Mathias J. Holmberg

Bystander automated external defibrillator use and clinical outcomes after out-of-hospital cardiac arrest: A systematic review and meta-analysis

AIM To systematically review studies comparing bystander automated external defibrillator (AED) use to no AED use in regard to clinical outcomes in out-of-hospital cardiac arrest (OHCA), and to provide a descriptive summary of studies on the cost-effectiveness of bystander AED use. METHODS We searched Medline, Embase, the Web of Science, and the Cochrane Library for randomized trials and observational studies published before June 1, 2017. Meta-analyses were performed for patients with all rhythms, shockable rhythms, and non-shockable rhythms. RESULTS Forty-four observational studies, 3 randomized trials, and 13 cost-effectiveness studies were included. Meta-analysis of 6 observational studies without critical risk of bias showed that bystander AED use was associated with survival to hospital discharge (all rhythms OR: 1.73 [95%CI: 1.36, 2.18], shockable rhythms OR: 1.66 [95%CI: 1.54, 1.79]) and favorable neurological outcome (all rhythms OR: 2.12 [95%CI: 1.36, 3.29], shockable rhythms OR: 2.37 [95%CI: 1.58, 3.57]). There was no association between bystander AED use and neurological outcome for non-shockable rhythms (OR: 0.76 [95%CI: 0.10, 5.87]). The Public-Access Defibrillation trial found higher survival rates when volunteers were equipped with AEDs. The other trials found no survival difference, although their study settings differed. The quality of evidence was low for randomized trials and very low for observational studies. AEDs were cost-effective in settings with high cardiac arrest incidence, with most studies reporting ratios <

Quick Sequential Organ Failure Assessment and Systemic Inflammatory Response Syndrome Criteria as Predictors of Critical Care Intervention Among Patients With Suspected Infection

100,000 per quality-adjusted life years. CONCLUSIONS The evidence supports the association between bystander AED use and improved clinical outcomes, although the quality of evidence was low to very low.

Postoperative Lactate Levels and Hospital Length of Stay After Cardiac Surgery

Objectives: The Sepsis III clinical criteria for the diagnosis of sepsis rely on scores derived to predict inhospital mortality. In this study, we introduce the novel outcome of “received critical care intervention” and investigate the related predictive performance of both the quick Sequential Organ Failure Assessment and the Systemic Inflammatory Response Syndrome criteria. Design: This was a single-center, retrospective analysis of electronic health records. Setting: Tertiary care hospital in the United States. Patients: Patients with suspected infection who presented to the emergency department and were admitted to the hospital between January 2010 and December 2014. Interventions: Systemic Inflammatory Response Syndrome and quick Sequential Organ Failure Assessment scores were calculated, and their relationships to the receipt of critical care intervention and inhospital mortality were determined. Measurement and Main Results: A total of 24,164 patients were included of whom 6,693 (27.7%) were admitted to an ICU within 48 hours; 4,453 (66.5%) patients admitted to the ICU received a critical care intervention. Among those with quick Sequential Organ Failure Assessment less than 2, 13.4% received a critical care intervention and 3.5% died compared with 48.2% and 13.4%, respectively, for quick Sequential Organ Failure Assessment greater than or equal to 2. The area under the receiver operating characteristic was similar whether quick Sequential Organ Failure Assessment was used to predict receipt of critical care intervention or inhospital mortality (0.74 [95% CI, 0.73–0.74] vs 0.71 [0.69–0.72]). The area under the receiver operating characteristic of Systemic Inflammatory Response Syndrome for critical care intervention (0.69) and mortality (0.66) was lower than that for quick Sequential Organ Failure Assessment (p < 0.001 for both outcomes). The sensitivity of quick Sequential Organ Failure Assessment for predicting critical care intervention was 38%. Conclusions: Emergency department patients with suspected infection and low quick Sequential Organ Failure Assessment scores frequently receive critical care interventions. The misclassification of these patients as “low risk,” in combination with the low sensitivity of quick Sequential Organ Failure Assessment greater than or equal to 2, may diminish the clinical utility of the quick Sequential Organ Failure Assessment score for patients with suspected infection in the emergency department.

Thiamine in septic shock patients with alcohol use disorders: An observational pilot study

OBJECTIVES The objective of this study was to characterize the association between lactate levels and hospital length of stay (LOS) after cardiac surgery. DESIGN A retrospective study using prospectively collected data from the Society of Thoracic Surgeons adult cardiac surgery database. SETTING A tertiary-care hospital. PARTICIPANTS Patients in the database who presented for major cardiac surgery between 2002 and 2014 and whose lactate level was measured within 3 hours after skin closure. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The authors performed multivariable linear regression with adjustment for more than 30 variables to assess the association between postoperative lactate levels and hospital LOS. The study included 1,208 patients whose median LOS was 6 days (quartiles: 5, 9). Median LOS in the low-, moderate-, and high-lactate groups was 5 days (quartiles: 4, 7), 6 days (quartiles: 5, 9) and 9 days (quartiles: 6, 17), respectively; p<0.001. In multivariable analysis, patients with a moderate lactate level had a 1.08 times (95% CI: 1.00-1.17; p = 0.04) longer LOS compared with those with a low lactate level. Patients with a high lactate level had a 1.12 times (95% CI: 1.00-1.26; p = 0.04) longer LOS compared with those with a low lactate level. Lactate levels also were associated with intensive care unit LOS and nonsurgical postoperative complications. CONCLUSIONS Postoperative lactate levels are associated with increased hospital LOS for patients undergoing major cardiac surgery.

Cytochrome C in Patients with Septic Shock.

Purpose: Alcohol‐use disorders (AUDs) have been associated with increased sepsis‐related mortality. As patients with AUDs are often thiamine deficient, we investigated practice patterns relating to thiamine administration in patients with AUDs presenting with septic shock and explored the association between receipt of thiamine and mortality. Materials: We performed a retrospective cohort study of patients presenting with septic shock between 2008 and 2014 at a single tertiary care center. We identified patients with an AUD diagnosis, orders for microbial cultures and use of antibiotics, vasopressor dependency, and lactate levels ≥ 4 mmol/L. We excluded those who received thiamine later than 48 h of sepsis onset. Results: We included 53 patients. Thirty‐four (64%) patients received thiamine. Five patients (15%) received their first thiamine dose in the emergency department. The median time to thiamine administration was 9 (quartiles: 4, 18) hours. The first thiamine dose was most often given parenterally (68%) and for 100 mg (88%). In those receiving thiamine, 15/34 (44%) died, compared to 15/19 (79%) of those not receiving thiamine, p = 0.02. Conclusions: A considerable proportion of patients with AUDs admitted for septic shock do not receive thiamine. Thiamine administration in this patient population was associated with decreased mortality. Highlights:Many patients with alcohol‐use‐disorders and septic shock do not receive thiamine.Thiamine was most often given in the ICU, rather than the emergency department.Failure to receive thiamine may be associated with increased mortality.

Outcomes in variceal hemorrhage following the use of a balloon tamponade device

Purpose: Cytochrome c is an essential component of the electron transport chain, and circulating cytochrome c might be an indicator of mitochondrial injury. The objective of this study was to determine whether cytochrome c levels are elevated in septic patients, whether there is an association between cytochrome c levels and lactate/inflammatory markers, and whether elevated levels of cytochrome c are associated with poor outcomes. Methods: This was a single-center, prospective, observational, pilot study within a randomized, placebo-controlled trial. We enrolled adult patients in septic shock and with an elevated lactate (>3 mmol/L). Blood was collected at enrollment and at 12 and 24 h thereafter. Cytochrome c was measured in plasma using an electrochemiluminescence immunoassay. Results: We included 77 patients. Plasma cytochrome c levels were significantly higher in septic patients than in healthy controls (0.70 ng/mL [quartiles: 0.06, 1.99] vs. 0.19 ng/mL [quartiles: 0.03, 1.32], P = 0.008). Cytochrome c levels at enrollment were positively correlated with lactate levels (rs = 0.40, P < 0.001) but not with inflammatory markers. Patients who died before hospital discharge had significantly higher cytochrome c levels than survivors (0.99 ng/mL [quartiles: 0.36, 4.09] vs. 0.58 ng/mL [quartiles: 0.03, 1.64], P = 0.01). When analyzed over time, the difference between survivors and nonsurvivors remained significant (P < 0.001). Conclusions: Cytochrome c levels are higher in septic patients than in controls. In unadjusted analysis, septic nonsurvivors had higher cytochrome c levels than survivors.

Neighborhood characteristics, bystander automated external defibrillator use, and patient outcomes in public out-of-hospital cardiac arrest

Background: Variceal hemorrhage is associated with high morbidity and mortality. A balloon tamponade device (BTD), such as the Sengstaken‐Blakemore or Minnesota tube, may be used in cases of variceal hemorrhage. While these devices may be effective at controlling acute bleeding, the effect on patient outcomes remains less clear. We sought to describe the number of patients with variceal hemorrhage and a BTD who survive to discharge, survive to one‐year, and develop complications related to a BTD. Methods: In this retrospective study, we identified patients at a single, tertiary care center who underwent placement of a BTD for upper gastrointestinal hemorrhage between 2003 and 2014. Patient characteristics and outcomes were summarized using descriptive statistics. Results: 34 patients with a BTD were identified. Median age was 57.5 (IQR 47–63) and 76% (26/34) were male. Approximately 59% (20/34) of patients survived to discharge, and 41% (13/32) were alive after one year. Two patients were lost to follow‐up. Of those surviving to discharge, 95% (19/20) had undergone transjugular intrahepatic portosystemic shunt (TIPS), while 36% (5/14) of patients who did not survive to discharge had TIPS (p < 0.01). One complication, an esophageal perforation, was identified and managed conservatively. Conclusion: In this cohort of patients undergoing BTD placement for variceal hemorrhage, approximately 59% of patients were alive at discharge and 41% were alive after one year. Placement of a BTD as a temporizing measure in the management of acute variceal hemorrhage may be helpful, particularly when utilized as a bridge to more definitive therapy.

Extracorporeal cardiopulmonary resuscitation for cardiac arrest: A systematic review

BACKGROUND Automated external defibrillators (AEDs) can be used by bystanders to provide rapid defibrillation for patients with out-of-hospital cardiac arrest (OHCA). Whether neighborhood characteristics are associated with AED use is unknown. Furthermore, the association between AED use and outcomes has not been well characterized for all (i.e. shockable and non-shockable) public OHCAs. METHODS We included public, non-911-responder witnessed OHCAs registered in the Cardiac Arrest Registry to Enhance Survival (CARES) between 2013 and 2016. The primary patient outcome was survival to hospital discharge with a favorable functional outcome. We first assessed the association between neighborhood characteristics and bystander AED use using logistic regression and then assessed the association between bystander AED use and patient outcomes in a propensity score matched cohort. RESULTS 25,182 OHCAs were included. Several neighborhood characteristics, including the proportion of people living alone, the proportion of white people, and the proportion with a high-school degree or higher, were associated with bystander AED use. 5132 OHCAs were included in the propensity score-matched cohort. Bystander AED use was associated with an increased risk of a favorable functional outcome (35% vs. 25%, risk difference: 9.7% [95% confidence interval: 7.2%, 12.2%], risk ratio: 1.38 [95% confidence interval: 1.27, 1.50]). This was driven by increased favorable functional outcomes with AED use in patients with shockable rhythms (58% vs. 39%) but not in patients with non-shockable rhythms (10% vs. 10%). CONCLUSIONS Specific neighborhood characteristics were associated with bystander AED use in OHCA. Bystander AED use was associated with an increase in favorable functional outcome.

Ubiquinol (Reduced Coenzyme Q10) and Cellular Oxygen Consumption in Patients Undergoing Coronary Artery Bypass Grafting

AIM To assess the use of extracorporeal cardiopulmonary resuscitation (ECPR), compared with manual or mechanical cardiopulmonary resuscitation (CPR), for out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) in adults and children. METHODS The PRISMA guidelines were followed. We searched Medline, Embase, and Evidence-Based Medicine Reviews for randomized clinical trials and observational studies published before May 22, 2018. The population included adult and pediatric patients with OHCA and IHCA of any origin. Two investigators reviewed studies for relevance, extracted data, and assessed risk of bias using the ROBINS-I tool. Outcomes included short-term and long-term survival and favorable neurological outcome. RESULTS We included 25 observational studies, of which 15 studies were in adult OHCA, 7 studies were in adult IHCA, and 3 studies were in pediatric IHCA. There were no studies in pediatric OHCA. No randomized trials were included. Results from individual studies were largely inconsistent, although several studies in adult and pediatric IHCA were in favor of ECPR. The risk of bias for individual studies was overall assessed to be critical, with confounding being the primary source of bias. The overall quality of evidence was assessed to be very low. Heterogeneity across studies precluded any meaningful meta-analyses. CONCLUSIONS There is inconclusive evidence to either support or refute the use of ECPR for OHCA and IHCA in adults and children. The quality of evidence across studies is very low.

Coenzyme Q10 in acute influenza

Ubiquinol is a fundamental component of cellular metabolism. Low ubiquinol levels have been associated with mortality. This was a substudy of a randomized trial in patients undergoing coronary artery bypass grafting. We drew blood before and after surgery. Ubiquinol or placebo was added to peripheral blood mononuclear cells for oxygen consumption (OCR) measurements. In vivo ubiquinol levels were lower postsurgery compared to presurgery (0.16 μmol/L [quartiles: 0.02-0.39], P = .01), although the difference disappeared when adjusting for hemoglobin levels (P = .30). There was no difference in presurgical basal (1.0 mL/min/mg [95% confidence interval [CI]: −0.9 to 2.2], P = .08) and maximal (0.5 mL/min/mg [95% CI: −4.3 to 7.3], P = .56) OCR in cells receiving ubiquinol or placebo. There was a difference in postsurgical basal (1.1 mL/min/mg [95% CI: 0.9-1.6], P < .001) and maximal (4.2 mL/min/mg [95% CI: 0.3-7.0], P = .01) OCR between the groups. We found no association between ubiquinol and OCR levels (all P > .05).