Roman Skulec

Induction of mild hypothermia in cardiac arrest survivors presenting with cardiogenic shock syndrome.

Background: Induction of mild hypothermia (MH) in patients resuscitated from cardiac arrest improves their outcome. However, benefits and risks of MH in patients who remain in cardiogenic shock after the return of spontaneous circulation (ROSC) are unclear. We analysed all cardiac arrest survivors who were treated with MH in our intensive coronary care unit (CCU) and compared the outcome of patients with cardiogenic shock syndrome (CSS) with those who were circulatory stable.

Pre-hospital cooling of patients following cardiac arrest is effective using even low volumes of cold saline

IntroductionPre-hospital induction of therapeutic mild hypothermia (TH) may reduce post-cardiac arrest brain injury in patients resuscitated from out-of-hospital cardiac arrest. Most often, it is induced by a rapid intravenous administration of as much as 30 ml/kg of cold crystalloids. We decided to assess the pre-hospital cooling effectivity of this approach by using a target dose of 15-20 ml/kg of 4°C cold normal saline in the setting of the physician-staffed Emergency Medical Service. The safety and impact on the clinical outcome have also been analyzed.MethodsWe performed a prospective observational study with a retrospective control group. A total of 40 patients were cooled by an intravenous administration of 15-20 ml/kg of 4°C cold normal saline during transport to the hospital (TH group). The pre-hospital decrease of tympanic temperature (TT) was analyzed as the primary endpoint. Patients in the control group did not undergo any pre-hospital cooling.ResultsIn the TH group, administration of 12.6 ± 6.4 ml/kg of 4°C cold normal saline was followed by a pre-hospital decrease of TT of 1.4 ± 0.8°C in 42.8 ± 19.6 min (p < 0.001). The most effective cooling was associated with a transport time duration of 38-60 min and with an infusion of 17 ml/kg of cold saline. In the TH group, a trend toward a reduced need for catecholamines during transport was detected (35.0 vs. 52.5%, p = 0.115). There were no differences in demographic variables, comorbidities, parameters of the cardiopulmonary resuscitation and in other post-resuscitation characteristics. The coupling of pre-hospital cooling with subsequent in-hospital TH predicted a favorable neurological outcome at hospital discharge (OR 4.1, CI95% 1.1-18.2, p = 0.046).ConclusionsPre-hospital induction of TH by the rapid intravenous administration of cold normal saline has been shown to be efficient even with a lower dose of coolant than reported in previous studies. This dose can be associated with a favorable impact on circulatory stability early after the return of spontaneous circulation and, when coupled with in-hospital continuation of cooling, can potentially improve the prognosis of patients.Trial RegistrationClinicalTrials (NCT): NCT00915421

Intravascular ultrasound assessment of coronary artery involvement in Fabry disease

SummaryAimWe used intravascular ultrasound (IVUS) to characterize coronary artery involvement in patients with Fabry disease (FD).MethodsNine FD patients (5 women) were matched to 10 control patients (5 women) chosen from our IVUS database. Standard volumetric IVUS analyses were performed along with assessment of plaque echodensity.ResultsPlaques in FD patients were diffuse and hypoechogenic compared with more focal and more echogenic lesions in control patients. Echogenicity of plaques was significantly lower in FD patients (median 30.7  ±  12.9 vs 55.9  ±  15.7, p  =  0.0052, mean 37.2  ±  15.6 vs 66.2  ±  13.3, p  =  0.0014). Diffusiveness was assessed as differences between mean and median plaque burden versus the plaque burden in each of the analysed cross-sections. These differences were lower in FD vs controls (5.8  ±  4.8 vs 8.7  ±  6.6, p  <  0.001 for mean, and 5.8  ±  4.9 vs 8.8  ±  7.3, p  <  0.001 for median) indicating a more diffuse involvement. The occurrence of lipid cores was significantly higher in FD patients than in controls (2.4  ±  1.5 vs 1.0  ±  0.94, p  =  0.02).ConclusionIVUS showed diffuse hypoechogenic plaques in patients with FD. The explanation may be higher lipid content in plaques and accumulation of glycosphingolipid in smooth-muscle and endothelial cells.

Long-term prognostic impact of hyponatremia in the ST-elevation myocardial infarction

Abstract Aims. The aim of the study was to analyse in-hospital outcomes and long-term prognostic implications of reduced sodium serum level (S-Na) in the early phase of ST elevation myocardial infarction (STEMI) treated, primarily, with direct percutaneous coronary intervention (dPCI). Methods and results. The study included 218 consecutive patients (144 males, the mean age 64 ± 13 years) with no history of heart failure admitted with acute STEMI. Out of them, 193 (88.5%) patients were treated with dPCI. The mean follow-up period was 39 ± 21 months. Hyponatremia was defined as S-Na value < 135 mmol/L. A total of 72 (33%) patients reached hyponatremia level; 51(23.4%) of them at admission and 21 (9.6%) later during hospitalization. The hyponatremic patients more frequently presented with reduced left ventricular systolic function, Killip class III or IV and were at increased risk of developing cardiogenic shock compared to patients with normonatremia. Compared to the rest of the population, patients who developed hyponatremia later during hospitalization had higher incidence of acute renal failure; (12 patients/6.1% vs. 5 patients/25.5%, p < 0.05). The difference in long-term survival between the hyponatremia and normonatremia groups was significant (p = 0.01, log-rank test). The multiple analysis of variance identified decrease of S-Na levels at admission independently associated with total mortality (p = 0.05). Conclusion. Patients who developed hyponatremia in the early phase of STEMI were at higher risk of worse in-hospital clinical outcome. During the long-term follow-up, higher mortality rates were recorded in hyponatremic patients.

Comparison of cold crystalloid and colloid infusions for induction of therapeutic hypothermia in a porcine model of cardiac arrest

IntroductionLarge-volume cold intravenous infusion of crystalloids has been used for induction of therapeutic hypothermia after cardiac arrest. However, the effectiveness of cold colloids has not been evaluated. Therefore, we performed an experimental study to investigate the cooling effect of cold normal saline compared to colloid solution in a porcine model of ventricular fibrillation.MethodsVentricular fibrillation was induced for 15 minutes in 22 anesthetized domestic pigs. After spontaneous circulation was restored, the animals were randomized to receive either 45 ml/kg of 1°C cold normal saline (Group A, 9 animals); or 45 ml/kg of 1°C cold colloid solution (Voluven®, 6% hydroxyethyl starch 130/0.4 in 0.9% NaCl) during 20 minutes (Group B, 9 animals); or to undergo no cooling intervention (Group C, 4 animals). Then, the animals were observed for 90 minutes. Cerebral, rectal, intramuscular, pulmonary artery, and subcutaneous fat body temperatures (BT) were recorded. In the mechanical ex-vivo sub study we added a same amount of cold normal saline or colloid into the bath of normal saline and calculated the area under the curve (AUC) for induced temperature changes.ResultsAnimals treated with cold fluids achieved a significant decrease of BT at all measurement sites, whereas there was a consistent significant spontaneous increase in group C. At the time of completion of infusion, greater decrease in pulmonary artery BT and cerebral BT in group A compared to group B was detected (−2.1 ± 0.3 vs. -1.6 ± 0.2°C, and −1.7 ± 0.4 vs. -1.1 ± 0.3°C, p < 0.05, respectively). AUC analysis of the decrease of cerebral BT revealed a more vigorous cooling effect in group A compared to group B (−91 ± 22 vs. -68 ± 23°C/min, p = 0.046). In the mechanical sub study, AUC analysis of the induced temperature decrease of cooled solution revealed that addition of normal saline led to more intense cooling than colloid solution (−7155 ± 647 vs. -5733 ± 636°C/min, p = 0.008).ConclusionsIntravenous infusion of cold normal saline resulted in more intense decrease of cerebral and pulmonary artery BT than colloid infusion in this porcine model of cardiac arrest. This difference is at least partially related to the various specific heat capacities of the coolants.

Prehospital cooling by cold infusion: searching for the optimal infusion regimen

Background The cooling efficacy of intravenous administration of cold crystalloids can be enhanced by optimisation of the procedure. This study assessed the temperature stability of different application regimens of cold normal saline (NS) in simulated prehospital conditions. Methods Twelve different application regimens of 4°C cold NS (volumes of 250, 500 and 1000 ml applied at infusion rates of 1000, 2000, 4000 and 6000 ml/h) were investigated for infusion temperature changes during administration to an artificial detention reservoir in simulated prehospital conditions. Results An increase in infusion temperature was observed in all regimens, with an average of 8.1±3.3°C (p<0.001). This was most intense during application of the residual 20% of the initial volume. The lowest rewarming was exhibited in regimens with 250 and 500 ml bags applied at an infusion rate of 6000 ml/h and 250 ml applied at 4000 ml/h. More intense, but clinically acceptable, rewarming presented in regimens with 500 and 1000 ml bags administered at 4000 ml/h, 1000 ml at 6000 ml/h and 250 ml applied at 2000 ml/h. Other regimens were burdened by excessive rewarming. Conclusion Rewarming of cold NS during application in prehospital conditions is a typical occurrence. Considering that the use of 250 ml bags means the infusion must be exchanged too frequently during cooling, the use of 500 or 1000 ml NS bags applied at an infusion rate of ≥4000 ml/h and termination of the infusion when 80% of the infusion volume has been administered is regarded as optimal.

Corrigendum to “EuReCa ONE—27 Nations, ONE Europe, ONE Registry A prospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe” [Resuscitation 105 (2016) 188–195]

Introduction The aim of the EuReCa ONE study was to determine the incidence, process, and outcome for out of hospital cardiac arrest (OHCA) throughout Europe. Methods This was an international, prospective, multi-centre one-month study. Patients who suffered an OHCA during October 2014 who were attended and/or treated by an Emergency Medical Service (EMS) were eligible for inclusion in the study. Data were extracted from national, regional or local registries. Results Data on 10,682 confirmed OHCAs from 248 regions in 27 countries, covering an estimated population of 174 million. In 7146 (66%) cases, CPR was started by a bystander or by the EMS. The incidence of CPR attempts ranged from 19.0 to 104.0 per 100,000 population per year. 1735 had ROSC on arrival at hospital (25.2%), Overall, 662/6414 (10.3%) in all cases with CPR attempted survived for at least 30 days or to hospital discharge. Conclusion The results of EuReCa ONE highlight that OHCA is still a major public health problem accounting for a substantial number of deaths in Europe. EuReCa ONE very clearly demonstrates marked differences in the processes for data collection and reported outcomes following OHCA all over Europe. Using these data and analyses, different countries, regions, systems, and concepts can benchmark themselves and may learn from each other to further improve survival following one of our major health care events.

Intra-arrest formation of right-heart thrombi – a case illustrated by real-time ultrasonography

The presence of free‐floating right‐heart thrombus has been reported in a cardiac arrest patient in the periarrest period. Free‐floating right atrial thrombus is a rare phenomenon seen in patients developing severe pulmonary embolism, and is associated with increased mortality. However, there have been no previously reported cases of right‐heart thrombus formation during a resuscitated cardiac arrest. We present the pre‐hospital case of a woman in the clinical setting of cardiogenic shock due to acute myocardial infarction who developed asystolic cardiac arrest on the scene. Recent implementation of ultrasonography into the regional pre‐hospital care protocol enabled sonographic investigation before and during cardiac arrest. This allowed detection of right atrial septal thrombus formation in the course of advanced life support and its migration through the tricuspid valve. The pathophysiological consequences, clinical significance and potential therapeutic options are discussed.

Implementation of pre-hospital therapeutic hypothermia in post-cardiac arrest patients in the Czech Republic

In the Czech Republic, post-cardiac arrest therapeutic hypotheria is now commonly used in hospitals.1 Indeed, the physiciantaffed emergency medical service system, and a network of ercutaneous coronary intervention centres offer a high-level ost-cardiac arrest care. This also now includes the pre-hospital nitiation of therapeutic hypothermia. After a feasibility study and ocal implementation of pre-hospital cooling, we undertook a surey about pre-hospital therapeutic hypothermia use in the Czech epublic.2 In October 2010, all physician members of the Czech ociety for Emergency and Disaster Medicine were sent a webased questionnaire. Fifty-five percent (126 out of 227) of the physicians responded. f these, 52 (41.3%) had used pre-hospital therapeutic hypothermia Fig. 1). Physicians who used pre-hospital therapeutic hypothermia sed it in about half of cases (45.4 ± 25.9%). A strong predicor of pre-hospital therapeutic hypothermia use was attendance y a physician with five or less years of pre-hospital emergency edicine experience (OR 5.6, 95%CI 1.8–19.7, p = 0.004). Taking part n, or knowledge of a local clinical study (PRE-COOL) was a strong redictor (n = 22, 42.3%), as well as familiarity with current Euroean and, or Czech resuscitation guidelines (n = 21, 40.4%).2–4 A ritten pre-hospital cooling protocol was used by 86.5% (n = 45) f the responders using pre-hospital therapeutic hypothermia. hirty-two (61.5%) of the pre-hospital therapeutic hypothermia sers accepted a broad indication for cooling irrespective of the iniial rhythm, the presence of witnesses and whether the supposed rigin was a cardiac or not. The need for vasopressors was given s a reason for not using pre-hospital therapeutic hypothermia by 7 (32.7%), suspected pulmonary embolism by 31 (59.6%), age less han 18 years by 25 (48.1%), and pregnancy by 43 (82.7%) of preospital therapeutic hypothermia users. The most frequently used ooling method was infusion of cold crystalloids (n = 44, 84.6%). Surace cooling with ice-packs was used less frequently (n = 14, 26.9%) nd other techniques (intranasal cooling, EMCOOLS) were rarely sed (n = 2, 3.8%). Only half of the respondents sedated patients outinely and 36.5% (n = 19) of the respondents never or rarely sed neuromuscular blocking agents during pre-hospital therapeuic hypothermia. Tympanic temperature was measured by 78.8% n = 41) of responders. A third of responders used pre-hospital herapeutic hypothermia without temperature measurement at aseline and on hospital arrival. Of non-users, 33.8% planned to mplement the use of pre-hospital therapeutic hypothermia as soon s possible. Common reasons for non-use were lack of equipment 59.1%), no in-hospital cooling in the local hospital (27.3%), lack f supporting evidence for pre-hospital therapeutic hypothermia 21.2%), and short transport times (15.1%).

Impact of gravitational interaction between the Moon and the Earth on the occurrence of episodes of cardiogenic pulmonary edema in the field

While circadian variation of occurrence of cardiovascular emergencies has been de-scribed, it has not been assessed whether fluctuations of gravitational interaction between the Earth and the Moon may in-duce other types of its variation in time have the similar impact. Therefore, we decided to evaluate whether there is an as-sociation between the occurrence of pre-hospital cardiogenic pulmonary edema (CPE) episodes treated by Emergency Medical Services (EMS) and fluctuations in the intensity of gravitational interaction between the Earth and the Moon. Methods. We extracted all dispatches to CPE episodes from the EMS database of the Central Bohemian Region, Czech Re-public, between 2.11.2008 and 1.7.2014. For each episode, the intensity of gravita-tional interaction between the Moon and the Earth was calculated. The study period was divided into 11 sections of equal dura-tion according to the different intensity of gravitational interaction, and occurrence of CPE was compared among the groups. Results. We observed up to 4,744 episodes of CPE during the study period. Occur-rence of CPE episodes was highest in the periods with the weakest intensity of gravitational interaction (≤1.80e1026 N), while in the periods of the most intense gravitational interaction (≥2.26e1026 N), the lowest proportion of CPE cases was observed (23.44 vs. 3.79 %, p <0.001). Conclusions. We identified a significant association between the intensity of gravi-tational interaction between the Earth and the Moon and occurrence of CPE, treated by our EMS. The weakest intensity was as-sociated with its increased occurrence and vice versa. Further research is required for potential use of this phenomenon in a chronotherapeutic approach to secondary prevention of CPE.