Andrej Markota

The introduction of an esophageal heat transfer device into a therapeutic hypothermia protocol: A prospective evaluation.

BACKGROUND Temperature management is a recommended part of post-resuscitation care of comatose survivors of cardiac arrest. A number of methods exist for temperature management, all of which have limitations. We aimed to evaluate the performance and ease of use of a new esophageal heat transfer device (EHTD; Advanced Cooling Therapy, Chicago, IL, USA) for temperature management of adult survivors of cardiac arrest. METHODS We performed a prospective study from March to June 2015. Our standard protocol uses servo-controlled water blankets supplemented with ice-cold saline in order to attain goal temperature (32°C-34°C) within 1 hour. We substituted the EHTD for our usual water blankets, then recorded temperature over time and adverse effects. MAIN FINDINGS A total of 14 patients were treated, with mean age 65.1±13.7 years, and median weight 75.5 (70; 83) kg. Initial temperature was 35.3±1.2°C. Mean cooling rate during the induction phase was 1.12±0.62°C/h, time to target temperature was 60 (41; 195) min and the volume of iced fluids infused was 1607±858 ml (as compared with 2-2.5L historically). The percentage of time outside target temperature range during the maintenance phase was 6.5% (0.0; 29.0). Rewarming rate was 0.22 (0.18; 0.31)°C/h. No major adverse effects were observed. CONCLUSION Using the EHTD, our patient population attained goal temperatures in one hour, the volume of ice-cold saline required to attain this cooling rate was decreased by one-third, and experienced a low percentage of time outside target temperature range and no major adverse effects.

Use of an oesophageal heat transfer device in therapeutic hypothermia

A number of methods exist for temperature management after ardiac arrest, all of which have limitations, namely, excessive uid loading with cold saline infusion, decreased efficacy in exteral cooling or rewarming methods and invasiveness required for ntravascular devices.1 Recently, a new esophageal heat transfer evice has become available, offering potential advantages over urrent methods.2 We report here the first clinical experience durng therapeutic hypothermia in Europe with this device. Our first patient was a 56-year-old male admitted after outf-hospital cardiac arrest. First recorded temperature in bladder as 35.5 ◦C and he received 1000 ml of iced saline after admission 2000 ml in all). The oesophageal heat transfer device (Esophageal ooling Device, Advanced Cooling Therapy, Chicago, Illinois, USA) as inserted when temperature in the bladder was 34.8 ◦C. In the

Difference Between Bladder and Esophageal Temperatures in Mild Induced Hypothermia

BACKGROUND Mild induced hypothermia is an established treatment strategy for comatose survivors of cardiac arrest. The goal of the induction phase of mild induced hypothermia is to cool the patients core body temperature to 32°-34°C. OBJECTIVE The main goal of this study was to compare temperature changes measured in the esophagus and urinary bladder in survivors of cardiac arrest undergoing mild induced hypothermia using cold saline infusion. METHODS We performed a prospective study in a 12-bed adult medical intensive care unit at a tertiary level hospital in comatose adult survivors of nontraumatic cardiac arrest admitted from January to April 2012. Paired temperature readings from bladder and esophageal probes were recorded every 5 min for 95 min (20 readings). Cold fluid infusion was terminated when the measured temperature from either of the probes reached 33.9°C. Factorial repeated-measures analysis of variance was used to determine the effect of time and site of measurement on temperature readings. RESULTS Measurements were performed in 8 patients. Target temperature was achieved in 33 ± 15 min in the esophagus and in 63 ± 15 min in the bladder (p = 0.006). We discovered a significant interaction effect (p < 0.001) between time and site of measurement, indicating that temperature changes differently depending on the site of measurement, with esophageal temperatures decreasing faster than temperatures measured in urinary bladder. CONCLUSIONS Our results indicate that esophageal temperature measurements show a faster response rate compared to temperature measured in the bladder when cold saline infusion is used to induce mild hypothermia.

Treatment of near-fatal beta blocker and calcium channel blocker intoxication with hyperinsulinemic euglycemia, intravenous lipid emulsions and high doses of norepinephrine

Background. Treatment of combined beta blocker and calcium channel blocker intoxication remains challenging due to a profound and treatment-resistant circulatory collapse. Along with standard therapy (calcium, glucagon, mechanical ventilation, vasopressors), two novel approaches are increasingly being reported as successful: hyperinsulinemic euglycemia and intravenous lipid emulsion. Case Report. Our patient: a 66-year-old Caucasian male who ingested approximately 450 mg of bisoprolol, 300 mg of amlodipine, 200 mg of doxazosin and smaller amounts of nifedipine, torasemide, acetysaliclic acid and ibuprofen in a suicide attempt. The patient was hypotensive and bradycardic on admission with left-ventricular ejection fraction estimated at 10-15%. By combining standard therapy (intubation, mechanical ventilation, vasopressors, calcium and glucagon) and new therapies (hyperinsulinemic euglycemia and intravenous lipid emulsions) in a stepwise approach we normalized systolic function and treated bradycardia SIGNA VITAE 2015; 10(1): 144 150

Corrigendum to “EuReCa ONE—27 Nations, ONE Europe, ONE Registry A prospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe” [Resuscitation 105 (2016) 188–195]

Introduction The aim of the EuReCa ONE study was to determine the incidence, process, and outcome for out of hospital cardiac arrest (OHCA) throughout Europe. Methods This was an international, prospective, multi-centre one-month study. Patients who suffered an OHCA during October 2014 who were attended and/or treated by an Emergency Medical Service (EMS) were eligible for inclusion in the study. Data were extracted from national, regional or local registries. Results Data on 10,682 confirmed OHCAs from 248 regions in 27 countries, covering an estimated population of 174 million. In 7146 (66%) cases, CPR was started by a bystander or by the EMS. The incidence of CPR attempts ranged from 19.0 to 104.0 per 100,000 population per year. 1735 had ROSC on arrival at hospital (25.2%), Overall, 662/6414 (10.3%) in all cases with CPR attempted survived for at least 30 days or to hospital discharge. Conclusion The results of EuReCa ONE highlight that OHCA is still a major public health problem accounting for a substantial number of deaths in Europe. EuReCa ONE very clearly demonstrates marked differences in the processes for data collection and reported outcomes following OHCA all over Europe. Using these data and analyses, different countries, regions, systems, and concepts can benchmark themselves and may learn from each other to further improve survival following one of our major health care events.

Impact of the New P2Y12 Receptor Inhibitors on Mortality in STElevationMyocardial Infarction Patients with Cardiogenic Shock and / orAfter Cardiopulmonary Resuscitation Undergoing Percutaneous CoronaryIntervention

Background: Little is known about clinical efficacy of newer P2Y12 receptor inhibitors in ST-elevation myocardial infarction patients presenting with cardiogenic shock or after cardiopulmonary resuscitation. The aim of our study was to establish the possible role of newer P2Y12 receptor inhibitors prasugrel and ticagrelor on survival in comparison to clopidogrel administration in ST-elevation myocardial infarction patients presenting with cardiogenic shock and / or after cardiopulmonary resuscitation. Method: The present study was an analysis of 187 patients with ST-elevation myocardial infarction presenting with cardiogenic shock and / or after cardiopulmonary resuscitation. Groups with newer P2Y12 receptor inhibitors (107 patients) and with clopidogrel (80 patients) were compared and followed for median 160 days (25th, 75th percentile: 6,841). Mortality at 14 days, 30 days and one year were compared between the groups. Results: Mortality at 14 days was similar in both groups. A strong trend towards a lower mortality at 30 days was noticed in the newer P2Y12 receptor inhibitors group [39 (48.8%) patients in clopidogrel group died versus 38 (35.5%) in the newer P2Y12 group receptor inhibitors; p = 0.07]. All-cause mortality at one year was significantly higher in the group with clopidogrel administration [47 (58.8%) patients in clopidogrel group died versus 46 (43.0%) in the newer P2Y12 receptor inhibitors group; p = 0.039]. Conclusion: In ST-elevation myocardial infarction patients presenting with cardiogenic shock and/or after cardiopulmonary resuscitation, the administration of newer P2Y12 receptor inhibitors reduced the one-year mortality in comparison to clopidogrel. The use of newer P2Y12 receptor inhibitors may be advocated in this very high risk group of patients.

Gender-related differences in patients with ST-elevation myocardial infarction

SummaryBackgroundA decade ago women with ST-elevation myocardial infarction (STEMI) were significantly older than men, with more comorbidities, less likely treated by primary percutaneous coronary intervention (PPCI) and their prognosis was worse. The progress in treatment led to increased survival after STEMI. Our aim was to evaluate the possible current differences between the genders in treatments, mortality and the changes in women over time in STEMI population.MethodsWe retrospectively evaluated 307 STEMI patients (224 men, 83 women), admitted between October 1, 2011 and December 31, 2012 and a historic group of 523 STEMI patients from 2008 to 2009 (361 men, 162 women). Reperfusion strategy was PPCI, combined with aspirin and clopidogrel or prasugrel or ticagrelor and a heparin with glycoprotein receptor IIb/IIIa antagonist or bivalirudin. Between the genders and in women over time we compared clinical data, the use and time to PPCI, in-hospital complications, 30-day and 6-month mortality.ResultsSTEMI patients in recent years were treated by PPCI in 94.5 %. Their 30-day mortality was 10.4 % and 6-month mortality 14.7 %. Between the genders we observed mostly nonsignificant differences (age, comorbidities, treatments, in-hospital complications, 30-day and 6-month mortality). Over the last years in women mean age significantly decreased, the use of PPCI significantly increased, the incidence of heart failure and bleedings decreased significantly, but mortalities nonsignificantly.ConclusionWomen still account for 1/4 of STEMI population, but the gap between the genders in presentation, treatments and outcome in STEMI population is decreasing.

Optimization of induction of mild therapeutic hypothermia with cold saline infusion: A laboratory experiment.

Cold fluid infusions can be used to induce mild therapeutic hypothermia after cardiac arrest. Fluid temperature higher than 4°C can increase the volume of fluid needed, prolong the induction phase of hypothermia and thus contribute to complications. We performed a laboratory experiment with two objectives. The first objective was to analyze the effect of wrapping fluid bags in ice packs on the increase of fluid temperature with time in bags exposed to ambient conditions. The second objective was to quantify the effect of insulating venous tubing and adjusting flow rate on fluid temperature increase from bag to the level of an intravenous cannula during a simulated infusion. The temperature of fluid in bags wrapped in ice packs was significantly lower compared to controls at all time points during the 120 minutes observation. The temperature increase from the bag to the level of intravenous cannula was significantly lower for insulated tubing at all infusion rates (median temperature differences between bag and intravenous cannula were: 8.9, 4.8, 4.0, and 3.1°C, for non-insulated and 5.9, 3.05, 1.1, and 0.3°C, for insulated tubing, at infusion rates 10, 30, 60, and 100 mL/minute, respectively). The results from this study could potentially be used to decrease the volume of fluid infused when inducing mild hypothermia with an infusion of cold fluids.

Cerebral tissue oximetry levels during prehospital management of cardiac arrest – A prospective observational study

INTRODUCTION Near-infrared spectroscopy (NIRS) enables continuous monitoring of regional oximetry (rSO2). The aim of this study was to describe dynamics of regional cerebral oximetry levels during out of hospital cardiac arrest (OHCA) resuscitation, specifically around the time of restoration of spontaneous circulation (ROSC). METHODS This prospective observational study was performed in the prehospital setting during cardio-pulmonary resuscitation (CPR) of OHCA patients. In the three-year study period, two-hundred eighty OHCAs were responded to; rSO2 was continuously measured throughout CPR and after attaining ROSC. RESULTS Final data analysis included 53 patients. Continuous rSO2dynamics were described and data was compared amongst ROSC (22 cases) and no-ROSC (31 cases) groups. Initial rSO2levels were below 15% (not detectable) in both groups. With ongoing CPR, rSO2levels were higher in the ROSC group (median 22% vs. 14% in no-ROSC group, p = 0.030). Until ROSC, rSO2levels were higher throughout CPR before ROSC (mean maximal value 47% at ROSC vs. 31% no-ROSC, p < 0.01). Furthermore, we found a pattern of significant, rapid and sustained rise in rSO2levels minutes prior to ROSC and normalization thereafter. CONCLUSIONS Initial rSO2levels during OHCA are generally undetectable by the time EMS teams initiate CPR. With CPR, rSO2levels rise and are higher during CPR in patients who later achieve ROSC. Patients who achieve ROSC exhibit significant, rapid, and sustained rise in rSO2minutes prior to attaining ROSC, and normalization of rSO2 levels thereafter. Persistently low levels of rSO2 during CPR likely portend poor neurologic outcomes.

GPIIb-IIIa Receptor Inhibitors in Acute Coronary Syndrome Patients Presenting With Cardiogenic Shock and/or After Cardiopulmonary Resuscitation

BACKGROUND Data on the use of GPIIb-IIIa receptor inhibitors (GPI) in acute coronary syndrome (ACS) patients presenting with cardiogenic shock and/or after cardiopulmonary resuscitation is sparse. The aim of the study was to establish the possible influence of the adjunctive use of GPI on 30-day and 1-year mortality in these high-risk patients. METHODS Acute coronary syndrome patients (261), who presented with cardiogenic shock and/or were cardiopulmonary resuscitated on admission, were analysed. Groups receiving (170 patients) and not receiving (91 patients) GPI were compared regarding 30-day and 1-year mortality. RESULTS The unadjusted all-cause 30-day and 1-year mortality were similar in patients receiving GPI and those not receiving GPI [79 patients (46.5%) vs 50 patients (54.9%) at 30 days; ns, 91 patients (53.5%) vs. 55 (61.1%) at 1 year; ns]. After the adjustment for baseline and clinical characteristics, the adjunctive usage of GPI was identified as an independent prognostic factor in lower 30-day mortality (adjusted OR: 0.41; 95%CI: 0.20 to 0.84; p=0.015) and 1-year mortality (HR 0.62; 95%CI 0.39-0.97; p=0.037). Age, left main PCI and major bleeding, were also identified as independent prognostic factors in worse 30-day and 1-year mortality. In addition, Thrombolysis in Myocardial Infarction (TIMI) flow 0/1 pre-percutaneous coronary intervention (PCI) predicted a worse 1-year outcome. Novel oral P2Y12 receptor antagonists predicted better 30-day and 1-year survival. CONCLUSION Our study suggests that the adjunctive usage of GPI may be beneficial in this high-risk group of patients in whom a delayed onset of action of oral antiplatelet therapy would be expected.