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Järpestam S, Martinell L, Rylander C, Lilja L. Post-cardiac arrest intensive care in Sweden: A survey of current clinical practice. Acta Anaesthesiol Scand 2023; 67:1249-1255. [PMID: 37314010 DOI: 10.1111/aas.14298] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 05/11/2023] [Accepted: 05/31/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND European guidelines recommend targeted temperature management (TTM) in post-cardiac arrest care. A large multicentre clinical trial, however, showed no difference in mortality and neurological outcome when comparing hypothermia to normothermia with early treatment of fever. The study results were valid given a strict protocol for the assessment of prognosis using defined neurological examinations. With the current range of recommended TTM temperatures, and applicable neurological examinations, procedures may differ between hospitals and the variation of clinical practice in Sweden is not known. AIM The aim of this study was to investigate current practice in post-resuscitation care after cardiac arrest as to temperature targets and assessment of neurological prognosis in Swedish intensive care units (ICUs). METHODS A structured survey was conducted by telephone or e-mail in all Levels 2 and 3 (= 53) Swedish ICUs during the spring of 2022 with a secondary survey in April 2023. RESULTS Five units were not providing post-cardiac arrest care and were excluded. The response rate was 43/48 (90%) of the eligible units. Among the responding ICUs, normothermia (36-37.7°C) was applied in all centres (2023). There was a detailed routine for the assessment of neurological prognosis in 38/43 (88%) ICUs. Neurological assessment was applied 72-96 h after return of spontaneous circulation in 32/38 (84%) units. Electroencephalogram and computed tomography and/or magnetic resonance imaging were the most common technical methods available. CONCLUSION Swedish ICUs use normothermia including early treatment of fever in post-resuscitation care after cardiac arrest and almost all apply a detailed routine for the assessment of neurological prognosis. However, available methods for prognostic evaluation varies between hospitals.
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Affiliation(s)
- Sara Järpestam
- School of Medical Sciences, University of Örebro, Örebro, Sweden
| | - Louise Martinell
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Christian Rylander
- Anaesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Linus Lilja
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Anaesthesia and Intensive Care, Karlstad Central Hospital, Karlstad, Sweden
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2
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Ryczek R, Kwasiborski PJ, Rzeszotarska A, Dymus J, Galas A, Kaźmierczak-Dziuk A, Karasek AM, Mielniczuk M, Buksińska-Lisik M, Korsak J, Krzesiński P. Neuron-Specific Enolase and S100B: The Earliest Predictors of Poor Outcome in Cardiac Arrest. J Clin Med 2022; 11:2344. [PMID: 35566469 PMCID: PMC9102826 DOI: 10.3390/jcm11092344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/03/2022] [Accepted: 04/18/2022] [Indexed: 02/05/2023] Open
Abstract
Background: Proper prognostication is critical in clinical decision-making following out-of-hospital cardiac arrest (OHCA). However, only a few prognostic tools with reliable accuracy are available within the first 24 h after admission. Aim: To test the value of neuron-specific enolase (NSE) and S100B protein measurements at admission as early biomarkers of poor prognosis after OHCA. Methods: We enrolled 82 consecutive patients with OHCA who were unconscious when admitted. NSE and S100B levels were measured at admission, and routine blood tests were performed. Death and poor neurological status at discharge were considered as poor clinical outcomes. We evaluated the optimal cut-off levels for NSE and S100B using logistic regression and receiver operating characteristic (ROC) analyses. Results: High concentrations of both biomarkers at admission were significantly associated with an increased risk of poor clinical outcome (NSE: odds ratio [OR] 1.042 per 1 ng/dL, [1.007−1.079; p = 0.004]; S100B: OR 1.046 per 50 pg/mL [1.004−1.090; p < 0.001]). The dual-marker approach with cut-off values of ≥27.6 ng/mL and ≥696 ng/mL for NSE and S100B, respectively, identified patients with poor clinical outcomes with 100% specificity. Conclusions: The NSE and S100B-based dual-marker approach allowed for early discrimination of patients with poor clinical outcomes with 100% specificity. The proposed algorithm may shorten the time required to establish a poor prognosis and limit the volume of futile procedures performed.
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Affiliation(s)
- Robert Ryczek
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, 04-141 Warsaw, Poland; (R.R.); (A.G.); (A.K.-D.); (A.M.K.); (M.M.); (P.K.)
| | - Przemysław J. Kwasiborski
- Department of Internal Diseases and Cardiology, Regional Hospital in Miedzylesie, 04-749 Warsaw, Poland
| | - Agnieszka Rzeszotarska
- Department of Clinical Transfusion, Military Institute of Medicine, 04-141 Warsaw, Poland; (A.R.); (J.K.)
| | - Jolanta Dymus
- Department of Laboratory Diagnostics, Military Institute of Medicine, 04-141 Warsaw, Poland;
| | - Agata Galas
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, 04-141 Warsaw, Poland; (R.R.); (A.G.); (A.K.-D.); (A.M.K.); (M.M.); (P.K.)
| | - Anna Kaźmierczak-Dziuk
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, 04-141 Warsaw, Poland; (R.R.); (A.G.); (A.K.-D.); (A.M.K.); (M.M.); (P.K.)
| | - Anna M. Karasek
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, 04-141 Warsaw, Poland; (R.R.); (A.G.); (A.K.-D.); (A.M.K.); (M.M.); (P.K.)
| | - Marta Mielniczuk
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, 04-141 Warsaw, Poland; (R.R.); (A.G.); (A.K.-D.); (A.M.K.); (M.M.); (P.K.)
| | - Małgorzata Buksińska-Lisik
- Third Department of Internal Diseases and Cardiology, Second Faculty of Medicine, Medical University of Warsaw, 04-749 Warsaw, Poland;
| | - Jolanta Korsak
- Department of Clinical Transfusion, Military Institute of Medicine, 04-141 Warsaw, Poland; (A.R.); (J.K.)
| | - Paweł Krzesiński
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, 04-141 Warsaw, Poland; (R.R.); (A.G.); (A.K.-D.); (A.M.K.); (M.M.); (P.K.)
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Aufderheide TP, Kalra R, Kosmopoulos M, Bartos JA, Yannopoulos D. Enhancing cardiac arrest survival with extracorporeal cardiopulmonary resuscitation: insights into the process of death. Ann N Y Acad Sci 2022; 1507:37-48. [PMID: 33609316 PMCID: PMC8377067 DOI: 10.1111/nyas.14580] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/30/2021] [Accepted: 02/02/2021] [Indexed: 01/03/2023]
Abstract
Extracorporeal cardiopulmonary resuscitation (ECPR) is an emerging method of cardiopulmonary resuscitation to improve outcomes from cardiac arrest. This approach targets patients with out-of-hospital cardiac arrest previously unresponsive and refractory to standard treatment, combining approximately 1 h of standard CPR followed by venoarterial extracorporeal membrane oxygenation (VA-ECMO) and coronary artery revascularization. Despite its relatively new emergence for the treatment of cardiac arrest, the approach is grounded in a vast body of preclinical and clinical data that demonstrate significantly improved survival and neurological outcomes despite unprecedented, prolonged periods of CPR. In this review, we detail the principles behind VA-ECMO-facilitated resuscitation, contemporary clinical approaches with outcomes, and address the emerging new understanding of the process of death and capability for neurological recovery.
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Affiliation(s)
- Tom P. Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Rajat Kalra
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN,Cardiovascular Division, University of Minnesota, Minneapolis, MN
| | - Marinos Kosmopoulos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Jason A. Bartos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN,Cardiovascular Division, University of Minnesota, Minneapolis, MN
| | - Demetris Yannopoulos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN,Cardiovascular Division, University of Minnesota, Minneapolis, MN
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Scarpino M, Rosso T, Lanzo G, Lolli F, Bonizzoli M, Lazzeri C, Mannaioni G, Baronti R, Fattapposta F, Grippo A. Severe neurological nicotine intoxication by e-cigarette liquids: Systematic literature review. Acta Neurol Scand 2021; 143:121-130. [PMID: 32866996 DOI: 10.1111/ane.13338] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/27/2020] [Accepted: 08/19/2020] [Indexed: 12/20/2022]
Abstract
Electronic cigarettes are a popular, easily purchased, alternative source of nicotine that is considered safer than conventional tobacco. However, Intentional or accidental exposure to e-liquid substances, mainly nicotine, can lead to serious, potentially fatal toxicity. Emergency and critical care physicians should keep in mind acute intoxication of this poison with a biphasic toxic syndrome. We highlight its potentially fatal outcome and suggest monitoring the adverse effects of nicotine according to a multimodal protocol integrating somatosensory evoked potentials, electroencephalography and neuroimaging data with anamnestic report and toxicological and laboratory data.
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Affiliation(s)
- Maenia Scarpino
- Neurophysiopathology Unit Neuromuscolar Department AOU Careggi Florence Italy
- IRCCS Don Carlo Gnocchi Florence Italy
| | - Tiziana Rosso
- UOC Neurologia Distretto di Asolo Azienda ULSS 2 Marca Trevigiana Treviso Italia
| | - Giovanni Lanzo
- Neurophysiopathology Unit Neuromuscolar Department AOU Careggi Florence Italy
| | - Francesco Lolli
- Biomedical Science Department Mario Serio University of Florence Florence Italy
| | - Manuela Bonizzoli
- Traumatic Intensive Care Unit Neuromuscolar Department AOU Careggi Florence Italy
| | - Chiara Lazzeri
- Traumatic Intensive Care Unit Neuromuscolar Department AOU Careggi Florence Italy
| | - Guido Mannaioni
- Section of Pharmacology and Toxicology Department of Neuroscience, Psychology, Drug Research and Child Health (NEURORFARBA) University Florence Florence Italy
| | - Roberto Baronti
- Laboratory of Clinical Toxicology and Antidoping Azienda USL Toscana Centro Florence Italy
| | | | - Antonello Grippo
- Neurophysiopathology Unit Neuromuscolar Department AOU Careggi Florence Italy
- IRCCS Don Carlo Gnocchi Florence Italy
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Coppler PJ, Callaway CW, Guyette FX, Baldwin M, Elmer J. Early risk stratification after resuscitation from cardiac arrest. J Am Coll Emerg Physicians Open 2020; 1:922-931. [PMID: 33145541 PMCID: PMC7593432 DOI: 10.1002/emp2.12043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 02/12/2020] [Accepted: 02/18/2020] [Indexed: 01/08/2023] Open
Abstract
Emergency clinicians often resuscitate cardiac arrest patients, and after acute resuscitation, clinicians face multiple decisions regarding disposition. Recent evidence suggests that out-of-hospital cardiac arrest patients with return of spontaneous circulation have higher odds of survival to hospital discharge, long-term survival, and improved functional outcomes when treated at centers that can provide advanced multidisciplinary care. For community clinicians, a high volume cardiac arrest center may be hours away. While current guidelines recommend against neurological prognostication in the first hours or days after return of spontaneous circulation, there are early findings suggestive of irrecoverable brain injury in which the patient would receive no benefit from transfer. In this Concepts article, we describe a simplified approach to quickly evaluate neurological status in cardiac arrest patients and identify findings concerning for irrecoverable brain injury. Characteristics of the arrest and resuscitation, initial neurological assessment, and brain computed tomography together can identify patients with high likelihood of irrecoverable anoxic injury. Patients who may benefit from centers with access to continuous electroencephalography are discussed. This approach can be used to identify patients who may benefit from rapid transfer to cardiac arrest centers versus those who may benefit from care close to home. Risk stratification also can provide realistic expectations for recovery to families.
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Affiliation(s)
- Patrick J. Coppler
- Department of Emergency MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Clifton W. Callaway
- Department of Emergency MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Francis X. Guyette
- Department of Emergency MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Maria Baldwin
- Department of NeurologyUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Jonathan Elmer
- Department of Emergency MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
- Department of NeurologyUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
- Department of Critical Care MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
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Abstract
Background Currently, there are limited data of prognostic clues for neurological recovery in comatose survivors undergoing therapeutic hypothermia (TH). We aimed to evaluate clinical signs and findings that could predict neurological outcomes, and determine the optimal time for the prognostication. Materials and Methods We retrospectively reviewed database of postarrest survivors treated with TH in our hospital from 2006 to 2014. Cerebral performance category (CPC), neurological signs and findings in electroencephalography (EEG) and brain computed tomography (CT) were evaluated. In addition, the optimal time to evaluate neurological status was analyzed. Results TH was performed in 51 postarrest patients. Approximately 53% of TH patients survived at discharge and 33% of the hospital survivors had favorable outcome (CPC1-2). The prognostic clues for unfavorable outcome (CPC3-5) at discharge were lack of pupillary light response (PLR) and/or gag reflex after rewarming, and the absence of at least one of the brainstem reflexes, no eye-opening, or abnormal motor response on the 7th day. Myoclonus and seizure could not be used to indicate poor prognosis. In addition, prognostic values of EEG and CT findings were inconclusive. Conclusions Our study showed the simple neurological signs helped predict short-term neurological prognosis. The most reliable sign determining unfavorable outcome was the lack of PLR. The optimal time to assess prognosis was either at 48-72 h or 7 days after return of spontaneous circulation.
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Affiliation(s)
- Napplika Kongpolprom
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Thailand
| | - Jiraphat Cholkraisuwat
- Division of Pulmonary and Critical Care Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Thailand
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Rajamani A, Seppelt I, Bourne J. Difficulties with neurological prognostication in a young woman with delayed-onset generalised status myoclonus after cardiac arrest due to acute severe asthma. Indian J Crit Care Med 2011; 15:137-9. [PMID: 21814383 PMCID: PMC3145302 DOI: 10.4103/0972-5229.83010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Neurological prognostication in cardiac arrest survivors is difficult, especially when the primary etiology is respiratory arrest. Prognostic factors designed to have zero false-positive rates to robustly confirm poor outcome are usually inadequate to rule out poor outcomes (i.e., high specificity and low sensitivity). One of the least understood prognosticators is generalised status myoclonus (GSM), with case reports confusing GSM, isolated myoclonic jerks and post-hypoxic intention myoclonus (Lance Adams syndrome [LAS]). With several prognostic indicators (including status myoclonus) having been validated in the pre-hypothermia era, their current relevance is debatable. New modalities such as brain magnetic resonance imaging (MRI) and continuous electroencephalography are being evaluated. We describe here a pregnant woman resuscitated from a cardiac arrest due to acute severe asthma, and an inability to reach a consensus based on published guidelines, with a brief overview of myoclonus, LAS and the role of MRI brain in assisting prognostication.
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