Benoit Champigneulle

Extracorporeal life support (ECLS) for refractory cardiac arrest after drowning: an 11-year experience.

AIM Neuroprotective effects of hypothermia may explain surprisingly high survival rates reported after drowning in cold water despite prolonged submersion. We described a cohort of refractory hypothermic cardiac arrests (CA) due to drowning treated by extracorporeal life support (ECLS) and aimed to identify criteria associated with 24-h survival. METHODS Eleven-year period (2002-2012) retrospective study in the surgical intensive care unit (ICU) of a tertiary hospital (European Hospital Georges Pompidou, Paris, France). All consecutive hypothermic patients admitted for refractory CA after drowning in the Seine River were included. Patients with core temperature below 30°C and submersion duration of less than 1h were potentially eligible for ECLS resuscitation. RESULTS Forty-three patients were admitted directly to the ICU during the study period. ECLS was initiated in 20 patients (47%). Among these 20 patients, only four (9%) survived more than 24h. A first hospital core temperature ≤26°C and a potassium serum level between 4.2 and 6mM at hospital admission have a sensitivity of 100% [95%CI: 28-100%] and a specificity of 100% [95%CI: 71-100%] to discriminate patients who survived more than 24h. Overall survival at ICU discharge and at 6-months was 5% [95%CI: 1-16%] (two patients). CONCLUSIONS Despite patient hypothermia and aggressive resuscitation with ECLS, the observed survival rate is low in the present cohort. Like existing algorithms for ECLS management in avalanche victims, we recommend to use first core temperature and potassium serum level to indicate ECLS for refractory CA due to drowning.

Increased survival of cirrhotic patients with septic shock

IntroductionThe overall outcome of septic shock has been recently improved. We sought to determine whether this survival gain extends to the high-risk subgroup of patients with cirrhosis.MethodsCirrhotic patients with septic shock admitted to a medical intensive care unit (ICU) during two consecutive periods (1997-2004 and 2005-2010) were retrospectively studied.ResultsForty-seven and 42 cirrhotic patients presented with septic shock in 1997-2004 and 2005-2010, respectively. The recent period differed from the previous one by implementation of adjuvant treatments of septic shock including albumin infusion as fluid volume therapy, low-dose glucocorticoids, and intensive insulin therapy. ICU and hospital survival markedly improved over time (40% in 2005-2010 vs. 17% in 1997-2004, P = 0.02 and 29% in 2005-2010 vs. 6% in 1997-2004, P = 0.009, respectively). Furthermore, this survival gain in the latter period was sustained for 6 months (survival rate 24% in 2005-2010 vs. 6% in 1997-2004, P = 0.06). After adjustment with age, the liver disease stage (Child-Pugh score), and the critical illness severity score (SOFA score), ICU admission between 2005 and 2010 remained an independent favorable prognostic factor (odds ratio (OR) 0.09, 95% confidence interval (CI) 0.02-0.4, P = 0.004). The stage of the underlying liver disease was also independently associated with hospital mortality (Child-Pugh score: OR 1.42 per point, 95% CI 1.06-1.9, P = 0.018).ConclusionsIn the light of advances in management of both cirrhosis and septic shock, survival of such patients substantially increased over recent years. The stage of the underlying liver disease and the related therapeutic options should be included in the decision-making process for ICU admission.

Predictors of long-term functional outcome and health-related quality of life after out-of-hospital cardiac arrest

BACKGROUND Even if a large majority of out-of-hospital cardiac arrest (OHCA) survivors appear to have a good neurological recovery with no important sequellae, whether health-related quality of life (HRQOL) is altered is less explored. PATIENTS AND METHODS HRQOL was evaluated by telephone interview using SF-36 questionnaire. Each OHCA case was age and gender-matched with 4 controls from the French general population. Association between current condition of the survivors with the 8 dimensions of the SF-36 questionnaire was investigated using MANCOVA. Cluster analysis was performed to identify patterns of HRQOL among CPC1 survivors. RESULTS 255 patients discharged alive from our referral centre between 2000 and 2013 (median age of 55y [45,64], 73.7% males) were interviewed. Global physical and mental components did not differ between CPC 1 survivors and controls (47.0 vs. 47.1, p=0.88 and 46.4 vs. 46.9, p=0.45) but substantially differed between CPC2, CPC3 and the corresponding controls. Younger age, male gender, good neurological recovery and daily-life autonomy at telephone interview were significantly associated with better scores in each SF-36 dimensions. Cluster analysis individualized 4 distinct subgroups of CPC1 patients characterised by progressively increased score of SF-36. Return to work and daily-life autonomy were differently distributed across these 4 groups while pre-hospital Utstein variables were not. CONCLUSION HRQOL of CPC1 OHCA survivors appeared similar to that of the general population, but patients with CPC2 or 3 had altered HRQOL. Younger age, male gender, good neurological recovery and daily-life autonomy were independently associated with a better HRQOL.

Gender differences in early invasive strategy after cardiac arrest: Insights from the PROCAT registry

AIM Early invasive strategy, including percutaneous coronary intervention (PCI), may improve survival in out-of-hospital-cardiac-arrest (OHCA) due to coronary artery disease but selection of suitable patients is challenging. Differences and results across gender remain unknown. We aimed to assess the relationship between gender and the use of an early invasive strategy after OHCA, and the relationship with outcome according to gender. METHODS All patients admitted after OHCA were prospectively included (2000-2013). Using a gender-independent algorithm for its indication, we assessed the association between the use of an early invasive strategy and the outcome at hospital discharge (using the Cerebral Performance Category scale), according to gender. RESULTS 1817 patients were included (520 women, 29%). Women were older (62.8 vs 59.1 years, P<0.0001). They had less shockable rhythm (42% vs 61%, P<0.001). After multivariate logistic regression, female gender was negatively associated with early coronary angiogram (OR=0.57, 95%CI 0.41-0.79, P=0.001). Results after propensity-score matching were consistent (P=0.02). Among 1157 patients who underwent coronary angiogram, rates of PCI did not differ between men and women (adjusted OR=1.26, 95%CI 0.87-1.82, P=0.23). Early invasive strategy was associated with favorable outcome in multivariate logistic regression (OR=1.43, 95%IC 1.02-2.0, P=0.04) with no interaction between gender and PCI (P for interaction=0.11). Association between PCI and outcome was consistent across genders. CONCLUSIONS After OHCA, women are less likely to undergo early invasive strategy. However, rates of PCI after coronary angiogram do not differ across gender, and the association between PCI and outcome is similar across gender.

Etiological diagnoses of out-of-hospital cardiac arrest survivors admitted to the intensive care unit: Insights from a French registry☆

BACKGROUND Respective proportions of final etiologies are disparate in cohorts of cardiac arrest patients, depending on examined population and diagnostic algorithms. In particular, prevalence and characteristics of sudden unexplained death syndrome (SUDS) are debated. We aimed at describing etiologies in a large cohort of aborted out-of-hospital cardiac arrest (OHCA) patients, in order to assess prevalence and outcome of SUDS. PATIENTS AND METHODS We analyzed data from our prospective registry of successfully resuscitated OHCA patients admitted to a cardiac arrest centre between January 2002 and December 2014. The in-ICU diagnostic strategy included early coronary angiogram, brain and chest CT scan. This was completed by an extensive diagnostic strategy, encompassing biological and toxicological tests, repeated electrocardiograms and echocardiography, MRI and pharmacologic tests. Two independent investigators reviewed each final diagnosis. Baseline characteristics were compared between subgroups of patients. Three-month mortality was compared between subgroups using univariate Kaplan-Meier curves. RESULTS Over the study period, 1657 patients were admitted to our unit after an aborted OHCA. The event was attributed to a non-cardiac and a cardiac cause in 478 (32.0%) and 978 (65.5%) patients, respectively. The main cause of cardiac related OHCA was ischemic heart disease (76.7%) while primary electrical diseases accounted for only 2.5%. Sudden unexplained deaths (SUDS) were observed in 37 (2.5%) patients. CONCLUSION We observed that ischemic heart disease was by far the most common cause of cardiac arrest, while primary electrical diseases were much less frequent. SUDS accounted for a very small proportion of patients who suffered an aborted OHCA.

Pheochromocytoma Crisis in the Icu: A French Multicenter Cohort Study With Emphasis on Rescue Extracorporeal Membrane Oxygenation

Objectives: To describe the characteristics, management, and outcome of patients admitted to ICUs for pheochromocytoma crisis. Design: A 16-year multicenter retrospective study. Setting: Fifteen university and nonuniversity ICUs in France. Patients: Patients admitted in ICU for pheochromocytoma crisis. Interventions: None. Measurement and Main Results: We included 34 patients with a median age of 46 years (40–54 yr); 65% were males. At admission, the median Sequential Organ Failure Assessment score was 8 (4–12) and median Simplified Acute Physiology Score II 49.5 (27–70). The left ventricular ejection fraction was consistently decreased with a median value of 30% (15–40%). Mechanical ventilation was required in 23 patients, mainly because of congestive heart failure. Vasoactive drugs were used in 23 patients (68%) and renal replacement therapy in eight patients (24%). Extracorporeal membrane oxygenation was used as a rescue therapy in 14 patients (41%). Pheochromocytoma was diagnosed by CT in 33 of 34 patients. When assayed, urinary metanephrine and catecholamine levels were consistently elevated. Five patients underwent urgent surgery, including two during extracorporeal membrane oxygenation. Overall ICU mortality was 24% (8/34), and overall 90-day mortality was 27% (9/34). Crude 90-day mortality was not significantly different between patients managed with versus without extracorporeal membrane oxygenation (22% vs 30%) (p = 0.7) despite higher severity scores at admission in the extracorporeal membrane oxygenation group. Conclusions: Mortality is high in pheochromocytoma crisis. Routinely considering this diagnosis and performing abdominal CT in patients with unexplained cardiogenic shock may allow an earlier diagnosis. Extracorporeal membrane oxygenation and adrenalectomy should be considered as a therapeutic in most severe cases.

Comparison of two sedation regimens during targeted temperature management after cardiac arrest

PURPOSE Although guidelines on post-resuscitation care recommend the use of short-acting agents for sedation during targeted temperature management (TTM) after cardiac arrest (CA), the potential advantages of this strategy have not been clinically demonstrated. METHODS We compared two sedation regimens (propofol-remifentanil, period P2, vs midazolam-fentanyl, period P1) among comatose TTM-treated CA survivors. Management protocol, apart from sedation and neuromuscular blockers use, did not change between the two periods. Baseline severity was assessed with Cardiac-Arrest-Hospital-Prognosis (CAHP) score. Time to awakening was measured starting from discontinuation of sedation at the end of rewarming. Awakening was defined as delayed when it occurred after more than 48 h. RESULTS 460 patients (134 in P2, 326 in P1) were included. CAHP score did not significantly differ between P2 and P1 (P = 0.93). Sixty percent of patients awoke in both periods (81/134 vs. 194/326, P = 0.85). Median time to awakening was 2.5 (IQR 1-9) hours in P2 vs. 17 (IQR 7-60) hours in P1. Awakening was delayed in 6% of patients in P2 vs. 29% in P1 (p < 0.001). After adjustment, P2 was associated with significantly lower odds of delayed awakening (OR 0.08, 95% CI 0.03-0.2; P < 0.001). Patients in P2 had significantly more ventilator-free days (25 vs. 24 days; P = 0.007), and lower catecholamine-free days within day 28. Survival and favorable neurologic outcome at discharge did not differ across periods. CONCLUSIONS During TTM following resuscitation from CA, sedation with propofol-remifentanil was associated with significantly earlier awakening and more ventilator-free days as compared with midazolam-fentanyl.

GENDER-RELATED DIFFERENCES AND SIMILARITIES IN ELIGIBILITY FOR CORONARY REPERFUSION AND OUTCOME AFTER OUT-OF-HOSPITAL CARDIAC ARREST

Results 1817 patients were included (520 women, 29%). Women were older than men (62.8 vs 59.1 years, P < 0.0001), with less cardiomyopathy. They had less frequently bystander cardiopulmonary resuscitation (84% vs 88%, P < 0.05) and less shockable rhythm (42% vs 61%, P < 0.001). After multivariate logistic regression, male sex was associated with the decision to perform coronary angiography (OR 1.73, 95%CI 1.28-2.34, P < 0.001) and results were consistent even after propensity-score matching (P = 0.02). Among 1157 patients who underwent coronary angiography, rate of PCI did not differ between men and women (OR 1.30, 95%CI 0.90 1.88, P = 0.17). Results after matching (211 men, 211 women) were consistent (P = 0.13). PCI was associated with favorable outcome by multivariate logistic regression (OR = 1.45, 95%IC = 1.07 1.96, P = 0.02) with no interaction between gender and PCI (P for interaction = 0.40). Association between PCI and outcome was consistent across genders.

Corrigendum to “Comparison of two sedation regimens during targeted temperature management after cardiac arrest” [Resuscitation 128 (2018) 204–210]

Université Paris-Descartes-Sorbonne-Paris-Cité, UFR de Médecine, Paris, France Medical ICU, Cochin Hospital, AP-HP, Paris, France c Paris Sudden-Death-Expertise-Center, Paris, France d Paris-Cardiovascular-Research-Center, INSERM U970, Paris, France e Emergency Department, Cochin-Hotel-Dieu Hospital, APHP, Paris, France f Surgical & Trauma Intensive Care Unit, Georges Pompidou European Hospital, APHP, Paris, France g ICU, Mignot Hospital, Le Chesnay, France Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy

Major traumatic complications after out-of-hospital cardiac arrest: Insights from the Parisian registry

AIM Due to collapse and cardiopulmonary resuscitation (CPR) maneuvers, major traumatic injuries may complicate the course of resuscitation for out-of-hospital cardiac arrest patients (OHCA). Our goals were to assess the prevalence of these injuries, to describe their characteristics and to identify predictive factors. METHODS We conducted an observational study over a 9-year period (2007-2015) in a French cardiac arrest (CA) center. All non-traumatic OHCA patients admitted alive in the ICU were studied. Major injuries identified were ranked using a functional two-level scale of severity (life-threatening or consequential) and were classified as CPR-related injuries or collapse-related injuries, depending of the predominant mechanism. Factors associated with occurrence of a CPR-related injury and ICU survival were identified using multivariable logistic regression. RESULTS A major traumatic injury following OHCA was observed in 91/1310 patients (6.9%, 95%CI: 5.6, 8.3%), and was classified as a life-threatening injury in 36% of cases. The traumatic injury was considered as contributing to the death in 19 (21%) cases. Injuries were related to CPR maneuvers in 65 patients (5.0%, (95%CI: 3.8, 6.1%)). In multivariable analysis, age [OR 1.02; 95%CI (1.00, 1.04); p = 0.01], male gender [OR 0.53; 95%CI (0.31, 0.91); p = 0.02] and CA occurring at home [OR 0.54; 95%CI (0.31, 0.92); p = 0.02] were significantly associated with the occurrence of a CPR-related injury. CPR-related injuries were not associated with the ICU survival [OR 0.69; 95%CI (0.36, 1.33); p = 0.27]. CONCLUSIONS Major traumatic injuries are common after cardiopulmonary resuscitation. Further studies are necessary to evaluate the interest of a systematic traumatic check-up in resuscitated OHCA patients in order to detect these injuries.