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Preliminary observations in systemic oxygen consumption during targeted temperature management after cardiac arrest.

ABSTRACT: AIM:Limited data suggests low oxygen consumption (VO2), driven by mitochondrial injury, is associated with mortality after cardiac arrest. Due to the challenges of measurement in the critically ill, post-arrest metabolism remains poorly characterized. We monitored VO2, carbon dioxide production (VCO2) and the respiratory quotient (RQ) in post-arrest patients and explored associations with outcome. METHODS:Using a gas exchange monitor, we measured continuous VO2 and VCO2 in post- arrest patients treated with targeted temperature management. We used area under the curve and medians over time to evaluate the association between VO2, VCO2, RQ and the VO2:lactate ratio with survival. RESULTS:In 17 patients, VO2 in the first 12?h after return of spontaneous circulation (ROSC) was associated with survival (median in survivors 3.35?mL/kg/min [2.98,3.88] vs. non-survivors 2.61?mL/kg/min [2.21,2.94], p?=?.039). This did not persist over 24?h. The VO2:lactate ratio was associated with survival (median in survivors 1.4 [IQR: 1.1,1.7] vs. non-survivors 0.8 [IQR: 0.6,1.2] p??0.7 (p?=?.131). VCO2 was not associated with survival. CONCLUSIONS:There was a significant association between VO2 and mortality in the first 12?h after ROSC, but not over 24?h. Lower VO2: lactate ratio was associated with mortality. A large percentage of patients had RQs below physiologic norms. Further research is needed to explore whether these parameters could have true prognostic value or be a potential treatment target.

SUBMITTER: Uber A

PROVIDER: S-EPMC6003666 | biostudies-literature | 2018 Jun

REPOSITORIES: biostudies-literature

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Preliminary observations in systemic oxygen consumption during targeted temperature management after cardiac arrest.

Uber Amy A Grossestreuer Anne V AV Ross Catherine E CE Patel Parth V PV Trehan Ambica A Donnino Michael W MW Berg Katherine M KM

Resuscitation 20180404

<h4>Aim</h4>Limited data suggests low oxygen consumption (VO<sub>2</sub>), driven by mitochondrial injury, is associated with mortality after cardiac arrest. Due to the challenges of measurement in the critically ill, post-arrest metabolism remains poorly characterized. We monitored VO<sub>2</sub>, carbon dioxide production (VCO<sub>2</sub>) and the respiratory quotient (RQ) in post-arrest patients and explored associations with outcome.<h4>Methods</h4>Using a gas exchange monitor, we measured c ...[more]

PMID: 29626611

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Project description:BACKGROUND:We sought to determine the outcome of suicidal hanging and the impact of targeted temperature management (TTM) on hanging-induced cardiac arrest (CA) through an Eastern Association for the Surgery of Trauma (EAST) multicenter retrospective study. METHODS:We analyzed hanging patient data and TTM variables from January 1992 to December 2015. Cerebral performance category score of 1 or 2 was considered good neurologic outcome, while cerebral performance category score of 3 or 4 was considered poor outcome. Classification and Regression Trees recursive partitioning was used to develop multivariate predictive models for survival and neurologic outcome. RESULTS:A total of 692 hanging patients from 17 centers were analyzed for this study. Their overall survival rate was 77%, and the CA survival rate was 28.6%. The CA patients had significantly higher severity of illness and worse outcome than the non-CA patients. Of the 175 CA patients who survived to hospital admission, 81 patients (46.3%) received post-CA TTM. The unadjusted survival of TTM CA patients (24.7% vs 39.4%, p < 0.05) and good neurologic outcome (19.8% vs 37.2%, p < 0.05) were worse than non-TTM CA patients. However, when subgroup analyses were performed between those with an admission Glasgow Coma Scale score of 3 to 8, the differences between TTM and non-TTM CA survival (23.8% vs 30.0%, p = 0.37) and good neurologic outcome (18.8% vs 28.7%, p = 0.14) were not significant. Targeted temperature management implementation and post-CA management varied between the participating centers. Classification and Regression Trees models identified variables predictive of favorable and poor outcome for hanging and TTM patients with excellent accuracy. CONCLUSION:Cardiac arrest hanging patients had worse outcome than non-CA patients. Targeted temperature management CA patients had worse unadjusted survival and neurologic outcome than non-TTM patients. These findings may be explained by their higher severity of illness, variable TTM implementation, and differences in post-CA management. Future prospective studies are necessary to ascertain the effect of TTM on hanging outcome and to validate our Classification and Regression Trees models. LEVEL OF EVIDENCE:Therapeutic study, level IV; prognostic study, level III.

Project description:BACKGROUND:Targeted temperature management (TTM) of 32 to 34 °C has been the standard treatment for out-of-hospital cardiac arrest since clinical trials in 2002 indicated benefit on survival and neurological outcome. In 2013, a clinical trial showed no difference in outcome between TTM of 33 °C and TTM of 36 °C. In this meta-analysis, we investigate the evidence for TTM in animal models of cardiac arrest. METHODS:We searched PubMed and EMBASE for adult animal studies using TTM as a treatment in different models of cardiac arrest or global brain ischemia which reported neurobehavioural outcome, brain histology or mortality. We used a random effects model to calculate estimates of efficacy and assessed risk of bias using an adapted eight-item version of the Collaborative Approach to Meta-Analysis and Review of Animal Data from Experimental Studies (CAMARADES) quality checklist. We also used a scoring system based on the recommendations of the Stroke Treatment Academic Industry Roundtable (STAIR), to assess the scope of testing in the field. Included studies which investigated a post-ischemic induction of TTM had their treatment regimens characterized with regard to depth, duration and time to treatment and scored against the modified STAIR criteria. RESULTS:The initial and updated search generated 17809 studies after duplicate removal. One hundred eighty-one studies met the inclusion criteria, including data from 1,787, 6,495 and 2,945 animals for neurobehavioural, histological and mortality outcomes, respectively. TTM was favoured compared to control for all outcomes. TTM was beneficial using short and prolonged cooling, deep and moderate temperature reduction, and early and delayed time to treatment. Median [IQR] study quality was 4 [3 to 6]. Eighteen studies checked seven or more of the eight CAMARADES quality items. There was no clear correlation between study quality and efficacy for any outcome. STAIR analysis identified 102 studies investigating post-ischemic induction of TTM, comprising 147 different treatment regimens of TTM. Only 2 and 8 out of 147 regimens investigated comorbid and gyrencephalic animals, respectively. CONCLUSIONS:TTM is beneficial under most experimental conditions in animal models of cardiac arrest or global brain ischemia. However, research on gyrencephalic species and especially comorbid animals is uncommon and a possible translational gap. Also, low study quality suggests risk of bias within studies. Future animal research should focus on mimicking the clinical scenario and employ similar rigour in trial design to that of modern clinical trials.

Project description:To describe outcomes and complications in the drowning subgroup from the Therapeutic Hypothermia After Pediatric Cardiac Arrest Out-of-Hospital trial.Exploratory post hoc cohort analysis.Twenty-four PICUs.Pediatric drowning cases.Therapeutic hypothermia versus therapeutic normothermia.An exploratory study of pediatric drowning from the Therapeutic Hypothermia After Pediatric Cardiac Arrest Out-of-Hospital trial was conducted. Comatose patients aged more than 2 days and less than 18 years were randomized up to 6 hours following return-of-circulation to hypothermia (n = 46) or normothermia (n = 28). Outcomes assessed included 12-month survival with a Vineland Adaptive Behavior Scale score of greater than or equal to 70, 1-year survival rate, change in Vineland Adaptive Behavior Scale-II score from prearrest to 12 months, and select safety measures. Seventy-four drowning cases were randomized. In patients with prearrest Vineland Adaptive Behavior Scale-II greater than or equal to 70 (n = 65), there was no difference in 12-month survival with Vineland Adaptive Behavior Scale-II score of greater than or equal to 70 between hypothermia and normothermia groups (29% vs 17%; relative risk, 1.74; 95% CI, 0.61-4.95; p = 0.27). Among all evaluable patients (n = 68), the Vineland Adaptive Behavior Scale-II score change from baseline to 12 months did not differ (p = 0.46), and 1-year survival was similar (49% hypothermia vs 42%, normothermia; relative risk, 1.16; 95% CI, 0.68-1.99; p = 0.58). Hypothermia was associated with a higher prevalence of positive bacterial culture (any blood, urine, or respiratory sample; 67% vs 43%; p = 0.04); however, the rate per 100 days at risk did not differ (11.1 vs 8.4; p = 0.46). Cumulative incidence of blood product use, serious arrhythmias, and 28-day mortality were not different. Among patients with cardiopulmonary resuscitation durations more than 30 minutes or epinephrine doses greater than 4, none had favorable Pediatric Cerebral Performance Category outcomes (? 3).In comatose survivors of out-of-hospital pediatric cardiac arrest due to drowning, hypothermia did not result in a statistically significant benefit in survival with good functional outcome or mortality at 1 year, as compared with normothermia. High risk of culture-proven bacterial infection was observed in both groups.

Project description:Coagulation can be visualised using whole blood coagulation analyses such as thromboelastometry and platelet aggregation tests; however, the role of temperature in the analyses is ambiguous. The aim was to examine whether temperature influences the whole blood coagulation tests.We included 40 patients treated with targeted temperature management (33 ± 1 °C) after out-of-hospital cardiac arrest. The blood samples were obtained on hypothermia and normothermia. Each blood sample was analysed simultaneously at 33 °C and 37 °C by thromboelastography (ROTEM®) employing the assays EXTEM®, INTEM®, FIBTEM® and HEPTEM®, and by Multiplate®Analyzer, using COLtest®, ADPtest®, ASPItest® and TRAPtest® as agonists. Data on antithrombotic drugs were collected systematically from medical records, and data were analysed using repeated measurement analysis of variance (ANOVA).The ROTEM® analyses showed increased clotting time, lower maximum velocity and increased time to maximum velocity (all p values <0.02) when performed at 33 °C compared with 37 °C, irrespective of the patients being hypothermic (median 33.1 °C) or normothermic (median 37.5 °C). However, EXTEM® time to maximum velocity showed no difference between the analyses performed at 33 °C and 37 °C when the patients were hypothermic (p = 0.83). No differences were found in maximum clot firmness (all p values >0.09) analysed at 33 °C and 37 °C, independent of the body temperature. In the hypothermic blood sample, no difference was found when using the COLtest®, ASPItest® or TRAPtest® to compare platelet aggregation analysed at 33 °C and 37 °C (all p values >0.19), but platelet aggregation was significantly higher using the ADPtest® (p < 0.001) when analysed at 33 °C. In the normothermic blood sample, the TRAPtest® showed no difference (p = 0.73) when performed at 33 °C; however, significantly lower aggregation was found using the COLtest® and ASPItest® (all p values <0.001), while a higher aggregation at 33 °C was found using the ADPtest® (p = 0.003).ROTEM® analyses seemed not to be dependent on body temperature but showed a slower initiation of coagulation when analysed at 33 °C compared with 37 °C. The Multiplate®Analyzer results were dependent on the temperature used in the analyses and the body temperature. In whole blood coagulation tests, the temperature used in the analyses should be kept at 37 °C irrespective of the patient's body temperature being 33 °C or 37 °C.

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Preliminary observations in systemic oxygen consumption during targeted temperature management after cardiac arrest.

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Preliminary observations in systemic oxygen consumption during targeted temperature management after cardiac arrest.

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