Abstract Lactate levels are commonly evaluated in acutely ill patients. Although most often used in the context of evaluating shock, lactate levels can be elevated for many reasons. While tissue ...hypoperfusion may be the most common cause of elevation, many other etiologies or contributing factors exist. Clinicians need to be aware of the many potential causes of lactate level elevation as the clinical and prognostic importance of an elevated lactate level varies widely by disease state. Moreover, specific therapy may need to be tailored to the underlying cause of elevation. The present review is based on a comprehensive PubMed search between the dates of January 1, 1960, to April 30, 2013, using the search term lactate or lactic acidosis combined with known associations, such as shock, sepsis, cardiac arrest, trauma, seizure, ischemia, diabetic ketoacidosis, thiamine, malignancy, liver, toxins, overdose, and medication. We provide an overview of the pathogenesis of lactate level elevation followed by an in-depth look at the varied etiologies, including medication-related causes. The strengths and weaknesses of lactate as a diagnostic/prognostic tool and its potential use as a clinical end point of resuscitation are discussed. The review ends with some general recommendations on the management of patients with elevated lactate levels.
Abstract Background Patients suffering in-hospital cardiac arrest often show signs of physiological deterioration before the event. The purpose of this study was to determine the prevalence of ...abnormal vital signs 1–4 h before cardiac arrest, and to evaluate the association between these vital sign abnormalities and in-hospital mortality. Methods We included adults from the Get With the Guidelines ® – Resuscitation registry with an in-hospital cardiac arrest. We used two a priori definitions for vital signs: abnormal (heart rate (HR) ≤ 60 or ≥100 min−1 , respiratory rate (RR) ≤ 10 or >20 min−1 and systolic blood pressure (SBP) ≤ 90 mm Hg) and severely abnormal (HR ≤ 50 or ≥130 min−1 , RR ≤ 8 or ≥30 min−1 and SBP ≤ 80 mm Hg). We evaluated the association between the number of abnormal vital signs and in-hospital mortality using a multivariable logistic regression model. Results 7851 patients were included. Individual vital signs were associated with in-hospital mortality. The majority of patients (59.4%) had at least one abnormal vital sign 1–4 h before the arrest and 13.4% had at least one severely abnormal sign. We found a step-wise increase in mortality with increasing number of abnormal vital signs within the abnormal (odds ratio (OR) 1.53 (CI: 1.42–1.64) and severely abnormal groups (OR 1.62 (CI: 1.38–1.90)). This remained in multivariable analysis (abnormal: OR 1.38 (CI: 1.28–1.48), and severely abnormal: OR 1.40 (CI: 1.18–1.65)). Conclusion Abnormal vital signs are prevalent 1–4 h before in-hospital cardiac arrest on hospital wards. In-hospital mortality increases with increasing number of pre-arrest abnormal vital signs as well as increased severity of vital sign derangements.
In-Hospital Cardiac Arrest: A Review Andersen, Lars W; Holmberg, Mathias J; Berg, Katherine M ...
JAMA : the journal of the American Medical Association,
03/2019, Letnik:
321, Številka:
12
Journal Article
Recenzirano
Odprti dostop
IMPORTANCE: In-hospital cardiac arrest is common and associated with a high mortality rate. Despite this, in-hospital cardiac arrest has received little attention compared with other high-risk ...cardiovascular conditions, such as stroke, myocardial infarction, and out-of-hospital cardiac arrest. OBSERVATIONS: In-hospital cardiac arrest occurs in over 290 000 adults each year in the United States. Cohort data from the United States indicate that the mean age of patients with in-hospital cardiac arrest is 66 years, 58% are men, and the presenting rhythm is most often (81%) nonshockable (ie, asystole or pulseless electrical activity). The cause of the cardiac arrest is most often cardiac (50%-60%), followed by respiratory insufficiency (15%-40%). Efforts to prevent in-hospital cardiac arrest require both a system for identifying deteriorating patients and an appropriate interventional response (eg, rapid response teams). The key elements of treatment during cardiac arrest include chest compressions, ventilation, early defibrillation, when applicable, and immediate attention to potentially reversible causes, such as hyperkalemia or hypoxia. There is limited evidence to support more advanced treatments. Post–cardiac arrest care is focused on identification and treatment of the underlying cause, hemodynamic and respiratory support, and potentially employing neuroprotective strategies (eg, targeted temperature management). Although multiple individual factors are associated with outcomes (eg, age, initial rhythm, duration of the cardiac arrest), a multifaceted approach considering both potential for neurological recovery and ongoing multiorgan failure is warranted for prognostication and clinical decision-making in the post–cardiac arrest period. Withdrawal of care in the absence of definite prognostic signs both during and after cardiac arrest should be avoided. Hospitals are encouraged to participate in national quality-improvement initiatives. CONCLUSIONS AND RELEVANCE: An estimated 290 000 in-hospital cardiac arrests occur each year in the United States. However, there is limited evidence to support clinical decision making. An increased awareness with regard to optimizing clinical care and new research might improve outcomes.
The fundamentals of cardiac resuscitation include the immediate provision of high-quality cardiopulmonary resuscitation combined with rapid defibrillation (as appropriate). These mainstays of therapy ...set the groundwork for other possible interventions such as medications, advanced airways, extracorporeal cardiopulmonary resuscitation, and post–cardiac arrest care, including targeted temperature management, cardiorespiratory support, and percutaneous coronary intervention. Since 2015, an increased number of studies have been published evaluating some of these interventions, requiring a reassessment of their use and impact on survival from cardiac arrest. This 2019 focused update to the American Heart Association advanced cardiovascular life support guidelines summarizes the most recent published evidence for and recommendations on the use of advanced airways, vasopressors, and extracorporeal cardiopulmonary resuscitation during cardiac arrest. It includes revised recommendations for all 3 areas, including the choice of advanced airway devices and strategies during cardiac arrest (eg, bag-mask ventilation, supraglottic airway, or endotracheal intubation), the training and retraining required, the administration of standard-dose epinephrine, and the decisions involved in the application of extracorporeal cardiopulmonary resuscitation and its potential impact on cardiac arrest survival.
Newborn screening (NBS) was established as a public health program in the 1960s and is crucial for facilitating detection of certain medical conditions in which early intervention can prevent ...serious, life-threatening health problems. Genomic sequencing can potentially expand the screening for rare hereditary disorders, but many questions surround its possible use for this purpose. We examined the use of exome sequencing (ES) for NBS in the North Carolina Newborn Exome Sequencing for Universal Screening (NC NEXUS) project, comparing the yield from ES used in a screening versus a diagnostic context. We enrolled healthy newborns and children with metabolic diseases or hearing loss (106 participants total). ES confirmed the participant’s underlying diagnosis in 15 out of 17 (88%) children with metabolic disorders and in 5 out of 28 (∼18%) children with hearing loss. We discovered actionable findings in four participants that would not have been detected by standard NBS. A subset of parents was eligible to receive additional information for their child about childhood-onset conditions with low or no clinical actionability, clinically actionable adult-onset conditions, and carrier status for autosomal-recessive conditions. We found pathogenic variants associated with hereditary breast and/or ovarian cancer in two children, a likely pathogenic variant in the gene associated with Lowe syndrome in one child, and an average of 1.8 reportable variants per child for carrier results. These results highlight the benefits and limitations of using genomic sequencing for NBS and the challenges of using such technology in future precision medicine approaches.
Cardiac arrest is one of the most challenging disease processes to study with clinical trials due to the emergent and unpredictable nature of these events and complexity of the patient population. In ...recent years, there has been a major push to complete more large, multicentre trials. In many cases, however, there remains little certainty on what treatments are most efficacious, in spite of the recent increase in evidence. This review was undertaken to address some of the unique barriers to address answering research questions in cardiac arrest with clinical trials.
Multiple examples of trials that have failed to reach definitive conclusions, and potential reasons for this, are discussed.
Trials on multiple major cardiac arrest interventions, including temperature management, drugs during cardiopulmonary resuscitation (CPR) and airway management, now have high-quality randomized trials, but significant questions on efficacy and best practices remain. Common pitfalls and reasons for this are explored, including heterogeneity of patients and providers, variability in exact interventions studied, delay in starting research interventions and lack of consistency across systems in decision making around appropriateness for resuscitation.
The combination of thiamine, ascorbic acid, and hydrocortisone has recently emerged as a potential adjunctive therapy to antibiotics, infectious source control, and supportive care for patients with ...sepsis and septic shock. In the present manuscript, we provide a comprehensive review of the pathophysiologic basis and supporting research for each element of the thiamine, ascorbic acid, and hydrocortisone drug combination in sepsis. In addition, we describe potential areas of synergy between these therapies and discuss the strengths/weaknesses of the two studies to date which have evaluated the drug combination in patients with severe infection. Finally, we describe the current state of current clinical practice as it relates to the thiamine, ascorbic acid, and hydrocortisone combination and present an overview of the randomized, placebo-controlled, multi-center Ascorbic acid, Corticosteroids, and Thiamine in Sepsis (ACTS) trial and other planned/ongoing randomized clinical trials.
There is no standard for categorizing reasons for death in those who achieve return of spontaneous circulation (ROSC) after cardiac arrest but die before hospital discharge. Categorization is ...important for comparing outcomes across studies, assessing benefits of interventions, and developing quality-improvement initiatives. We developed and tested a method for categorizing reasons for death after cardiac arrest in both in-hospital (IHCA) and out-of-hospital (OHCA) arrests.
Single-center, retrospective, cohort study of patients with ROSC after IHCA or OHCA between 2008 and 2017 who died before hospital discharge. Traumatic arrests and patients with “do-not-resuscitate” orders prior to their arrest were excluded. Two investigators assigned each patient to one of five predefined reasons for death. Interrater reliability was assessed using Fleiss’ kappa. For final categorization, discrepancies were resolved by a third investigator.
There were 182 IHCA and 226 OHCA included. There was substantial agreement between raters (kappa of 0.62 and 0.61 for IHCA and OHCA, respectively). Reasons for death for IHCA and OHCA were: neurological withdrawal of care (27% vs 73%), comorbid withdrawal of care (36% vs 4%), refractory hemodynamic shock (25% vs 17%), respiratory failure (1% vs 3%), and sudden cardiac death (11% vs 4%). The differences in reasons for death among the two groups were significant (p-value < 0.001).
Categorizing reasons for death after cardiac arrest with ROSC is feasible using our proposed categories, with substantial inter-rater agreement. Neurologic withdrawal of care is much less common in IHCA than OHCA, which may have implications for further research.
OBJECTIVE:To determine if intravenous thiamine would reduce lactate in patients with septic shock.
DESIGN:Randomized, double-blind, placebo-controlled trial.
SETTING:Two US hospitals.
PATIENTS:Adult ...patients with septic shock and elevated (> 3 mmol/L) lactate between 2010 and 2014.
INTERVENTIONS:Thiamine 200 mg or matching placebo twice daily for 7 days or until hospital discharge.
MEASUREMENTS AND MAIN RESULTS:The primary outcome was lactate levels 24 hours after the first study dose. Of 715 patients meeting the inclusion criteria, 88 patients were enrolled and received study drug. There was no difference in the primary outcome of lactate levels at 24 hours after study start between the thiamine and placebo groups (median2.5 mmol/L 1.5, 3.4 vs. 2.6 mmol/L 1.6, 5.1, p = 0.40). There was no difference in secondary outcomes including time to shock reversal, severity of illness and mortality. 35% of the patients were thiamine deficient at baseline. In this predefined subgroup, those in the thiamine treatment group had statistically significantly lower lactate levels at 24 hours (median 2.1 mmol/L 1.4, 2.5 vs. 3.1 1.9, 8.3, p = 0.03). There was a statistically significant decrease in mortality over time in those receiving thiamine in this subgroup (p = 0.047).
CONCLUSION:Administration of thiamine did not improve lactate levels or other outcomes in the overall group of patients with septic shock and elevated lactate. In those with baseline thiamine deficiency, patients in the thiamine group had significantly lower lactate levels at 24 hours and a possible decrease in mortality over time.
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