Exploring the multiple disciplinary model of emergent extracorporeal membrane oxygenation for cardiac arrest patients北大核心CSCD

Objective To explore the multiple disciplinary model of emergent extracorporeal membrane oxygenation (ECMO) for cardiac anest (CA) patients. Methods A retrospective investigation was done to analyze the general material, multiple disciplinary corporations, the complication and its treatment of patients who underwent emergent ECMO for non-surgery CA from January 2016 to August 2017. Results Three patients were all men with mean age 45. 3 ± 20.3 years. Their mean cardiopulmonary resuscitation duration was 34 ± 10 mm, and 2 patients returned to spontaneous circulation, yet hemodynaniics instability. 2 patients discharged with cerebral performance category 1-2, however the third died. 3 cannulation of femoral artery and venous were all operated by cardiac surgery using surgical exposure via open cutdown. Mean duration of CA to ECMO pump-on was 132 ±93 mm, while the mean duration of ECMO was 3 858 ± 1 092mm. The implementation and maintenance of ECMO needed collaboration of emergent physicians, cardiovascular medicine and surgeon, anesthetists, nurses and so on. At the same time, incision site oozing blood, platelet counting decreasing, coagulopathy and other complications would occur, which needed interventional vascular surgeon and blood bank to participate in. Conclusions Emergent ECMO for CA patients need corporations of prehospital emergent medical system, emergent physicians, cardiovascular physicians and surgeons, anesthetists, perfusionists, blood bank and so on. Establishing coordination and cooperation model of multiple disciplinary quick response team with emergency department as the guide is the important guarantee for emergent department developing emergent extracorporeal resuscitation.     

beta-Blockers for the treatment of cardiac arrest from ventricular fibrillation?

More than 160,000 people suffer sudden cardiac death each year in the US. It is estimated that ventricular fibrillation (VF) is the initial rhythm in approximately 30% of these cases. Ventricular fibrillation that does not respond to the first few defibrillation attempts is associated with mortality rates of up to 97%. Currently, no pharmacological intervention has been shown to increase long-term survival in patients with shock-refractory VF. The purpose of this review article is to evaluate whether beta-blocker administration during the resuscitation of cardiac arrest from VF or pulseless ventricular tachycardia (VT) improves outcome. We searched the MEDLINE and EMBASE databases for human clinical trials, animal experimental trials, review articles, case reports and abstracts published between 1966 and September 2006. No human prospective randomized controlled trial has studied the effects of beta-blocker administration during VF directly. Prospective trials of anti-arrhythmics with beta-blocking properties have been published, as well as several case reports/case series and experimental animal studies. The evidence thus far suggests that beta-blockade during resuscitation from VF may be associated with increasing rates of resuscitation, greater post-resuscitation survival, and improved post-resuscitation myocardial function. These positive effects on outcome may be mediated by a decrease in the oxygen requirements of the fibrillating heart, thus improving the overall balance between myocardial oxygen supply and demand during resuscitation. While no significant detrimental effects directly related to low dose beta-blockade during VF have been reported in the studies reviewed, concerns relating to possible loss of myocardial contractility and hypotension remain. To this day, high quality human trials are lacking. Preliminary human studies are needed to assess the effects of beta-blockers in the treatment of cardiac arrest from ventricular fibrillation or pulseless VT further.     

Deeper chest compression – More complications for cardiac arrest patients?

Aim of the study

Sternal and rib fractures are frequent complications caused by chest compressions during cardiopulmonary resuscitation (CPR). This study aimed to investigate the potential association of CPR-related thoracic and abdominal injuries and compression depth measured with an accelerometer.

Methods

We analysed the autopsy records, CT scans or chest radiographs of 170 adult patients, suffering in-hospital cardiac arrest at the Tampere University Hospital during the period 2009–2011 to investigate possible association of chest compressions and iatrogenic injuries. The quality of manual compressions during CPR was recorded on a Philips, HeartStart MRx Q-CPR™-defibrillator.

Results

Patients were 110 males and 60 females. Injuries were found in 36% of male and 23% of female patients. Among male patients CPR-related injuries were associated with deeper mean – and peak compression depths (p < 0.05). No such association was observed in women. The frequency of injuries in mean compression depth categories <5, 5–6 and >6 cm, was 28%, 27% and 49% (p = 0.06). Of all patients 27% sustained rib fractures, 11% sternal fracture and eight patients had haematomas/ruptures in the myocardium. In addition, we observed one laceration of the stomach without bleeding, one ruptured spleen, one mediastinal haemorrhage and two pneumothoraxes.

Conclusion

The number of iatrogenic injuries in male patients was associated with chest compressions during cardiopulmonary resuscitation increased as the measured compression depth exceeded 6 cm. While there is an increased risk of complications with deeper compressions it is important to realize that the injuries were by and large not fatal.     

What is the appropriate outcome for studies of treatments for out-of-hospital cardiac arrest?

BACKGROUND: A good outcome following out-of-hospital medical care for cardiac arrest is survival to hospital discharge. Because a large number of patients are required to detect a minimum clinically important difference in survival, an intermediate outcome such as hospital admittance is commonly used. For an intermediate outcome to be a useful surrogate, the survival rate conditional on achieving the intermediate outcome should not depend upon the field treatment. If so, an advantage of the intermediate outcome may be a smaller sample size. However, recent trials demonstrate that survival conditional on admittance may depend upon the field treatment. Even if the resources are available to power a study for survival, is survival the right outcome? For example, no increase in survival and a large increase in admittance could be considered a bad result, as it represents a substantial waste of resources. Similarly no increase in mortality and a decrease in admittance should be considered a good result, as it represents a substantial cost savings without any sacrifice of life. Both admittance and survival are important outcomes and need to be considered jointly, that is, as a bivariate outcome. METHODS: Cost-effectiveness concepts are used to distinguish between a good and bad (bivariate) outcome. Simulations are conducted to compare the impact of the univariate and the bivariate outcomes in a variety of trial scenarios. A table of sample sizes is computed for the bivariate outcome across a range of trial scenarios. RESULTS: The bivariate outcome outperforms both univariate outcomes for most alternatives. The required sample size for the joint outcome of admittance and survival may be substantially, over 50%, less than that for the survival outcome alone. CONCLUSION: Use of the bivariate outcome could provide more informed decision making about resuscitation strategies and at less cost then the current gold standard of hospital survival.     

Do we hyperventilate cardiac arrest patients?

INTRODUCTION: Hyperventilation during cardiopulmonary resuscitation is detrimental to survival. Several clinical studies of ventilation during hospital and out-of-hospital cardiac arrest have demonstrated respiratory rates far in excess of the 10 min(-1) recommended by the ERC. We observed detailed ventilation variables prospectively during manual ventilation of 12 cardiac arrest patients treated in the emergency department of a UK Hospital. METHODS: Adult cardiac arrest patients were treated according to ERC guidelines. Ventilation was provided using a self-inflating bag. A COSMOplus monitor (Respironics Inc.) was inserted into the ventilation circuit at the beginning of the resuscitation from which ventilation data were downloaded to a laptop. RESULTS: Data were collected from 12 patients (7 male; age 47-82 years). The maximum respiratory rate was 9-41 breaths per minute (median 26). The median tidal volume was 619 ml (374-923 ml) and the median respiratory rate was 21 min(-1) (7-37 min(-1)). The corresponding median minute volume was 13.0 l/min (4.6-21.3 min(-1)). Median peak inspiratory pressures were 60.6 cmH(2)O (range 46-106). Airway pressure was positive for 95.3% of the respiratory cycle (range 87.9-100%). CONCLUSIONS: Hyperventilation was common, mostly through high respiratory rates rather than excessive tidal volumes. This is the first study to document tidal volumes and airway pressures during resuscitation. The persistently high airway pressures are likely to have a detrimental effect on blood flow during CPR. Guidelines on respiratory rates are well known, but it would appear that in practice they are not being observed.     

Can successful treatment of cardiac arrest be a performance indicator for hospitals?

BACKGROUND: Although resuscitation from cardiac arrest prevents more deaths from acute myocardial infarction (MI) than any other treatment, results have not been audited widely nor performance standards proposed. METHODS: The Myocardial Infarction National Audit Project (MINAP) uses electronic transmission of a 53-item dataset to a central cardiac audit database (CCAD). From October 2000 to August 2002, transmission by 218 hospitals of data from 55,906 cases of MI with 4934 attempted resuscitations from a first arrest, allowed for examination of factors determining survival, and for possible future measurement of success in resuscitation as a performance indicator. We investigated two possible indicators: (i) numbers of survivors from arrest in ventricular fibrillation or pulseless ventricular tachycardia (VF/VT) per 1000 cases of MI; and (ii) observed/expected (O/E) ratios for survival taking all VF/VT arrests rather than MI as the denominator, and adjusting for differing age structures and admission delays among individual hospitals. FINDINGS: Of the 4934 reported patients suffering a first arrest, 1778 (36%) survived to be discharged from hospital. The presenting rhythm was VF/VT in 2321 (47%) patients of whom 1461 (63%) survived. Survival for all 218 hospitals together had the relatively small 95% confidence limits of 26 (25-27) survivors from VF/VT per 1000 MI. However, the small numbers from individual hospitals made it impossible in most cases, whichever of the two indicators was used, to separate quality of performance and completeness of reporting from the factor of chance. INTERPRETATION: Audit of success in resuscitation is essential if performance in the treatment of MI is to be assessed. However, the relatively small numbers of arrests occurring in individual hospitals means that if year on year improvements are to be documented, audit must be carried out among groups of hospitals or on a national scale.     

In-hospital cardiac arrest: Is outcome related to the time of arrest?

BACKGROUND: Whether outcome from in-hospital cardiopulmonary resuscitation (CPR) is poorer when it occurs during the night remains controversial. This study examined the relationship between CPR during the various hospital shifts and survival to discharge. METHODS: CPR attempts occurring in a tertiary hospital with a dedicated, certified resuscitation team were recorded prospectively (Utstein template guidelines) over 24 months. Medical records and patient characteristics were retrieved from patient admission files. RESULTS: Included were 174 in-hospital cardiac arrests; 43%, 32% and 25% in morning evening and night shifts, respectively. Shift populations were comparable in demographic and treatment related variables. Asystole (p < 0.01) and unwitnessed arrests (p = 0.05) were more common during the night. Survival to discharge was poorer following night shift CPR than following morning and evening shift CPR (p = 0.04). When asystole (being synonymous with death) was excluded from the analysis, the odds of survival to discharge was not higher for witnessed compared to unwitnessed arrest but was 4.9 times higher if the cardiac arrest did not occur during the night shift (p = 0.05, logistic regression). The relative risk of eventual in-hospital death for patients with return of spontaneous circulation (ROSC) following night shift resuscitation was 1.9 that of those with ROSC following morning or evening resuscitation (Cox regression). CONCLUSIONS: Although unwitnessed arrest is more prevalent during night shift, resuscitation during this shift is associated with poorer outcomes independently of witnessed status. Further research is required into the causes for the increased mortality observed after night shift resuscitation.     

Out-of-hospital cardiac arrest: always coronary angiography?

Introduction: Out-of-hospital cardiac arrest (OHCA) remains one of the principle challenges in the setting of critical care medicine and emergency cardiology.

Areas covered: Long-term survival rates even after successful resuscitation are variable but increasing in the recent years; due to the improvement of base and advanced cardiac life support techniques an increasing number of resuscitated patients are admitted to the hospital. Recent data suggested that patients surviving to hospital discharge after OHCA presented long-term outcome similar to patients with ST-elevation myocardial infarction. However, limited and incompletely clear data are available in the literature about the selection and risk stratification of patients to be subjected to coronary angiography, particularly in patients who have unfavorable clinical features in whom procedures may be futile and may affect public reporting of morality. Recently the ESC and AHA addressed appropriate treatments for ST-elevation myocardial infarction (STEMI) patients with out-of-hospital cardiac arrest.

Expert commentary: Immediate coronary intervention in the setting of OHCA appears to be associated with better survival to discharge; the documentation of an occluded coronary artery in medium 25% of patients without signs of STEMI at ECG helps to explain why early angiography can improve outcomes. In the treatment of OHCA we can find some ethical issues; for example a combination of comorbidities with advanced age and prolonged ischemia indicated by severe lactic acidosis may signify a high enough chance of multiorgan failure or anoxic brain injury and where the benefit of coronary reperfusion therapy appears minimal.     

Cardioprotective effect of δ-opioid receptor agonist vs mild therapeutic hypothermia in a rat model of cardiac arrest with extracorporeal life support

Background

To compare the effect of δ-opioid receptor agonist, d-Ala2-d-Leu5 enkephalin (DADLE) with normothermic control and therapeutic hypothermia on post resuscitation myocardial function in a model of extracorporeal life support (ECLS).

Methods

Ventricular fibrillation (VF) was induced in male Wistar rats. After 10 min of untreated VF, venoarterial ECLS was instituted for 60 min. At the beginning of ECLS animals were randomized to three groups of ten: normothermia, hypothermia (32 °C) and DADLE intravenous infusion (1 mg/kg/h). Cooling to 32 °C or normothermia or drug infusion lasted for the entire ECLS. Plasma samples and myocardial biopsies were obtained and left-ventricular (LV) function was assessed by a conductance catheter at baseline and after weaning from ECLS.

Results

DADLE administration resulted in a significantly enhanced recovery of LV systolic function expressed by slope of the LV end-systolic pressure volume relationship (Ees) and preload recruitable stroke work (PRSW) than hypothermia and normothermia. LV stiffness indicated by end-diastolic pressure volume relationship (EDPVR) was significantly lower after DADLE administration (P < 0.01). LV relaxation described by Tau was preserved after DADLE treatment but not after normothermia or mild hypothermia (P < 0.01). Plasma lactate concentrations were lower in DADLE group (P < 0.05). DADLE and not conventional hypothermia significantly increased phosphorylation of the kinases ERK1 and 2 (3.9 ± 0.3 and 3.1 ± 0.5 vs 0.4 ± 0.1 and 0.3 ± 0.1-fold of baseline levels) (P < 0.001). Both DADLE and hypothermia but not normothermia increase phosphorylation of Akt.

Conclusions

DADLE was more effective than mild therapeutic hypothermia in recovering myocardial function and activation of the pro-survival kinases Akt and ERK after ECLS.     

Postresuscitation accelerated idioventricular rhythm: a potential prognostic factor for out-of-hospital cardiac arrest survivors

Objective Data are lacking on the relationship between postresuscitation ECG and outcome in out-of-hospital cardiac arrest (OHCA). We examined the prognostic information that postresuscitation ECG rhythm can provide for predicting outcome in OHCA survivors. Methods The retrospective observational study enrolled 56 successfully resuscitated nontraumatic adult OHCA patients. Postresuscitation 12-lead ECGs of the enrolled patients were interpreted independently by two cardiologists. We compared baseline clinical characteristics, CPR process, and outcome in the 8 patients with postresuscitation accelerated idioventricular rhythm (AIVR, n = 8) and the 48 without AIVR. Results The AIVR group had a higher proportion of patients with coronary artery disease (50% vs. 15%), initial ventricular tachycardia/fibrillation rhythm (50% vs. 8%), and cardiac origin of OHCA (75% vs. 23%). AIVR patients had longer total CPR duration (32 vs. 18 min) and higher dose of epinephrine use (10 vs. 3 mg). Postresuscitation AIVR was associated with an increased incidence of repeated CPR within 1 h after return of spontaneous circulation (38% vs. 4%), and lower 7-day survival rate (0% vs. 50%). Conclusions AIVR on postresuscitation ECG offers a prognostic factor related to a higher repeated CPR rate within 1 h after return of spontaneous circulation and a lower 7-day survival rates in successfully resuscitated OHCA victims.     

Epinephrine,vasopressin and steroids for in-hospital cardiac arrest: the right cocktail therapy?

Citation

Mentzelopoulos SD, Malachias S, Chamos C, Konstantopoulos D, Ntaidou T, Papastylianou A, Kolliantzaki I, Theodoridi M, Ischaki H, Makris D, Zakynthinos E, Zintzaras E, Sourlas S, Aloizos S, Zakynthinos SG: Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest: a randomized clinical trial. JAMA 2013, 310: 270– 279.