Anne Chao

Analysis and results of prolonged resuscitation in cardiac arrest patients rescued by extracorporeal membrane oxygenation

OBJECTIVES We conducted this study to determine the result of prolonged cardiopulmonary resuscitation (CPR) with extracorporeal membrane oxygenation (ECMO) and the predictive factors for hospital discharge and ECMO weaning. BACKGROUND Prolonged CPR carries considerable associated mortality and morbidity. As yet, ECMO for prolonged CPR has no definite results. Only small groups of patients and no detailed analysis have been reported. METHODS Candidates for ECMO resuscitation were patients in cardiac arrest receiving CPR >10 min without return of spontaneous circulation and no absolute contraindication. Venoarterial ECMO was set up during CPR. We reviewed the data of 57 prolonged CPR patients who received ECMO during CPR over a six-year period. RESULTS The mean duration of CPR was 47.6 +/- 13.4 min and that of ECMO was 96.1 +/- 87.9 h. The rate of weaning was 66.7%, and the survival rate was 31.6%. Multiple-organ failure was the major reason for mortality, despite successful weaning. Among survivors, long-term follow-up revealed 88.9% survival, and only 5.6% had a severe neurologic deficit. The results indicate that a shorter CPR duration, postcardiotomy arrest, myocardial indicators, a hepatic indicator, and lactic acid are significantly correlated with both weaning and survival, whereas late damage (level on the third or seventh day of reperfusion) rather than initial damage (level on the first day) was more predictive of the results. CONCLUSIONS Prolonged CPR rescue by ECMO provides an acceptable survival rate and outcome in survivors. Our results of the selected cases encourage further investigations of the wider application of ECMO in CPR.

Pain relief by applying transcutaneous electrical nerve stimulation (TENS) on acupuncture points during the first stage of labor: a randomized double-blind placebo-controlled trial.

Abstract Transcutaneous electrical nerve stimulation (TENS) is one of the non‐pharmacological means of pain relief for labor and delivery. We aimed to investigate the efficacy and safety of TENS on specific acupuncture points for reducing pain in the first stage of labor. In this double‐blind, placebo‐controlled trial, we randomly assigned healthy full‐term parturients in active phase of first‐stage labor to either TENS on four acupuncture points (Hegu [Li 4] and Sanyinjiao [Sp 6]) (n = 52) or the TENS placebo (n = 53). Visual analogue scale (VAS) was used to assess pain before and 30 and 60 min after treatment. The primary outcome was the rate of VAS score decrease ⩾3 in each group. A questionnaire was given at 24 h post‐partum to evaluate the satisfaction of pain relieving method and the willingness to have the same treatment again. Mode of delivery and neonatal effect were measured as secondary outcome. One hundred women were eligible for analysis. TENS group experienced VAS score reduction ⩾3 significantly more common than the TENS placebo group (31/50 [62%] vs 7/50 [14%], P < 0.001). Willingness of using the same analgesic method for a future childbirth was also significantly different (TENS: 48/50 [96%] vs TENS placebo: 33/50 [66%], P < 0.001). Operative delivery was increased in the TENS group (12/50 [24%] vs 4/50 [8%], P = 0.05), but the neonatal outcomes were not different. The application of TENS on specific acupuncture points could be a non‐invasive adjunct for pain relief in the first stage of labor.

Outcome of antenatally diagnosed cardiac rhabdomyoma: case series and a meta‐analysis

Rhabdomyoma, the most common primary fetal cardiac tumor, is often associated with tuberous sclerosis (TS). We aimed to evaluate outcome in cases diagnosed with fetal cardiac rhabdomyoma.

Hyperbilirubinemia after cardiac operation: Incidence, risk factors, and clinical significance

Three hundred and two consecutive patients who had undergone cardiac operation for various cardiac lesions were studied prospectively to evaluate the incidence, risk factors, and the associated mortality of postoperative hyperbilirubinemia after cardiopulmonary bypass. Concentrations of the serum total (conjugated and unconjugated) bilirubin, alanine aminotransferase, aspartate aminotransferase, lactate dehydrogenase, alkaline phosphatase, albumin, globulin, and serum haptoglobin were measured before the operation and again on the first, second, and seventh postoperative days. Postoperative hyperbilirubinemia was defined as occurrence of a serum total bilirubin concentration of more than 3 mg/dl in any measurement during the postoperative period. Logistic regression was done to identify possible risk factors for postoperative hyperbilirubinemia. Overall incidence of postoperative hyperbilirubinemia was 35.1%; the incidence of postoperative hyperbilirubinemia was higher in patients whose valves were replaced with mechanical prostheses than in those without prostheses (p < 0.00001). In patients with postoperative hyperbilirubinemia, 70% of the increase of total bilirubin on the first postoperative day came about from an increase in unconjugated bilirubin. Serum haptoglobin decreased significantly at the same time (p < 0.01). Development of the postoperative hyperbilirubinemia was associated with a higher mortality (5.6% versus 0.5%, p < 0.01) and higher frequency of use of intraaortic balloon counterpulsation, especially for patients in whom the highest postoperative total bilirubin occurred after the first 2 days. The numbers of valves replaced, preoperative right atrial pressure, and preoperative total bilirubin concentration are the significant risk factors that, in combination, correctly predict the occurrence of postoperative hyperbilirubinemia in 80% of the patients. We concluded that postoperative hyperbilirubinemia results mainly from an increase in unconjugated bilirubin and is associated with higher mortality, especially for patients in whom highest postoperative total bilirubin occurred late after operation. Patients with the higher preoperative right atrial pressure and total bilirubin level who then underwent multiple valve replacement procedures are at greater risk for development of postoperative hyperbilirubinemia.

Phaeochromocytoma crisis – a rare indication for extracorporeal membrane oxygenation

We report on a case of phaeochromocytoma whose initial presentation mimicked an acute myocardial infarction. Veno‐arterial extracorporeal membrane oxygenation was used for the management of refractory cardiogenic shock and massive lung oedema. Suspicion and diagnosis of a phaeochromocytoma were made due to its unique clinical presentation during extracorporeal membrane oxygenation. Stabilisation of the crisis and recovery of cardiopulmonary function were achieved using the support of extracorporeal membrane oxygenation. This case highlights the difficulty in the differential diagnosis of cardiogenic shock secondary to phaeochromocytoma and the important role of extracorporeal membrane oxygenation can have in the successful resuscitation and management of these patients.

Abdominal compartment syndrome secondary to ovarian mucinous cystadenoma.

BACKGROUND: Abdominal compartment syndrome secondary to a very large benign ovarian tumor has been rarely reported in gynecology. With the increase of intraabdominal pressure in abdominal compartment syndrome, all major organ systems are adversely affected, causing a potentially fatal condition. CASE: A 43-year-old woman presenting with a tensely distended abdomen developed hypotension, difficulty in ventilation, and anuria. An ovarian tumor complicated by abdominal compartment syndrome was diagnosed, along with hemodynamic decompensation. Prompt resuscitation with immediate surgical removal of the tumor reversed the life-threatening situation. CONCLUSION: Timely aggressive resuscitation, prompt surgical decompression, and intensive perioperative hemodynamic management are required for patients with ovarian mucinous cystadenoma complicated by abdominal compartment syndrome.

Extracorporeal membrane oxygenation resuscitation for traumatic brain injury after decompressive craniotomy

Acute cardiopulmonary failure in patients with increased intracranial pressure is a significant management challenge to physicians. We report on a 21-year-old patient with traumatic brain injury who developed intractable hypoxemia and hypotension after undergoing a decompressive craniotomy. Venoarterial extracorporeal membrane oxygenation was initiated to resuscitate the patient. Extracorporeal membrane oxygenation is considered contraindicated in patients with intracranial bleeding because systemic heparin is needed during the support of extracorporeal membrane oxygenation. We describe our successful experience in tackling this dilemma.

Laser speckle contrast imaging for assessing microcirculatory changes in multiple splanchnic organs and the gracilis muscle during hemorrhagic shock and fluid resuscitation.

OBJECTIVE Hemorrhagic shock induces both macrocirculatory and microcirculatory impairment. Persistent microcirculatory dysfunction is associated with the dysfunction of multiple organs, especially in the splanchnic organs. However, few studies have simultaneously investigated microcirculation in multiple organs. In the present study, we used laser speckle contrast imaging to simultaneously investigate microcirculatory changes secondary to hemorrhagic shock and after fluid resuscitation among multiple splanchnic organs and the gracilis muscle. MATERIALS AND METHODS 72 male Wistar rats were subjected to sham operation, hemorrhagic shock (total blood loss of 30mL/kg) and saline resuscitation. Macrocirculatory parameters, including the mean arterial pressure (MAP) and heart rate, and microcirculatory parameters, including microcirculatory blood flow intensity and tissue oxygen saturation in the liver, kidney, intestine (mucosa, serosal muscular layer, and Peyers patch), and gracilis muscle were compared in a period of 3h. RESULTS Hemorrhagic shock induced a significant reduction of microcirculatory blood flow intensity in the kidney and intestine (especially the mucosa). Tissue oxygen saturation reduction secondary to hemorrhagic shock was comparable among the various splanchnic organs but lower than the gracilis muscle. Fluid resuscitation restored the MAP but not the microcirculatory blood flow in the intestine and the tissue oxygen saturation in each splanchnic organ. CONCLUSION Hemorrhagic shock induced the largest reduction in microcirculatory blood flow intensity in the intestinal mucosa. By comparison, the reduction of tissue oxygen saturation was not significantly different among the various splanchnic organs. Although fluid resuscitation restored the MAP, the intestinal microcirculation remained damaged.

Acute pancreatitis secondary to primary hyperparathyroidism in a postpartum patient: A case report and literature review

OBJECTIVE Primary hyperparathyroidism (PHPT) is a rare clinical entity in reproductive women. Unusual hypercalcemia causing pancreatitis in the peripartum period carries significant morbidity to both the fetus and the mother. CASE REPORT A 38-year-old woman developed a morbid course of intractable intra-abdominal abscess by pancreatitis, hydronephrosis by renal lithiasis, and unusual neurological presentations soon after delivery. Serial serum calcium level and imaging studies lead to the final diagnosis of PHPT due to a parathyroid adenoma. Data on 14 patients who suffered from pancreatitis due to hyperparathyroidism were collected from a MEDLINE search. The reasons for delayed diagnosis and literature review of acute pancreatitis in PHPT are discussed. CONCLUSION Hypercalcemia can be masked during pregnancy and in severe pancreatitis, as was detected in about half of the case series. Clinicians should have a high level of suspicion of parathyroid adenoma in cases with a profound pancreatitis. Timely diagnosis and early therapeutic intervention are important to resolve complications and improve the outcomes of mothers and fetuses.

Effects of Polymyxin B Hemoperfusion on Mortality in Patients With Severe Sepsis and Septic Shock: A Systemic Review, Meta-analysis Update, and Disease Severity Subgroup Meta-analysis

Objective: Several studies have reported a survival benefit for polymyxin B hemoperfusion treatment in patients with severe sepsis and septic shock. However, recently, a propensity-matched analysis and a randomized controlled trial reported no survival benefit for polymyxin B hemoperfusion treatment. We performed an up-to-date meta-analysis to determine the effect of polymyxin B hemoperfusion treatment on mortality in patients with severe sepsis and septic shock. Data Sources: PubMed, Embase, and Cochrane Library were searched from inception to May 2016. Study Selection: Studies investigating the effect of polymyxin B hemoperfusion on mortality were considered eligible. We searched for terms related to severe sepsis and septic shock and terms related to polymyxin B hemoperfusion. Data Extraction: The following data were extracted from the original articles: the name of the first author and publication year, subjects and setting, inclusion and exclusion criteria, mean age and size of the study population, male percentage, mortality, blood pressure, Sequential Organ Failure Assessment score, pulmonary oxygenation, and levels of endotoxin and humoral cytokines. Data Synthesis: A total of 17 trials were included. The pooled risk ratio for overall mortality was 0.81 (95% CI, 0.70–0.95), favoring polymyxin B hemoperfusion (p = 0.007). Disease severity subgroup meta-analysis revealed a significant reduction of mortality in the intermediate- and high-risk groups (risk ratio, 0.84; 95% CI, 0.77–0.92 and risk ratio, 0.64; 95% CI, 0.52–0.78, respectively), but not in the low-risk group (risk ratio, 1.278; 95% CI, 0.888–1.839). The nonlinear meta-regression with restricted cubic spline showed an almost linear inverse association between the baseline mortality rate and reduction in the risk of mortality. Conclusion: The present study demonstrated that polymyxin B hemoperfusion treatment may reduce mortality in patients with severe sepsis and septic shock in specific disease severity subgroups.