intensive Care 2022; 12:48. [PMID: 35666323 PMCID: PMC9170852 DOI: 10.1186/s13613-022-01023-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/11/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Organ shortage is a major public health issue, and patients who die after out-of-hospital cardiac arrest (OHCA) could be a valuable source of organs. Here, our objective was to identify factors associated with organ donation after brain death complicating OHCA, in unselected patients entered into a comprehensive real-life registry covering a well-defined geographic area. METHODS We prospectively analyzed consecutive adults with OHCA who were successfully resuscitated, but died in intensive care units in the Paris region in 2011-2018. The primary outcome was organ donation after brain death. Independent risk factors were identified using logistic regression analysis. One-year graft survival was assessed using Cox and log-rank tests. RESULTS Of the 3061 included patients, 136 (4.4%) became organ donors after brain death, i.e., 28% of the patients with brain death. An interaction between admission pH and post-resuscitation shock was identified. By multivariate analysis, in patients with post-resuscitation shock, factors associated with organ donation were neurological cause of OHCA (odds ratio [OR], 14.5 [7.6-27.4], P < 0.001), higher pH (OR/0.1 increase, 1.3 [1.1-1.6], P < 0.001); older age was negatively associated with donation (OR/10-year increase, 0.7 [0.6-0.8], P < 0.001). In patients without post-resuscitation shock, the factor associated with donation was neurological cause of OHCA (OR, 6.9 [3.0-15.9], P < 0.001); higher pH (OR/0.1 increase, 0.8 [0.7-1.0], P = 0.04) and OHCA at home (OR, 0.4 [0.2-0.7], P = 0.006) were negatively associated with organ donation. One-year graft survival did not differ according to Utstein characteristics of the donor. CONCLUSIONS 4% of patients who died in ICU after OHCA led to organ donation. Patients with OHCA constitute a valuable source of donated organs, and special attention should be paid to young patients with OHCA of neurological cause.
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Affiliation(s)
- M Renaudier
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France.,Paris Sudden Death Expertise Center, Paris, France
| | - Y Binois
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France.,Paris Sudden Death Expertise Center, Paris, France
| | - F Dumas
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France.,Paris Sudden Death Expertise Center, Paris, France.,Emergency Department, Cochin-Hotel-Dieu Hospital, AP-HP, Paris, France.,Université de Paris, Paris, France
| | - L Lamhaut
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France.,Paris Sudden Death Expertise Center, Paris, France.,Université de Paris, Paris, France.,Intensive Care Unit and SAMU 75, Necker Enfants-Malades Hospital, Paris, France
| | - F Beganton
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France.,Paris Sudden Death Expertise Center, Paris, France
| | - D Jost
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France.,Paris Sudden Death Expertise Center, Paris, France.,Brigade Des Sapeurs-Pompiers de Paris (BSPP), Paris, France
| | - J Charpentier
- Medical Intensive Care Unit, AP-HP, Cochin Hospital, Paris Cedex 14, France
| | - O Lesieur
- Université de Paris, Paris, France.,Intensive Care Unit, Saint Louis General Hospital, La Rochelle, France
| | - E Marijon
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France.,Paris Sudden Death Expertise Center, Paris, France.,Université de Paris, Paris, France.,Cardiology Department, European Georges Pompidou Hospital, AP-HP, Paris, France
| | - X Jouven
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France.,Paris Sudden Death Expertise Center, Paris, France.,Université de Paris, Paris, France.,Cardiology Department, European Georges Pompidou Hospital, AP-HP, Paris, France
| | - A Cariou
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France. .,Paris Sudden Death Expertise Center, Paris, France. .,Université de Paris, Paris, France. .,Medical Intensive Care Unit, AP-HP, Cochin Hospital, Paris Cedex 14, France.
| | - W Bougouin
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France.,Paris Sudden Death Expertise Center, Paris, France.,Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, Massy, France
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Touron M, Javaudin F, Lebastard Q, Baert V, Heidet M, Hubert H, Leclere B, Lascarrou JB. Effect of sodium bicarbonate on functional outcome in patients with out-of-hospital cardiac arrest: a post-hoc analysis of a French and North-American dataset. Eur J Emerg Med 2022; 29:210-220. [PMID: 35297385 DOI: 10.1097/mej.0000000000000918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND IMPORTANCE No large randomised controlled trial has assessed the potential benefits on neurologic outcomes of prehospital sodium bicarbonate administration in patients with nontraumatic out-of-hospital cardiac arrest (OHCA). OBJECTIVE To obtain information of assistance in designing a randomised controlled trial of bicarbonate therapy after OHCA in specific patient subgroups. DESIGN We conducted two, separate, simultaneous, retrospective studies of two distinct, unlinked datasets. SETTING AND PARTICIPANTS One dataset was a French nationwide population-based registry (RéAC Registry, French dataset) and the other was a randomised controlled trial comparing continuous to interrupted chest compressions in North America (ROC-CCC trial, North-American dataset). INTERVENTION We investigated whether prehospital bicarbonate administration was associated with better neurologic outcomes. OUTCOME MEASURES AND ANALYSES The main outcome measure was the functional outcome at hospital discharge. To adjust for potential confounders, we conducted a nested propensity-score-matched analysis with inverse probability-of-treatment weighting. MAIN RESULTS In the French dataset, of the 54 807 patients, 1234 (2.2%) received sodium bicarbonate and 450 were matched. After propensity-score matching, sodium bicarbonate was not associated with a higher likelihood of favourable functional outcomes on day 30 [adjusted odds ratio (aOR), 0.912; 95% confidence interval (95%CI), 0.501-1.655]. In the North-American dataset, of the 23 711 included patients, 4902 (20.6%) received sodium bicarbonate and 1238 were matched. After propensity-score matching, sodium bicarbonate was associated with a lower likelihood of favourable functional outcomes at hospital discharge (aOR, 0.45; 95% CI, 0.34-0.58). CONCLUSION In patients with OHCA, prehospital sodium bicarbonate administration was not associated with neurologic outcomes in a French dataset and was associated with worse neurologic outcomes in a North-American dataset. Given the considerable variability in sodium bicarbonate use by different prehospital care systems and the potential resuscitation-time bias in the present study, a large randomised clinical trial targeting specific patient subgroups may be needed to determine whether sodium bicarbonate has a role in the prehospital management of prolonged OHCA.
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Affiliation(s)
- Maxime Touron
- Medecine Intensive Reanimation, Nantes University Hospital
| | | | | | - Valentine Baert
- Univ. Lille, CHU Lille, ULR 2694 - METRICS, Évaluation des technologies de santé et des pratiques médicales, Lille
- French National Out-Of-Hospital Cardiac Arrest Registry, Registre électronique des Arrêts Cardiaques, Lille
| | - Mathieu Heidet
- Emergency Department, University Hospital Centre, Creteil
| | - Hervé Hubert
- Univ. Lille, CHU Lille, ULR 2694 - METRICS, Évaluation des technologies de santé et des pratiques médicales, Lille
- French National Out-Of-Hospital Cardiac Arrest Registry, Registre électronique des Arrêts Cardiaques, Lille
| | - Brice Leclere
- Public Health Department, University Hospital Centre, Nantes
| | - Jean-Baptiste Lascarrou
- Medecine Intensive Reanimation, Nantes University Hospital
- AfterROSC Network
- Université de Paris, INSERM, Paris Cardiovascular Research Centre, Paris, France
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43
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Mentzelopoulos SD, Pappa E, Malachias S, Vrettou CS, Giannopoulos A, Karlis G, Adamos G, Pantazopoulos I, Megalou A, Louvaris Z, Karavana V, Aggelopoulos E, Agaliotis G, Papadaki M, Baladima A, Lasithiotaki I, Lagiou F, Temperikidis P, Louka A, Asimakos A, Kougias M, Makris D, Zakynthinos E, Xintara M, Papadonta ME, Koutsothymiou A, Zakynthinos SG, Ischaki E. Physiologic effects of stress dose corticosteroids in in-hospital cardiac arrest (CORTICA): A randomized clinical trial. Resusc Plus 2022; 10:100252. [PMID: 35652112 PMCID: PMC9149191 DOI: 10.1016/j.resplu.2022.100252] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 05/09/2022] [Accepted: 05/11/2022] [Indexed: 01/15/2023] Open
Abstract
Aim Postresuscitation hemodynamics are associated with hospital mortality/functional outcome. We sought to determine whether low-dose steroids started during and continued after cardiopulmonary resuscitation (CPR) affect postresuscitation hemodynamics and other physiological variables in vasopressor-requiring, in-hospital cardiac arrest. Methods We conducted a two-center, randomized, double-blind trial of patients with adrenaline (epinephrine)-requiring cardiac arrest. Patients were randomized to receive either methylprednisolone 40 mg (steroids group) or normal saline-placebo (control group) during the first CPR cycle post-enrollment. Postresuscitation shock was treated with hydrocortisone 240 mg daily for 7 days maximum and gradual taper (steroids group), or saline-placebo (control group). Primary outcomes were arterial pressure and central-venous oxygen saturation (ScvO2) within 72 hours post-ROSC. Results Eighty nine of 98 controls and 80 of 86 steroids group patients with ROSC were treated as randomized. Primary outcome data were collected from 100 patients with ROSC (control, n = 54; steroids, n = 46). In intention-to-treat mixed-model analyses, there was no significant effect of group on arterial pressure, marginal mean (95% confidence interval) for mean arterial pressure, steroids vs. control: 74 (68–80) vs. 72 (66–79) mmHg] and ScvO2 [71 (68–75)% vs. 69 (65–73)%], cardiac index [2.8 (2.5–3.1) vs. 2.9 (2.5–3.2) L/min/m2], and serum cytokine concentrations [e.g. interleukin-6, 89.1 (42.8–133.9) vs. 75.7 (52.1–152.3) pg/mL] determined within 72 hours post-ROSC (P = 0.12–0.86). There was no between-group difference in body temperature, echocardiographic variables, prefrontal blood flow index/cerebral autoregulation, organ failure-free days, and hazard for poor in-hospital/functional outcome, and adverse events (P = 0.08–>0.99). Conclusions Our results do not support the use of low-dose corticosteroids in in-hospital cardiac arrest. Trial Registration:ClinicalTrials.gov number: NCT02790788 (https://www.clinicaltrials.gov).
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Affiliation(s)
- Spyros D. Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
- Corresponding author at: Department of Intensive Care Medicine, Evaggelismos General Hospital, 45-47 Ipsilandou Street, GR-10675 Athens, Greece.
| | - Evanthia Pappa
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Sotirios Malachias
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Charikleia S. Vrettou
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Achilleas Giannopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - George Karlis
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - George Adamos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Ioannis Pantazopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Aikaterini Megalou
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Zafeiris Louvaris
- Faculty of Movement and Rehabilitation Sciences, Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Belgium
- University Hospitals Leuven, Department of Intensive Care Medicine, Leuven, Belgium
| | - Vassiliki Karavana
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Epameinondas Aggelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Gerasimos Agaliotis
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Marielen Papadaki
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Aggeliki Baladima
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | | | - Fotini Lagiou
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Prodromos Temperikidis
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Aggeliki Louka
- Department of Anesthesiology, Evaggelismos General Hospital, Athens, Greece
| | - Andreas Asimakos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Marios Kougias
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Demosthenes Makris
- Department of Intensive Care Medicine, University of Thessaly Medical School, Larissa, Greece
| | | | - Maria Xintara
- Department of Intensive Care Medicine, University of Thessaly Medical School, Larissa, Greece
| | | | | | - Spyros G. Zakynthinos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Eleni Ischaki
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
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Ortuno S, Geri G, Bouguoin W, Cariou A, Aissaoui N. Myocardial dysfunction after cardiac arrest: tips and pitfalls. Eur J Emerg Med 2022; 29:188-194. [PMID: 35135980 DOI: 10.1097/mej.0000000000000904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Postcardiac arrest shock (PCAS) is defined by hemodynamic instability occurring in the first hours after cardiac arrest (CA) and is a major cause of mortality among patients hospitalized after CA. It includes vasoplegia and myocardial dysfunction. This postcardiac arrest myocardial dysfunction is supposed to recover within the 3 days. However, there are many unknowns regarding its definition, its prognosis value and its management. In this review dedicated to emergency physicians, we choose to address tips and pitfalls they should know regarding this prevalent syndrome.
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Affiliation(s)
- Sofia Ortuno
- Assistance Publique des Hôpitaux de Paris (APHP) Cochin, Intensive Care Medicine
- Université de Paris, Paris
| | - Guillaume Geri
- Department of Cardiology and Critical Care, Clinique Ambroise Paré, Neuilly-sur-Seine
- After-ROSC Network, Paris
| | - Wulfran Bouguoin
- After-ROSC Network, Paris
- Service de Médecine Intensive Réanimation, Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy
- INSERM U970
- Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital
- Paris Sudden-Death-Expertise-Centre, Paris, France
| | - Alain Cariou
- Assistance Publique des Hôpitaux de Paris (APHP) Cochin, Intensive Care Medicine
- Université de Paris, Paris
- After-ROSC Network, Paris
- INSERM U970
- Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital
- Paris Sudden-Death-Expertise-Centre, Paris, France
| | - Nadia Aissaoui
- Assistance Publique des Hôpitaux de Paris (APHP) Cochin, Intensive Care Medicine
- Université de Paris, Paris
- After-ROSC Network, Paris
- INSERM U970
- Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital
- Paris Sudden-Death-Expertise-Centre, Paris, France
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45
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Wongtanasarasin W, Ungrungseesopon N, Phinyo P. Association between Intra-Arrest Blood Glucose Level and Outcomes of Resuscitation at the Emergency Department: A Retrospective Study. J Clin Med 2022; 11:jcm11113067. [PMID: 35683454 PMCID: PMC9181384 DOI: 10.3390/jcm11113067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 05/20/2022] [Accepted: 05/27/2022] [Indexed: 02/07/2023] Open
Abstract
Since current cardiac arrest guidelines do not address the benefit of blood glucose measurement, the ideal ranges and target of blood glucose (BG) levels during cardiac arrest to achieve a better result are warranted. We intended to investigate the associations between intra-arrest BG levels and outcomes of cardiac arrest resuscitation at the emergency department (ED). We conducted a retrospective observational study at a single university hospital. Cardiac arrest patients at the ED between 2017 and 2020 were included. Multivariable logistic regression analysis was performed to examine the associations between intra-arrest BG levels and clinical outcomes. We categorized intra-arrest BG into five groups: <70 mg/dL, 70−99 mg/dL, 100−180 mg/dL, 181−250 mg/dL, and >250 mg/dL. Eight hundred and nineteen patients experienced ED cardiac arrest during the study period. Of all, 385 intra-arrest BG measurements were included in the data analysis. The mean age was 60.4 years. The mean intra-arrest BG level was 171.1 mg/dL, with 64 (16.6%) patients who had intra-arrest BG level below 70 mg/dL and 73 (19.0%) patients who had intra-arrest BG level more than 250 mg/dL. Markedly low (<70 mg/dL) and low (70−99 mg/dL) intra-arrest BG levels were significantly associated with a lower chance of return of spontaneous circulation (ROSC, OR 0.36, 95% CI 0.14−0.99, p = 0.05 and OR 0.33, 95% CI 0.12−0.93, p = 0.04, respectively). For patients who experienced cardiac arrest at the ED, an intra-arrest BG level of less than 100 was inversely correlated with sustained ROSC. Although we could not draw a causal relationship between variables concerning this study design, normalizing intra-arrest BG was shown to result in good clinical outcomes.
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Affiliation(s)
- Wachira Wongtanasarasin
- Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand;
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, CA 95817, USA
- Correspondence: ; Tel.: +66-99-270-0493
| | - Nat Ungrungseesopon
- Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand;
| | - Phichayut Phinyo
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand;
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
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46
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Pequignot B, Lescroart M, Orlowski S, Reynette N, Martini B, Albuisson E, Pina H, Tran N, Grandmougin D, Levy B. Methylene Blue Reduces Fluid Loading and Norepinephrine Requirements for Post-Resuscitation Syndrome in a Pig Model of Refractory Cardiac Arrest Resuscitated with Veno-Arterial ECMO. J Clin Med 2022; 11:2515. [PMID: 35566640 PMCID: PMC9100142 DOI: 10.3390/jcm11092515] [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: 04/01/2022] [Revised: 04/21/2022] [Accepted: 04/26/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Refractory cardiac arrest management relies on extracorporeal cardiopulmonary resuscitation (ECPR), requiring the use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Circulatory flow recovery can be associated with an ischemia-reperfusion injury, leading to vasoplegia and vasopressor requirement. The aim of this work was to evaluate the impact on hemodynamics of a methylene blue bolus infusion in a porcine model of ischemic refractory cardiac arrest. METHODS Ischemic refractory cardiac arrest was induced in 20 pigs. After a low flow period of 30 min, VA-ECMO was initiated and the pigs were randomly assigned to the standard care group (norepinephrine + crystalloids) or methylene blue group (IV 2 mg·kg-1 bolus of methylene blue over 30 min + norepinephrine and crystalloids). Macrocirculatory parameters and lactate clearance were measured. Sublingual microcirculation was evaluated with sidestream dark field (SDF) imaging. The severity of the ischemic digestive lesions was assessed according to the histologic Chiu/Park scale. RESULTS Eighteen pigs were included. The total crystalloid load (5000 (6000-8000) mL vs. 17,000 (10,000-19,000) mL, p = 0.007, methylene blue vs. standard care group) and catecholamine requirements (0.31 (0.14-0.44) μg·kg-1·min-1 vs. 2.32 (1.17-5.55) μg·kg-1·min-1, methylene blue vs. standard care group, p = 0.004) were significantly reduced in the methylene blue group. There were no significant between-group differences in lactate clearance, sublingual capillary microvascular parameters assessed by SDF or histologic Chiu/Park scale. CONCLUSIONS In our refractory cardiac arrest porcine model treated with ECPR, methylene blue markedly reduced fluid loading and norepinephrine requirements in comparison to standard care during the first 6 h of VA-ECMO.
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Affiliation(s)
- Benjamin Pequignot
- Service de Medecine Intensive et Réanimation, Hôpital Brabois, CHRU Nancy, 54500 Vandoeuvre les Nancy, France; (B.P.); (M.L.)
- INSERM U 1116, Equipe 2, Groupe Choc, Faculté de Médecine, 54500 Vandoeuvre les Nancy, France; (S.O.); (D.G.)
- Faculté de Médecine, Université de Lorraine, 54000 Nancy, France; (E.A.); (N.T.)
| | - Mickael Lescroart
- Service de Medecine Intensive et Réanimation, Hôpital Brabois, CHRU Nancy, 54500 Vandoeuvre les Nancy, France; (B.P.); (M.L.)
- INSERM U 1116, Equipe 2, Groupe Choc, Faculté de Médecine, 54500 Vandoeuvre les Nancy, France; (S.O.); (D.G.)
- Faculté de Médecine, Université de Lorraine, 54000 Nancy, France; (E.A.); (N.T.)
| | - Sophie Orlowski
- INSERM U 1116, Equipe 2, Groupe Choc, Faculté de Médecine, 54500 Vandoeuvre les Nancy, France; (S.O.); (D.G.)
- Faculté de Médecine, Université de Lorraine, 54000 Nancy, France; (E.A.); (N.T.)
- Service de Biochimie, Pôle Laboratoires Hôpital Central, CHRU de Nancy, 54000 Nancy, France
| | - Nathan Reynette
- Ecole de Chirurgie, Faculté de Médecine, Université de Lorraine, 54000 Nancy, France; (N.R.); (B.M.)
| | - Bana Martini
- Ecole de Chirurgie, Faculté de Médecine, Université de Lorraine, 54000 Nancy, France; (N.R.); (B.M.)
| | - Eliane Albuisson
- Faculté de Médecine, Université de Lorraine, 54000 Nancy, France; (E.A.); (N.T.)
- Plateforme d’Aide à la Recherche Clinique (PARC), ESPRI-Biobase, Hôpital de Brabois, CHRU de Nancy, 54500 Vandoeuvre les Nancy, France
| | - Héloise Pina
- Département d’Anatomie Pathologique, Laboratoires de Biologie Médicale et de Biopatholgie, Hôpital Brabois, CHRU de Nancy, 54500 Vandoeuvre les Nancy, France;
| | - N’Guyen Tran
- Faculté de Médecine, Université de Lorraine, 54000 Nancy, France; (E.A.); (N.T.)
- Ecole de Chirurgie, Faculté de Médecine, Université de Lorraine, 54000 Nancy, France; (N.R.); (B.M.)
| | - Daniel Grandmougin
- INSERM U 1116, Equipe 2, Groupe Choc, Faculté de Médecine, 54500 Vandoeuvre les Nancy, France; (S.O.); (D.G.)
- Faculté de Médecine, Université de Lorraine, 54000 Nancy, France; (E.A.); (N.T.)
- Service de Chirurgie Cardiaque, Hôpital Brabois, CHRU Nancy, 54500 Vandoeuvre les Nancy, France
| | - Bruno Levy
- Service de Medecine Intensive et Réanimation, Hôpital Brabois, CHRU Nancy, 54500 Vandoeuvre les Nancy, France; (B.P.); (M.L.)
- INSERM U 1116, Equipe 2, Groupe Choc, Faculté de Médecine, 54500 Vandoeuvre les Nancy, France; (S.O.); (D.G.)
- Faculté de Médecine, Université de Lorraine, 54000 Nancy, France; (E.A.); (N.T.)
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Abstract
The efficacy of ultrasound (US) in real-time differential diagnosis and guiding further treatment decisions has been well demonstrated in prearrest conditions and during resuscitation. Evidence is limited regarding the application of US in postresuscitation care. Most of the patients following resuscitation remain comatose, and the requirement for transportation to other examination rooms increases their risk of injury. US can be performed at the bedside with high accessibility and timeliness without radiation. This narrative review provides an overview of current evidence regarding the application of US in identifying the cause of cardiac arrest (CA), hemodynamic monitoring, and prognostication in postresuscitation care. For identifying the cause of CA, cardiac US is mainly used to detect regional wall motion abnormality. However, postarrest myocardial dysfunction would confound the sonographic findings that a combination of electrocardiograms and biomarkers besides the cardiac US could improve the positive predictive value of coronary artery disease. For hemodynamic monitoring, left ventricular outlet tract velocity time integral has the best performance in predicting fluid responsiveness in conjunction with the passive leg raising test. The RUSH protocol assists in determining the subtypes of shock with high sensitivity and specificity in hypovolemic, cardiogenic, or obstructive shock. Evidence regarding the application of US for prognostication is still limited, and further evaluation should be needed.
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48
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Tennyson CD, Yapejian R. Arrhythmogenic Right Ventricular Cardiomyopathy: Overview and Case Study. AACN Adv Crit Care 2022; 33:14-22. [PMID: 35259221 DOI: 10.4037/aacnacc2022384] [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: 11/01/2022]
Abstract
This article provides a broad overview of arrhythmogenic right ventricular cardiomyopathy, including evaluation, diagnosis, and treatment options. Nursing considerations and clinical management are reviewed through the lens of a case study. Early diagnosis to prevent sudden cardiac death is essential for patients with arrhythmogenic right ventricular cardiomyopathy.
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Affiliation(s)
- Carolina D Tennyson
- Carolina D. Tennyson is a Nurse Practitioner specializing in the advanced heart failure population at the Duke Heart Center, Durham, North Carolina, and an Assistant Professor at Duke University School of Nursing, 307 Trent Drive, Office 3112, Durham, NC 27710
| | - Rebecca Yapejian
- Rebecca Yapejian is a Nurse Practitioner specializing in clinical cardiac electrophysiology and implantable cardiac device management at the Duke Heart Center, Durham, North Carolina
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49
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Grimaldi D, Legriel S, Pichon N, Colardelle P, Leblanc S, Canouï-Poitrine F, Salem OBH, Muller G, de Prost N, Herrmann S, Marque S, Baron A, Sauneuf B, Messika J, Dior M, Creteur J, Bedos JP, Boutin E, Cariou A. Ischemic injury of the upper gastrointestinal tract after out-of-hospital cardiac arrest: a prospective, multicenter study. Crit Care 2022; 26:59. [PMID: 35287719 PMCID: PMC8919548 DOI: 10.1186/s13054-022-03939-9] [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: 11/29/2021] [Accepted: 03/02/2022] [Indexed: 11/12/2022] Open
Abstract
Background The consequences of cardiac arrest (CA) on the gastro-intestinal tract are poorly understood. We measured the incidence of ischemic injury in the upper gastro-intestinal tract after Out-of-hospital CA (OHCA) and determined the risk factors for and consequences of gastrointestinal ischemic injury according to its severity.
Methods Prospective, non-controlled, multicenter study in nine ICUs in France and Belgium conducted from November 1, 2014 to November 30, 2018. Included patients underwent an esophago-gastro-duodenoscopy 2 to 4 d after OHCA if still intubated and the presence of ischemic lesions of the upper gastro-intestinal tract was determined by a gastroenterologist. Lesions were a priori defined as severe if there was ulceration or necrosis and moderate if there was mucosal edema or erythema. We compared clinical and cardiac arrest characteristics of three groups of patients (no, moderate, and severe lesions) and identified variables associated with gastrointestinal ischemic injury using multivariate regression analysis. We also compared the outcomes (organ failure during ICU stay and neurological status at hospital discharge) of the three groups of patients. Results Among the 214 patients included in the analysis, 121 (57%, 95% CI 50–63%) had an upper gastrointestinal ischemic lesion, most frequently on the fundus. Ischemic lesions were severe in 55/121 (45%) patients. In multivariate regression, higher adrenaline dose during cardiopulmonary resuscitation (OR 1.25 per mg (1.08–1.46)) was independently associated with increased odds of severe upper gastrointestinal ischemic lesions; previous proton pump inhibitor use (OR 0.40 (0.14–1.00)) and serum bicarbonate on day 1 (OR 0.89 (0.81–0.97)) were associated with lower odds of ischemic lesions. Patients with severe lesions had a higher SOFA score during the ICU stay and worse neurological outcome at hospital discharge. Conclusions More than half of the patients successfully resuscitated from OHCA had upper gastrointestinal tract ischemic injury. Presence of ischemic lesions was independently associated with the amount of adrenaline used during resuscitation. Patients with severe lesions had higher organ failure scores during the ICU stay and a worse prognosis. Clinical Trial RegistrationNCT02349074. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03939-9.
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Affiliation(s)
- D Grimaldi
- Department of Intensive Care CUB-Erasme, Route de Lennik, 808, Université Libre de Bruxelles (ULB), 1070, Brussels, Belgium. .,AfterROSC Network Group, Paris, France.
| | - S Legriel
- AfterROSC Network Group, Paris, France.,Medico-Surgical Intensive Care Unit, Versailles Hospital, Le Chesnay, Paris, France
| | - N Pichon
- AfterROSC Network Group, Paris, France.,Medico-surgical Intensive Care Unit, General Hospital Center, Brive-la-Gaillarde, France
| | - P Colardelle
- Gastroenterology, C.H. Versailles, Le Chesnay, France
| | - S Leblanc
- Gastroenterology, APHP, Hôpital Cochin, Paris, France
| | - F Canouï-Poitrine
- Unité de Recherche Clinique (URC Mondor), Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France.,INSERM, IMRB, Equipe CEpiA (Clinical Epidemiology and Ageing), University Paris Est Creteil, Créteil, France
| | - O Ben Hadj Salem
- INSERM, IMRB, Equipe CEpiA (Clinical Epidemiology and Ageing), University Paris Est Creteil, Créteil, France.,Intensive Care Unit, Centre Hospitalier Intercommunal Meulan - Les Mureaux, Meulan en Yvelines, France
| | - G Muller
- AfterROSC Network Group, Paris, France.,Intensive Care Unit, Centre Hospitalier Intercommunal Meulan - Les Mureaux, Meulan en Yvelines, France.,ICU, Centre Hospitalier Régional Orleans, Orléans, France
| | - N de Prost
- Medical Intensive Care Unit, Hôpitaux Universitaires Henri-Mondor, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France.,Université Paris-Est Créteil Val de Marne, Créteil, France.,Groupe de Recherche Clinique CARMAS, Université Paris Est-Créteil, Créteil, France
| | - S Herrmann
- Gastro-enterology, Centre Hospitalier Régional d'Orleans, Orléans, France
| | - S Marque
- ICU, Centre Hospitalier Sud Francilien, Corbeil-Essonnes, France
| | - A Baron
- Gastroenterology, Centre Hospitalier Sud Francilien, Corbeil-Essonnes, France
| | - B Sauneuf
- AfterROSC Network Group, Paris, France.,ICU, Chpc - Centre Hospitalier Public Du Cotentin : Hospital Louis Pasteur, Cherbourg-en-Cotentin, France
| | - J Messika
- APHP.Nord-Université de Paris, Medico-surgical ICU, Hôpital Louis Mourier, Colombes, France.,INSERM, PHERE UMRS 1152, Université de Paris, Paris, France
| | - M Dior
- DMU ESPRIT, Department of Gastroenterology, AP-HP, Hopital Louis Mourier, 92700, Colombes, France
| | - J Creteur
- Department of Intensive Care CUB-Erasme, Route de Lennik, 808, Université Libre de Bruxelles (ULB), 1070, Brussels, Belgium
| | - J P Bedos
- Medico-Surgical Intensive Care Unit, Versailles Hospital, Le Chesnay, Paris, France
| | - E Boutin
- Unité de Recherche Clinique (URC Mondor), Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France.,INSERM, IMRB, Equipe CEpiA (Clinical Epidemiology and Ageing), University Paris Est Creteil, Créteil, France
| | - A Cariou
- AfterROSC Network Group, Paris, France.,Medical Intensive Care Unit, Cochin University Hospital (APHP), Paris, France; University of Paris - Medical School, Paris, France.,University of Paris - Medical School, Paris, France
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50
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Epinephrine versus norepinephrine in cardiac arrest patients with post-resuscitation shock. Intensive Care Med 2022; 48:300-310. [PMID: 35129643 DOI: 10.1007/s00134-021-06608-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 12/21/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE Whether epinephrine or norepinephrine is preferable as the continuous intravenous vasopressor used to treat post-resuscitation shock is unclear. We assessed outcomes of patients with post-resuscitation shock after out-of-hospital cardiac arrest according to whether the continuous intravenous vasopressor used was epinephrine or norepinephrine. METHODS We conducted an observational multicenter study of consecutive patients managed in 2011-2018 for post-resuscitation shock. The primary outcome was all-cause hospital mortality, and secondary outcomes were cardiovascular hospital mortality and unfavorable neurological outcome (Cerebral Performance Category 3-5). A multivariate regression analysis and a propensity score analysis were performed, as well as several sensitivity analyses. RESULTS Of the 766 patients included in five hospitals, 285 (37%) received epinephrine and 481 (63%) norepinephrine. All-cause hospital mortality was significantly higher in the epinephrine group (OR 2.6; 95%CI 1.4-4.7; P = 0.002). Cardiovascular hospital mortality was also higher with epinephrine (aOR 5.5; 95%CI 3.0-10.3; P < 0.001), as was the proportion of patients with CPC of 3-5 at hospital discharge. Sensitivity analyses produced consistent results. The analysis involving adjustment on a propensity score to control for confounders showed similar findings (aOR 2.1; 95%CI 1.1-4.0; P = 0.02). CONCLUSION Among patients with post-resuscitation shock after out-of-hospital cardiac arrest, use of epinephrine was associated with higher all-cause and cardiovascular-specific mortality, compared with norepinephrine infusion. Until additional data become available, intensivists may want to choose norepinephrine rather than epinephrine for the treatment of post-resuscitation shock after OHCA.
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