Fabio Cavallaro

Prognostication in comatose survivors of cardiac arrest: An advisory statement from the European Resuscitation Council and the European Society of Intensive Care Medicine ☆

OBJECTIVES To review and update the evidence on predictors of poor outcome (death, persistent vegetative state or severe neurological disability) in adult comatose survivors of cardiac arrest, either treated or not treated with controlled temperature, to identify knowledge gaps and to suggest a reliable prognostication strategy. METHODS GRADE-based systematic review followed by expert consensus achieved using Web-based Delphi methodology, conference calls and face-to-face meetings. Predictors based on clinical examination, electrophysiology, biomarkers and imaging were included. RESULTS AND CONCLUSIONS Evidence from a total of 73 studies was reviewed. The quality of evidence was low or very low for almost all studies. In patients who are comatose with absent or extensor motor response at ≥72 h from arrest, either treated or not treated with controlled temperature, bilateral absence of either pupillary and corneal reflexes or N20 wave of short-latency somatosensory evoked potentials were identified as the most robust predictors. Early status myoclonus, elevated values of neuron specific enolase at 48 72 h from arrest, unreactive malignant EEG patterns after rewarming, and presence of diffuse signs of postanoxic injury on either computed tomography or magnetic resonance imaging were identified as useful but less robust predictors. Prolonged observation and repeated assessments should be considered when results of initial assessment are inconclusive. Although no specific combination of predictors is sufficiently supported by available evidence, a multimodal prognostication approach is recommended in all patients.

Predictors of poor neurological outcome in adult comatose survivors of cardiac arrest: A systematic review and meta-analysis. Part 2: Patients treated with therapeutic hypothermia

AIMS AND METHODS To systematically review the accuracy of early (≤7 days) predictors of poor outcome, defined as death or vegetative state (Cerebral Performance Categories [CPC] 4-5) or death, vegetative state or severe disability (CPC 3-5), in comatose adult survivors from cardiac arrest (CA) treated using therapeutic hypothermia (TH). Electronic databases were searched for eligible studies. Sensitivity, specificity, and false positive rates (FPR) for each predictor were calculated. Quality of evidence (QOE) was evaluated according to the GRADE guidelines. RESULTS 37 studies (2403 patients) were included. A bilaterally absent N20 SSEP wave during TH (4 studies; QOE: Moderate) or after rewarming (5 studies; QOE: Low), a nonreactive EEG background (3 studies; QOE: Low) after rewarming, a combination of absent pupillary light and corneal reflexes plus a motor response no better than extension (M≤2) (1 study; QOE: Very low) after rewarming predicted CPC 3-5 with 0% FPR and narrow (<10%) 95% confidence intervals. No consistent threshold for 0% FPR could be identified for blood levels of biomarkers. In 6/8 studies on SSEP, in 1/3 studies on EEG reactivity and in the single study on clinical examination the investigated predictor was used for decisions to withdraw treatment, causing the risk of a self-fulfilling prophecy. CONCLUSIONS in the first 7 days after CA, a bilaterally absent N20 SSEP wave anytime, a nonreactive EEG after rewarming or a combination of absent ocular reflexes and M≤2 after rewarming predicted CPC 3-5 with 0% FPR and narrow 95% CIs, but with a high risk of bias.

A survey of the in-hospital response to cardiac arrest on general wards in the hospitals of Rome

OBJECTIVE To investigate the response to cardiac arrest in general wards. METHODS Direct interview with the cardiac arrest team (CAT) members in 32 hospitals in Rome, Italy. RESULTS The majority of CATs are activated by telephone but only two (6%) hospitals have a dedicated telephone number for emergency calls. The CAT always includes a physician, who is usually an anaesthesiologist (30 hospitals, 94%), and usually includes one or two other members (23 hospitals, 72%). In 21 hospitals (65%) there is less than one defibrillator per floor but in only six hospitals (19%), CATs are equipped with defibrillators. Resuscitation guidelines are adopted by 15 teams (47%). The Utstein style of data collection is used in only one hospital. The most common problems reported by the CATs are: insufficient training of ward personnel (29 hospitals, 91%), insufficient staff (19 hospitals, 59%) and insufficient equipment (18 hospitals, 56%). Average maximum arrival time for the CAT to arrive is 220 s, but varies significantly between single-building and the multiple-building hospitals (88 vs. 390 s; P<0.001). CONCLUSIONS The majority of the cardiac arrest teams have acceptable response times, but their efficiency may be impaired by the lack of staff, equipment and co-ordination with the ward personnel. CAT members identified a strong need for BLS training of ward personnel. More widespread introduction of standard protocols for resuscitation and reporting of cardiac arrest are necessary to evaluate aspects that may need improvement.

Nonthyroidal Illness Syndrome and Prolonged Mechanical Ventilation in Patients Admitted to the ICU

BACKGROUND The effect of the nonthyroidal illness syndrome (NTIS) on the duration of mechanical ventilation (MV) has not been extensively investigated. This study aims to determine whether the NTIS is associated with the duration of MV in patients admitted to the ICU. METHODS We evaluated all patients admitted over a 6-year period to our ICU who underwent invasive MV and had measurement of serum free triiodothyronine (fT3), free thyroxine (fT4), and thyroid-stimulating hormone (TSH) performed in the first 4 days after ICU admission and, subsequently, at least every 8 days during the time they received MV. The primary outcome measure was prolonged MV (PMV), which was defined as dependence on MV for > 13 days. RESULTS Two hundred sixty-four patients were included. Fifty-six patients (normal-hormone group) had normal thyroid function test results, whereas 208 patients (low-fT3 group) had, at least in one hormone dosage, low levels of fT3 with normal (n = 145)/low (n = 63) levels of fT4 and normal (n = 189)/low (n = 19) levels of TSH. Patients in the low-fT3 group showed significantly higher mortality and simplified acute physiology score II, and significantly longer duration of MV and ICU length of stay compared with the normal-hormone group. Two of the variables studied were associated with PMV, as follows: the NTIS (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.18 to 4.29; p = 0.01); and the presence of pneumonia (OR, 1.17; 95% CI, 1.06 to 3.01; p = 0.03). CONCLUSION The NTIS represents a risk factor for PMV in mechanically ventilated, critically ill patients.

Are patients brain-dead after successful resuscitation from cardiac arrest suitable as organ donors? A systematic review

AIM To compare the outcome of organs retrieved from patients brain dead due to cardiac arrest (CA) with that of organs retrieved from patients brain dead due to other causes (non-CA). METHODS Systematic review. Clinical studies comparing the outcome of patients and organs retrieved from donors brain dead after being resuscitated from cardiac arrest with that of patients and organs retrieved from donors brain dead not due to cardiac arrest were considered for inclusion. Full-text articles were searched on MEDLINE, EmBASE, Cochrane Register of Controlled Trials and Cochrane Register of Systematic Reviews. MAIN OUTCOME MEASURE One-year patient or organ survival rate. RESULTS Four studies fulfilling inclusion criteria were found and three had sufficient quality to be included in final analysis. A total of 858 organs were transplanted from 741 donors. Since the transplanted organs (heart, liver, kidney, lung and intestine) were different in the three studies, metanalysis was not performed. There were no significant differences in 1-year survival rates between CA and non-CA groups. No significant differences were reported for 5-year survival rates, early recovery of transplanted organ function, and organ rejection rates. CONCLUSION Survival rates of kidneys, livers, hearts and intestines retrieved from CA donors were not significantly different from that of organs transplanted from non-CA donors. Patients brain dead after having been resuscitated from cardiac arrest can be considered as potential donors for organ transplantation.

Successful treatment with enoximone for severe poisoning with atenolol and verapamil: a case report

Combined poisoning with calcium channel blockers (CCBs) and beta‐blockers is usually associated with severe hypotension and heart failure. Due to the block of the beta receptors, treatment with adrenergic agonists, even at high doses, can be insufficient, and beta‐independent inotropes, such as glucagon, may be required. Phosphodiesterase III (PDEIII) inhibitors represent a possible alternative to glucagon in these cases as they have an inotropic effect which is not mediated by a beta receptor.

Therapeutic hypothermia: is it effective for non-VF/VT cardiac arrest?

Sudden cardiac death represents a major health problem. In adults, the prevalence of out-of-hospital cardiac arrest (OHCA) attended by the emergency medical services (EMS) ranges from 52 to 112 per 100,000 person-years in developed countries [1], whereas the prevalence of adult in-hospital cardiac arrest (IHCA) ranges from 1 to 5 per 1,000 patient admissions [2].

Enoximone in cardiac arrest caused by propranolol: two case reports.

We report two clinical cases of cardiac arrest, the former due to an adverse effect of intravenous (i.v.) propranolol in a patient with systemic sclerosis, the latter from a propranolol suicidal overdose. In both cases, conventional advanced life support (ALS) was ineffective but both patients eventually responded to the administration of enoximone, a phosphodiesterase III (PDE III) inhibitor. After the arrest, both patients regained consciousness and were discharged home. The chronotropic and inotropic effects of PDE III inhibitors are due to inhibition of intracellular PDEIII and are therefore unaffected by beta‐blockers. These cases suggest that PDEIII inhibitors may be useful in restoring spontaneous circulation in cardiac arrest associated with beta‐blocker administration when standard ALS is ineffective.

Good neurological recovery after cardiopulmonary resuscitation and thrombolysis in two old patients with pulmonary embolism

The use of thrombolysis as an emergency treatment for cardiac arrest (CA) due to massive pulmonary embolism (MPE) has been described. However, there are no reports of successful treatment of MPE‐associated CA in patients over 77 years of age. We report two cases of successful cardiopulmonary resuscitation for an MPE‐associated CA in two very old women (87 and 86 years of age). In both cases, typical signs of MPE were documented using emergency echocardiography, which showed an acute right ventricle enlargement and a paradoxical movement of the interventricular septum. Emergency thrombolysis was administered during resuscitation, which lasted 45 and 21 min, respectively. Despite old age and prolonged resuscitation efforts, both patients had good neurological recovery and one of them was alive and neurologically intact 1 year later. Thrombolysis is a potentially useful therapy in MPE‐associated CA. A good neurological outcome can be obtained even in very old patients and after prolonged resuscitation.

Sub-acute hydrocephalus in a patient with influenza A (H3N2) virus-related cerebellitis

A 47-year-old man with a history of HCV-related hepatitis, bilateral kidney malformations with chronic renal failure in dialysis, and an attempt of kidney transplantation failed for rejection, developed rapidly worsening bitemporal headache without any preceding symptoms. He was at home, and was able to drive to the hospital where he should have undergone a scheduled dialysis session. Soon after his arrival to the hospital, and just before starting haemodialysis in the nephrology department, he presented a hypertensive crisis (systolic blood pressure >200 mm Hg) associated with agitation, mental confusion and …