Andreja Sinkovič

Erythropoietin facilitates the return of spontaneous circulation and survival in victims of out-of-hospital cardiac arrest

BACKGROUND Erythropoietin activates potent protective mechanisms in non-hematopoietic tissues including the myocardium. In a rat model of ventricular fibrillation, erythropoietin preserved myocardial compliance enabling hemodynamically more effective CPR. OBJECTIVE To investigate whether intravenous erythropoietin given within 2 min of physician-led CPR improves outcome from out-of-hospital cardiac arrest. METHODS Erythropoietin (90,000 IU of beta-epoetin, n=24) was compared prospectively with 0.9% NaCl (concurrent controls=30) and retrospectively with a preceding group treated with similar protocol (matched controls=48). RESULTS Compared with concurrent controls, the erythropoietin group had higher rates of ICU admission (92% vs 50%, p=0.004), return of spontaneous circulation (ROSC) (92% vs 53%, p=0.006), 24-h survival (83% vs 47%, p=0.008), and hospital survival (54% vs 20%, p=0.011). However, after adjusting for pretreatment covariates only ICU admission and ROSC remained statistically significant. Compared with matched controls, the erythropoietin group had higher rates of ICU admission (92% vs 65%, p=0.024) and 24-h survival (83% vs 52%, p=0.014) with statistically insignificant higher ROSC (92% vs 71%, p=0.060) and hospital survival (54% vs 31%, p=0.063). However, after adjusting for pretreatment covariates all four outcomes were statistically significant. End-tidal PCO(2) (an estimate of blood flow during chest compression) was higher in the erythropoietin group. CONCLUSIONS Erythropoietin given during CPR facilitates ROSC, ICU admission, 24-h survival, and hospital survival. This effect was consistent with myocardial protection leading to hemodynamically more effective CPR (Trial registration: http://isrctn.org. Identifier: ISRCTN67856342).

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.

Therapeutic hypothermia and inhalation anesthesia in a patient with severe pneumococcal meningitis and secondary cardiac arrest

Therapeutic hypothermia was associated with increased mortality in patients with severe bacterial meningitis in a large randomized trial. It still remains a treatment strategy for comatose survivors of cardiac arrest. There are several potential advantages of inhalational anesthetics as long-term sedation agents compared to intravenous sedation, however, uncontrollable increases of intracranial pressure were observed in neurocritical patients. Here we present a patient with severe bacterial meningitis and secondary cardiac arrest where therapeutic hypothermia and inhalational anesthesia were successfully used. A 59-year old female with a history of a vestibular Schwannoma surgery on the left side was admitted with signs of meningitis. Within minutes after admission, she further deteriorated with respiratory arrest, followed by cardiac arrest. She remained comatose after return of spontaneous circulation. The standard treatment of severe meningitis (steroids, antibiotics, insertion of intracranial pressure probe and external ventricular drainage) along with therapeutic hypothermia and inhalational anesthesia were implemented. Intracranial pressure remained stable and daily neurological examination was possible without being confounded by concurrent sedation. She was discharged home without neurological sequelae after 27days. In selected patients with meningitis, therapeutic hypothermia may still present a treatment option, and the long-term use of inhalational anesthetics could be appropriate with concomitant intracranial pressure monitoring.

Low-dose intravenous lipid emulsion for the treatment of severe quetiapine and citalopram poisoning.

Abstract The treatment of quetiapine and/or citalopram poisoning is mainly supportive and involves gastric lavage, activated charcoal, intubation, and mechanical ventilation. Recently, however, there were reports of successful treatment with intravenous lipid emulsion. Here we report a case of a 19-year-old Caucasian girl who ingested approximately 6000 mg of quetiapine, 400 mg of citalopram, and 45 mg of bromazepam in a suicide attempt. The patient developed ventricular tachycardia and epileptic seizures 12 h after admission to the hospital. As the patient’s condition deteriorated, we combined standard therapy (intubation, mechanical ventilation, and vasopressors) with low-dose intravenous lipid emulsion (ILE) (a total of 300 mL of 20 % lipid emulsion) and normalised her heart rhythm and stopped the seizures. She was discharged to the psychiatric ward after 48 h and home after a prolonged (2-month) psychiatric rehabilitation. Intravenous lipid emulsion turned out to be effective even in the lower dose range than previously reported for quetiapine poisoning in patients presenting with seizure and ventricular arrhythmia. To our knowledge, there are no case reports describing the use of ILE in treating citalopram poisoning.