Sylweriusz Kosinski

Severe Accidental Hypothermia Center.

Hypothermic patients may be rewarmed using passive or active techniques. In case of severe accidental hypothermia (temperature<28°C) and stage III/IV according to the Swiss Staging System, standard methods might not be effective and aggressive treatment is needed. Extracorporeal membrane oxygenation (ECMO) has proved to be both effective and safe in such cases. The Department of Anesthesiology and Intensive Care, John Paul II Hospital, Cracow, Poland, established the Severe Accidental Hypothermia Center, which provides 24 h on-call to consult and accept patients who need ECMO implantation for profound hypothermia rewarming. Our center is so far the only one in Poland and can accept patients from south-east Poland. Most importantly, it collaborates with all prehospital medical services, namely, with 115 Ambulances, Polish Medical Air Rescue, Mountain Rescue Services, and all 28 Emergency Departments in the area. Severe Accidental Hypothermia Center is a solution for advanced treatment of patients with accidental hypothermia requiring ECMO implantation.

Accidental hypothermia in Poland – estimation of prevalence, diagnostic methods and treatment

BackgroundThe incidence of hypothermia is difficult to evaluate, and the data concerning the morbidity and mortality rates do not seem to fully represent the problem. The aim of the study was to estimate the actual prevalence of accidental hypothermia in Poland, as well as the methods of diagnosis and management procedures used in emergency rooms (ERs).MethodsA specially designed questionnaire, consisting of 14 questions, was mailed to all the 223 emergency rooms (ER) in Poland. The questions concerned the incidence, methods of diagnosis and risk factors, as well as the rewarming methods used and available measurement instruments.ResultsThe analysis involved data from 42 ERs providing emergency healthcare for the population of 5 305 000. The prevalence of accidental hypothermia may have been 5.05 cases per 100.000 residents per year. Among the 268 cases listed 25% were diagnosed with codes T68, T69 or X31, and in 75% hypothermia was neither included nor assigned a code in the final diagnosis. The most frequent cause of hypothermia was exposure to cold air alongside ethanol abuse (68%). Peripheral temperature was measured in 57%, core temperature measurement was taken in 29% of the patients. Peripheral temperature was measured most often at the axilla, while core temperature measurement was predominantly taken rectally. Mild hypothermia was diagnosed in 75.5% of the patients, moderate (32-28°C) in 16.5%, while severe hypothermia (less than 28°C) in 8% of the cases. Cardiopulmonary resuscitation was carried out in 7.5% of the patients. The treatment involved mainly warmed intravenous fluids (83.5%) and active external rewarming measures (70%). In no case was extracorporeal rewarming put to use.ConclusionsThe actual incidence of accidental hypothermia in Polish emergency departments may exceed up to four times the official data. Core temperature is taken only in one third of the patients, the treatment of hypothermic patients is rarely conducted in intensive care wards and extracorporeal rewarming techniques are not used. It may be expected that personnel education and the development of management procedures will brighten the prognosis and increase the survival rate in accidental hypothermia.

Profound accidental hypothermia - systematic approach to active recognition and treatment

We sought to organize a functional system of recognition and advanced treatment of hypothermic patients with extracorporeal rewarming as a treatment option. All patients with suspected hypothermia are consulted with the hypothermia coordinator (HC), whose role is to provide expertise on hypothermia recognition and treatment to all rescue and medical services. Patients with Swiss staging system of hypothermia class III and IV are subjected to extracorporeal rewarming. Patients with class I and II are managed in local hospitals, after the HC provides instructions. From program initiation (July 29, 2013) to November 1, 2015, HC consulted 104 hypothermic patients; 21 in hypothermia class III and IV were subjected to extracorporeal rewarming in the John Paul II Hospital in Cracow, Poland. The remaining people were rewarmed in the referring hospitals. Cardiac arrest upon referral was present in 10 cases (resuscitation times from arrest to extracorporeal membrane oxygenation implantation ranged 107–345 minutes). Seven patients died, and the remaining 14 have been rewarmed with the restoration of hemodynamic stability. Systematic approach to active recognition and treatment of profound accidental hypothermia patients, on the basis of HC cooperation with emergency medical services, enables advanced management with good outcomes, especially in patients with cardiac arrest.

Comparison of continuous epidural block and continuous paravertebral block in postoperative analgaesia after video-assisted thoracoscopic surgery lobectomy: a randomised, non-inferiority trial

BACKGROUND Video-assisted (VATS) lung lobectomy can be associated with stronger postoperative pain than is commonly believed. It is generally accepted to introduce multimodal analgaesic strategies based on regional blockade, opioids and non-steroidal anti-inflammatory drugs. However, there is still no consensus regarding the optimal regional technique. The aim of this study was to compare the analgaesic efficacy of continuous thoracic epidural block (TEA) and percutaneous continuous paravertebral block (PVB) in patients undergoing video-assisted lung lobectomy. METHODS Fifty-one patients undergoing VATS lobectomy were enrolled in the present prospective, randomised clinical trial. The same analgaesic regimen in both groups included continuous infusion of 0.25% bupivacaine with epinephrine, intravenous ketoprofen and paracetamol. The doses of local anaesthetics were determined to achieve the spread of at least 4 segments in both groups. Postoperative static and dynamic visual analogue pain scores, as well as patient-controlled morphine usage, were used to compare the efficacy of analgaesia. Side effects and failure rates of both blocks were analysed. RESULTS Static and dynamic pain scores at 24 postoperative hours were significantly lower in the paravertebral group, as were the static pain score at 36 and 48 postoperative hours (P < 0.05). No difference between the treatment groups was identified regarding postoperative morphine usage. The failure rate was higher in the epidural group than in the paravertebral group. No complications were noted in either group, but side effects (urinary retention, hypotension) were more frequent in the epidural group (P < 0.05). CONCLUSIONS Postoperative pain following VATS lung resection procedures is significant and requires the application of complex analgaesic techniques. Percutaneous paravertebral block is equally effective as thoracic epidural block in providing analgaesia in patients undergoing VATS lobectomy. Paravertebral block has a better safety profile than thoracic epidural block.

New diastolic cardiomyopathy in patients with severe accidental hypothermia after ECMO rewarming: a case-series observational study

IntroductionAccidental hypothermia is a condition associated with significant morbidity and mortality. Hypothermia has been reported to affect left ventricular systolic and diastolic function. However, most of the data come from animal experimental studies.Aim of the studyThe purpose of the present study was to assess the impact of severe accidental hypothermia on systolic and diastolic ventricular function in patients treated using veno-arterial extracorporeal membrane oxygenation (ECMO).MethodsWe prospectively assessed nine hypothermic patients (8 male, age 25–78 years) who were transferred to the Severe Accidental Hypothermia Center and treated with ECMO. Transthoracic echocardiography was performed on admission (in patients without cardiac arrest) and on discharge from ICU after achieving cardiovascular stability. Cardiorespiratory stability and full neurologic recovery was achieved in all patients.ResultsBiomarkers of myocardial damage (CK, CKMB, hsTnT) were significantly elevated in all study patients. Admission echocardiography performed in patients in sinus rhythm, revealed moderate-severe bi-ventricular systolic dysfunction and moderate bi-ventricular diastolic dysfunction. Discharge echocardiography showed persistent mild bi-ventricular diastolic dysfunction, although systolic function of both ventricles returned to normal. Discharge echocardiography in patients admitted with cardiac arrest showed normal (5 patients) or moderately impaired (1 patient) global LV systolic function on discharge. However, mild or moderate LV diastolic dysfunction was observed in all 6 patients. Discharge RV systolic function was normal, whereas mild RV diastolic dysfunction was present in these patients.ConclusionAfter severe accidental hypothermia bi-ventricular diastolic dysfunction persists despite systolic function recovery in survivors treated with ECMO.

Measuring core temperature using the proprietary application and thermo-smartphone adapter

Fast and accurate measurement of core body temperature is crucial for accidental hypothermia treatment. We have developed a novel light and small adapter to the headset jack of a mobile phone based on Android. It has been applied to measure temperature and set up automatic notifications (e.g. Global Positioning System coordinates to emergency services dispatcher, ECMO coordinator). Its validity was confirmed in comparison with Vital Signs Monitor Spacelabs Healthcare Elance 93300 as a reference method, in a series of 260 measurements in the temperature range of 10–42 °C. Measurement repeatability was verified in a battery of 600 measurements (i.e. 100 readings at three points of 10, 25, 42 °C for both esophageal and tympanic catheters). Inter-method difference of ≤0.5 °C was found for 98.5% for esophageal catheter and 100% for tympanic catheter measurements, with concordance correlation coefficient of 0.99 for both. The readings were almost completely repeatable with water bath measurements (difference of ≤0.5 °C in 10 °C: 100% for both catheters; in 25 °C: 99% for esophageal catheter and 100% tympanic catheter; in 42 °C: 100% for both catheters). This lightweight adapter attached to smartphone and standard disposable probes is a promising tool to be applied on-site for temperature measurement in patients at risk of hypothermia.

Problems and Pitfalls of Qualification for Extracorporeal Rewarming in Severe Accidental Hypothermia

OBJECTIVES When establishing the Severe Hypothermia Treatment Centre, certain problems and pitfalls regarding the qualification for extracorporeal rewarming were encountered. The authors shared their experience and opened a discussion with other centers that deal with severe, accidental hypothermia. DESIGN Retrospective analysis of medical records of all patients examined by the hypothermia coordinator. SETTING Patients consulted and treated by the Severe Hypothermia Treatment Centre. PARTICIPANTS Patients who underwent accidental hypothermia. INTERVENTIONS From July 2013 until January 2016, hypothermia coordinators at the Severe Hypothermia Treatment Centre examined the cases of 152 hypothermic patients. Of those cases, 127 patients were subjected to noninvasive rewarming in referral hospitals and 25 were accepted to the center for extracorporeal rewarming. MEASUREMENTS AND MAIN RESULTS Difficulties that deferred or delayed the implementation of extracorporeal membrane oxygen rewarming were identified and addressed, including low platelet/red blood count, intraperitoneal fluid of unknown origin, abnormal results of head computed tomography, extremes of age, bleeding from the external auditory meatus, inaccuracy of infrared-based thermometers, iatrogenic trauma to the femoral vessels, chronic/terminal comorbidities, poisonings, pregnancy, hypoglycemia, hemodynamic stability despite severe hypothermia, and decontamination protocol. CONCLUSIONS The problems discussed may delay the use of extracorporeal membrane oxygen rewarming in hypothermic patients but should not discourage medical teams from the implementation of extracorporeal rewarming. The prognosis for severe hypothermia is favorable, even with a long resuscitation time and low core temperatures.

Extracorporeal Rewarming From Accidental Hypothermia of Patient With Suspected Trauma

AbstractThe use of extracorporeal membrane oxygenation is a new approach to rewarming patients with severe hypothermia and hemodynamic instability. There are, however, many questions regarding qualification for this technique in case of suspected or confirmed trauma.A male with confirmed accidental hypothermia (25°C) and after successful cardiopulmonary resuscitation from in-hospital cardiac arrest was subjected to a protocol of extracorporeal rewarming from profound hypothermia. Because of unclear history, a full trauma computed tomography was performed that showed pericerebral hematoma and signs of previously undergone right craniotomy, multiple right-sided rib fractures and the presence of intraperitoneal fluid. Based on repeated imaging and specialist consultation, no life-threatening injuries were identified and rewarming with extracorporeal membrane oxygenation was safely performed. In a year follow-up, the patient was found to be alive, with no neurologic deficits.Although this case highlights the first successful utilization of extracorporeal rewarming in a trauma patient at our center there are several limitations to its widespread use

The Role of Hypothermia Coordinator: A Case of Hypothermic Cardiac Arrest Treated with ECMO

Abstract Darocha, Tomasz, Sylweriusz Kosinski, Maciej Moskwa, Anna Jarosz, Dorota Sobczyk, Robert Galazkowski, Marcin Slowik, and Rafal Drwila. The role of hypothermia coordinator: A case of hypothermic cardiac arrest treated with ECMO. High Alt Biol Med 16:352-355, 2015.—We present a description of emergency medical rescue procedures in a patient suffering from severe hypothermia who was found in the Babia Gora mountain range (Poland). After diagnosing the symptoms of II/III stage hypothermia according to the Swiss Staging System, the Mountain Rescue Service notified the coordinator from the Severe Accidental Hypothermia Center (CLHG) Coordinator in Krakow and then kept in constant touch with him. In accordance with the protocol for managing such situations, the coordinator started the procedure for patients in severe hypothermia with the option of extracorporeal warming and secured access to a device for continuous mechanical chest compression. After reaching the hospital, extracorporeal warming with ECMO support in the arteriovenuous configuration was started. The total duration of circulatory arrest was 150 minutes. The rescue procedures were supervised by the coordinator, who was on 24-hour duty and was reached by means of an alarm phone. The task of the coordinator is to consult the management of hypothermia cases, use his knowledge and experience to help in the diagnosis and treatment. and if the need arises refer the patient for ECMO at CLHG. Good coordination, planning, predicting possible problems, and acting in accordance with the agreed procedures in the scheme, make it possible to shorten the time of reaching the destination hospital and implement effective treatment.

Video-assisted thoracic surgery thymectomy: subxiphoid approach

Background: To describe the use of the subxiphoid approach for thymectomy and to present a variant of the technique of minimally invasive extended thymectomy for thymoma or myasthenia gravis (MG) without thymoma done via a sole (uniportal) subxiphoid incision with aid of the sternal lifting. Methods: The infrasternal (subxiphoid) technique was used. The whole specimen containing the thymus surrounded by the right and left mediastinal pleural sheets and the fat of the anterior mediastinum and the lower neck region was resected en bloc through the incision made above the xiphoid process for insertion of a videothoracoscope [video-assisted thoracic surgery (VATS)] and, finally for introduction of chest drains. The sternum was lifted by two hooks attached to the Zakopane bar (B.Braun, Aesculap-Chifa, Nowy Tomysl, Poland). The lower hook was elevating the lower sternal angle and the upper hook was inserted through a puncture made above the sternal notch while the major mediastinal structures were pressed down toward the spine to avoid injury. Results: The entire group of patients in whom the subxiphoid approach was used for thymectomy included 611 patients, overall (80 patients with thymomas, 516 patients with MG without thymoma and 15 patients with repeated thymectomy) operated on from Sep 2000 to Sep 2017. There were 5 uniportal subxiphoid-VATS extended thymectomies (for non-thymomatous MG in 2 patients and for thymic tumors in 2 patients). The mean time of the operation 118.5 min (range, 85–130 min). For the whole group of 611 patients there was no mortality and less than 5% morbidity. The complete remission rate 53.1% for the transcervical-subxiphoid-VATS maximal thymectomy approach for non-thymomatous MG was reported. Conclusions: The subxiphoid uniportal incision with sternal lifting facilitates performance of extended thymectomy for thymomas or MG without thymoma.