Christof Havel

Serial lactate determinations for prediction of outcome after cardiac arrest.

Abstract: We investigated the relationship between lactate clearance and outcome in patients surviving the first 48 hours after cardiac arrest. We conducted the study in the emergency department of an urban tertiary care hospital. We analyzed the data for all 48-hour survivors after successful resuscitation from cardiac arrest during a 10-year period. Serial lactate measurements, demographic data, and key cardiac arrest data were correlated to survival and best neurologic outcome within 6 months after cardiac arrest. Parameters showing significant results in univariate analysis were tested for significance in a logistic regression model. Of 1502 screened patients, 394 were analyzed. Survivors (n = 194, 49%) had lower lactate levels on admission (median, 7.8 [interquartile range, 5.4-10.8] vs 9 [6.6-11.9] mmol/L), after 24 hours (1.4 [1-2.5] vs 1.7 [1.1-3] mmol/L), and after 48 hours (1.2 [0.9-1.6] vs 1.5 [1.1-2.3] mmol/L). Patients with favorable neurologic outcome (n = 186, 47%) showed lower levels on admission (7.6 [5.4-10.3] vs 9.2 [6.7-12.1] mmol/L) and after 48 hours (1.2 [0.9-1.6] vs 1.5 [1-2.2] mmol/L). In multivariate analysis, lactate levels at 48 hours were an independent predictor for mortality (odds ratio [OR]: 1.49 increase per mmol/L, 95% confidence interval [CI]: 1.17-1.89) and unfavorable neurologic outcome (OR: 1.28 increase per mmol/L, 95% CI: 1.08-1.51). Lactate levels higher than 2 mmol/L after 48 hours predicted mortality with a specificity of 86% and poor neurologic outcome with a specificity of 87%. Sensitivity for both end points was 31%. Lactate at 48 hours after cardiac arrest is an independent predictor of mortality and unfavorable neurologic outcome. Persisting hyperlactatemia over 48 hours predicts a poor prognosis.

Life after death: Posttraumatic stress disorder in survivors of cardiac arrest: Prevalence, associated factors, and the influence of sedation and analgesia

ObjectiveCardiac arrest is possibly one of the most traumatizing conditions for patients, but to date, its influence on psychic morbidity remains unknown. Posttraumatic stress disorder is a unique symptom configuration after an extreme event consisting of intrusion re-experiencing, avoidance and numbness, and hyperarousal symptoms. We studied a) the prevalence of posttraumatic stress disorder (PTSD) in long term survivors of cardiac arrest; b) the role of specific stress factors related to cardiac arrest for the development of PTSD; and c) the influence of sedation and analgesia during or after cardiac arrest on the occurrence of PTSD. DesignProspective, cohort study. SettingUniversity teaching hospital. PatientsAnalysis was performed in cardiac arrest survivors who were discharged with favorable neurologic outcome during an 8-yr period (1991–1999). InterventionsAll patients received the Davidson Trauma Score for the assessment of PTSD and a modified German version of the EuroQol questionnaire for assessment of quality of life. Cardiac arrest circumstances and administration of sedation and analgesia were assessed. Measurements and Main ResultsOf 1,630 initially resuscitated patients, 270 patients were discharged with good neurologic outcome. A total of 226 patients were contacted, and 143 patients (63% of all eligible patients) completed the study. Mean time from cardiac arrest to follow up was 45 months (range, 24–66). Thirty-nine patients (27%; 95% confidence interval, 21% to 35%) had a Davidson Trauma Score >40 and fulfilled criteria for PTSD. Patients with PTSD had a significantly lower quality of life. The only independent risk factor for the development of PTSD was younger age. There was no difference between patients with or without PTSD regarding the use of sedation and analgesia during or after cardiac arrest. ConclusionThe prevalence of PTSD in cardiac arrest survivors is high. Besides younger age, neither clinical factors nor the use of sedation and analgesia were associated with development of PTSD.

Therapeutic hypothermia after cardiac arrest.

The use of therapeutic hypothermia following different hypoxic-ischaemic insults has played an important role in various concepts of non-specific protection of cells for a long time. Although the use of deep therapeutic hypothermia after cardiac arrest in the last century did not lead to an improved outcome, recent data have demonstrated very positive effects of mild therapeutic hypothermia. The data from the European multicenter trial as well as those from Australia have clearly demonstrated a decrease in mortality and a better neurological outcome for patients being cooled to 32-34 degrees C for 12 or 24 h. In 2003, this led to the implementation of mild therapeutic hypothermia (32-34 degrees C) into the International Liaison Committee on Resuscitation (ILCOR) recommendations and guidelines for the treatment of unconscious patients after prehospital cardiac arrest. This article gives an overview on existing concepts and future perspectives of therapeutic mild hypothermia.

Accuracy of Noninvasive Multiwave Pulse Oximetry Compared With Carboxyhemoglobin From Blood Gas Analysis in Unselected Emergency Department Patients

STUDY OBJECTIVE Accurate and timely diagnosis of carbon monoxide (CO) poisoning is difficult because of nonspecific symptoms. Multiwave pulse oximetry might facilitate the screening for occult poisoning by noninvasive measurement of carboxyhemoglobin (COHb), but its reliability is still unknown. We assess bias and precision of COHb oximetry compared with the criterion standard blood gas analysis. METHODS This was a prospective diagnostic accuracy study according to STARD (Standards for the Reporting of Diagnostic accuracy studies) criteria, performed at a tertiary care hospital emergency department. We included all patients for whom both invasive and noninvasive measurement within 60 minutes was available, regardless of their complaints, during a 1-year period. RESULTS One thousand five hundred seventy-eight subjects were studied, of whom 17 (1.1%) received a diagnosis of CO poisoning. In accordance with this limited patient cohort, we found a bias of 2.99% COHb (1.50% for smokers, 4.33% for nonsmokers) and a precision of 3.27% COHb (2.90% for smokers, 2.98% for nonsmokers), limits of agreement from -3.55% to 9.53% COHb (-4.30% to 7.30% for smokers, -1.63% to 10.29% for nonsmokers). Upper limit of normal cutoff of 6.6% COHb had the highest sensitivity in screening for CO poisoning. Smoking status and COHb level had the most influence on the deviation between measurements. CONCLUSION Multiwave pulse oximetry was found to measure COHb with an acceptable bias and precision. These results suggest it can be used to screen large numbers of patients for occult CO poisoning.

Lunar phases are not related to the occurrence of acute myocardial infarction and sudden cardiac death

BACKGROUND Mass media deliver pertinacious rumours that lunar phases influence the progress and long-term results in several medical procedures. Peer reviewed studies support this, e.g. in myocardial infarction, others do not. METHODS We looked retrospectively at the dates of cardiac arrests (CA; n=368) of cardiac origin and of acute myocardial infarctions (AMI) with consecutive thrombolytic therapy or acute PTCA (n=872) and at the lunar phases at the corresponding dates. Medical data had been collected prospectively on the patients admission. The lunar phases were defined as full moon+/-1 day, new moon+/-1 day and the days in between as waning and waxing moon. The incidence of these cardiac events at each phase was calculated as days with a case divided by the total number of days of the specific moon phase in the observation period (1992-1998). Wilcoxon Rank Test was used for statistical analysis. RESULTS AMI and CA occurred on equal percentages of days within each lunar phase: AMI on 35% of all days with new moon, on 38% of full moon days, on 39% waning, and on 41% of the waxing moon days; CA on 19, 17, 16 and 16% of all days of the respective lunar phase. This difference was not significant. CONCLUSION Lunar phases do not appear to correlate with acute coronary events leading to myocardial infarction or sudden cardiac death.

Quality of closed chest compression on a manikin in ambulance vehicles and flying helicopters with a real time automated feedback

CONTEXT Automated verbal and visual feedback improves quality of resuscitation in out-of-hospital cardiac arrest and was proven to increase short-term survival. Quality of resuscitation may be hampered in more difficult situations like emergency transportation. Currently there is no evidence if feedback devices can improve resuscitation quality during different modes of transportation. OBJECTIVE To assess the effect of real time automated feedback on the quality of resuscitation in an emergency transportation setting. DESIGN Randomised cross-over trial. SETTING Medical University of Vienna, Vienna Municipal Ambulance Service and Helicopter Emergency Medical Service Unit (Christophorus Flugrettungsverein) in September 2007. PARTICIPANTS European Resuscitation Council (ERC) certified health care professionals performing CPR in a flying helicopter and in a moving ambulance vehicle on a manikin with human-like chest properties. INTERVENTIONS CPR sessions, with real time automated feedback as the intervention and standard CPR without feedback as control. MAIN OUTCOME MEASURES Quality of chest compression during resuscitation. RESULTS Feedback resulted in less deviation from ideal compression rate 100 min(-1) (9+/-9 min(-1), p<0.0001) with this effect becoming steadily larger over time. Applied work was less in the feedback group compared to controls (373+/-448 cm x compression; p<0.001). Feedback did not influence ideal compression depth significantly. There was some indication of a learning effect of the feedback device. CONCLUSIONS Real time automated feedback improves certain aspects of CPR quality in flying helicopters and moving ambulance vehicles. The effect of feedback guidance was most pronounced for chest compression rate.

Transport with ongoing cardiopulmonary resuscitation may not be futile

BACKGROUND Despite it being generally regarded as futile, patients are regularly brought to the emergency department with ongoing cardiopulmonary resuscitation (CPR). METHODS Long-term outcome and its predictors in patients who were transported during ongoing CPR were evaluated in an observational study. Adult patients with non-traumatic cardiac arrest admitted to the Department of Emergency Medicine of a tertiary-care facility after transport with ongoing chest compression were retrospectively analysed. Multivariate analysis of epidemiological variables, treatment, blood gas values on admission, cause of arrest, and location of arrest was performed to find factors that were predictive for favourable long-term outcome (6-month survival, best cerebral performance category 1 or 2). RESULTS Over 15 yr (1991-2006), a total of 2643 patients were treated after cardiac arrest. Of these, 327 patients received chest compressions during transport and were analysed (out-of-hospital cardiac arrest: n=244, in-hospital: n=83; the remaining 2316 patients were either stabilized before transport or suffered their arrest in our department). Return of spontaneous circulation was achieved in 31% of patients (n=102). Of these, 19 (19%) had favourable long-term outcome (6% of total). Independent predictors of good outcome were age, witnessed arrest, amount of epinephrine, and initial shockable rhythm. Among the patients with cardiac origin of arrest, 11 out of 197 patients (6%) survived; pulmonary origin, 4 out of 46 patients (9%); hypothermic arrest, 1 of 10 patients (10%); and intoxications, one out of nine patients (11%). CONCLUSIONS Post-resuscitation care in patients who receive CPR during transport is not futile. Once restoration of spontaneous circulation is established, one out of five patients will have good long-term outcome.

Randomized placebo controlled trial of furosemide on subjective perception of dyspnoea in patients with pulmonary oedema because of hypertensive crisis.

Eur J Clin Invest 2011; 41 (6): 627–634

Safety, feasibility, and hemodynamic and blood flow effects of active compression-decompression of thorax and abdomen in patients with cardiac arrest.

Objective:During closed chest compression for cardiac arrest, any increase in coronary perfusion pressure accounts for a proportional increase in myocardial blood flow and therefore the resuscitability of the patient. The objectives of this study were to evaluate the safety, feasibility, and hemodynamic effects of phased chest and abdominal compression–decompression and to compare it with mechanical chest compression during cardiopulmonary resuscitation. Design:In this prospective, single-center, phase II study, we compared patients treated with the Datascope Lifestick Resuscitator with patients who had been treated with mechanical precordial compression. Setting:Emergency department of a tertiary care university hospital. Patients:We included 31 patients with cardiac arrest who had received cardiopulmonary resuscitation in the emergency department. Interventions:The Lifestick device was used in 20 patients. In 11 patients, mechanical chest compression with the Thumper device was used as a control intervention. Measurements and Main Results:We evaluated the safety, feasibility, and hemodynamic effects of both interventions and observed, with the help of echocardiography, the mechanisms through which blood flow was generated. We found no significant difference between the use of the Lifestick device and standard chest compression with the Thumper device in resuscitations. Most operators regarded the Lifestick as a feasible alternative to the Thumper. We could observe a mean increase in coronary perfusion pressure of 9.33 mm Hg (interquartile range, 1.96–14.36; p = .08) and an increase of end-tidal CO2 of 10 mm Hg (interquartile range, 5–16; p = .003) (1333Pa [interquartile range, 665–2133]) during resuscitation with the Lifestick compared with using the Thumper. Conclusion:In this preliminary study, resuscitation with the Lifestick was found to be safe and feasible. The design of the study and small number of patients included in it limit the conclusions about the hemodynamic effects of the Lifestick.

Accelerated management of patients with ST-segment elevation myocardial infarction in the ED

PURPOSES The objective of this study was to evaluate improvement opportunities in the emergency department for timely ST-segment elevation myocardial infarction management and evaluated the new process flow. BASIC PROCEDURES In a prospective study, we compared time from door to cath laboratory before and after implementation of a new ST-segment elevation myocardial infarction (STEMI) protocol. The new protocol included a blend of strategies to reduce door to cath laboratory time. MAIN FINDINGS We included 55 patients. After implementing a new STEMI protocol, we included 54 patients. Time to cath laboratory was 21 (interquartile range, 9-40) minutes before and 10 (interquartile range 5-25) minutes after initiation of the new protocol (P = .02). A door to cath laboratory time less than 15 minutes was reached in 36% of our patients in phase 1 and in 61% in phase 2 (odds ratio; 0.36, 95% confidence interval, 0.16-0.81; P = .01). PRINCIPAL CONCLUSION Simple changes in organizational strategies resulted in a significantly faster care for patients with acute uncomplicated STEMI.