Cost-utility of extracorporeal membrane oxygenation rewarming in accidentally hypothermic patients-A single-centre retrospective study

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) has become the treatment of choice for severely hypothermic patients in cardiac arrest or acute cardiac failure. Highly specialized ECMO centres have been established, however, no centre has ever reported the costs of extracorporeal rewarming. The aim of this study was to assess the costs of the treatment of patients in Swiss Stage III and IV rewarmed with veno-arterial ECMO.

METHODS

A retrospective exploratory cohort study analysed twenty-nine consecutive patients treated for hypothermia in the Severe Accidental Hypothermia Centre in Cracow, Poland. The main outcome parameters were the overall and specific costs of the ICU treatment of patients rewarmed with veno-arterial ECMO. The secondary outcome parameter was cost utility, determined by the costs involved for every year of life gained. Costs were processed using the bottom-up method and classified into six categories. Survivors were followed up after 1 year.

RESULTS

The mean cost of VA-ECMO was $5133 USD, which equalled 35% of all ICU expenditures ($14 668 USD). One year after discharge, 13 of 29 patients were still alive (45%). The overall gain of life of the thirteen 1-year survivors was 28 years, while the mean cost related to treatment with VA-ECMO for each year of life gained was 1138 USD.

CONCLUSIONS

In this study, the costs of VA-ECMO rewarming and intensive care treatment per patient were substantially lower than in other studies reporting ECMO and intensive care treatment of other causes.

Short-term repeated corticosterone administration enhances glutamatergic but not GABAergic transmission in the rat motor cortex

It has been demonstrated that stress impairs performance of skilled reaching and walking tasks in rats due to the action of glucocorticoids involved in the stress response. Skilled reaching and walking are controlled by the primary motor cortex (M1); however, it is not known whether stress-related impairments in skilled motor tasks are related to functional and/or structural alterations within the M1. We studied the effects of single and repeated injections of corticosterone (twice daily for 7 days) on spontaneous excitatory and inhibitory postsynaptic currents (sEPSCs and sIPSCs) recorded from layer II/III pyramidal neurons in ex vivo slices of the M1, prepared 2 days after the last administration of the hormone. We also measured the density of dendritic spines on pyramidal cells and the protein levels of selected subunits of AMPA, NMDA, and GABA_A receptors after repeated corticosterone administration. Repeatedly administered corticosterone induced an increase in the frequency but not in the amplitude of sEPSCs, while a single administration had no effect on the recorded excitatory currents. The frequency and amplitude of sIPSCs as well as the excitability of pyramidal cells were changed neither after single nor after repeated corticosterone administration. Treatment with corticosterone for 7 days did not modify the density of dendritic spines on pyramidal neurons. Corticosterone influenced neither the protein levels of GluA1, GluA2, GluN1, GluN2A, and GluN2B subunits of glutamate receptors nor those of α₁, β₂, and γ₂ subunits of the GABA_A receptor. The increase in sEPSCs frequency induced by repeated corticosterone administration faded out within 7 days. These data indicate that prolonged administration of exogenous corticosterone selectively and reversibly enhances glutamatergic, but not GABAergic transmission in the rat motor cortex. Our results suggest that corticosterone treatment results in an enhancement of spontaneous glutamate release from presynaptic terminals in the M1 and thereby uncovers a potential mechanism underlying stress-induced motor functions impairment.

Excitatory orexinergic innervation of rat nucleus incertus--Implications for ascending arousal, motivation and feeding control

Orexin/hypocretin peptides play a central role in the integrated control of feeding/reward and behavioural activation, principally via interactions with other neural systems. A brainstem area involved in behavioural activation is the nucleus incertus (NI), located in the posterior ventromedial central grey. Several studies have implicated NI in control of arousal/stress and reward/feeding responses. Orexin receptor mRNA expression identifies NI as a putative target of orexin modulation. Therefore, in this study we performed neural tract-tracing and immunofluorescence staining to characterise the orexinergic innervation of NI. Our results indicate a convergent innervation of the NI area by different orexin neuron populations, with an abundance of orexin-A-containing axons making putative synaptic contacts with relaxin-3-positive NI neurons. The influence of orexin-A on NI neuron activity was investigated using patch-clamp recordings. Orexin-A depolarised the majority (64%) of recorded neurons and this effect was maintained in the presence of tetrodotoxin and glutamate and GABA receptor antagonists, indicating a likely postsynaptic action. Voltage-clamp experiments revealed that in 'type I' NI neurons comprising relaxin-3-positive cells, orexin-A acted via L-type calcium channels, whereas in 'type II' relaxin-3-negative neurons, activation of a sodium/calcium exchanger was involved. A majority of the orexin-A sensitive neurons tested for the presence of orexin receptor mRNA, were OX2 mRNA-positive. Immunohistochemical staining for putative orexin receptors on NI neurons, confirmed stronger expression of OX2 than OX1 receptors. Our data demonstrate a strong influence of orexin-A on NI neurons, consistent with an important role for this hypothalamic/tegmental circuit in the regulation of arousal/vigilance and motivated behaviours.