Abstract Introduction The neutrophil lymphocyte ratio(NLR) is a marker of systemic inflammation. We hypothesized that admission NLR is related to mortality and that epinephrine application during ...resuscitation influences NLR in patients after successful resuscitation from out of hospital cardiac arrest (OHCA). Methods This retrospective cohort study is based on a registry including all OHCA patients who had a presumed cardiac cause of cardiac arrest and achieved sustained ROSC prior to admission between 2005 and 2014. Patients were categorized into three groups according to the calculated NLR at admission (NLR <6, ≥6, and ‘abnormal differential’ indicating no differential blood cell count on patients report due to exceedance of machine predefined parameter limits). The primary outcome measure was long-term mortality after OHCA. Cox proportional hazards models were used for multivariable analysis. Results Out of 2273 OHCA patients during the study period a total of 1188(52%) patients were eligible for analysis, of those 274(23%) were female and mean age was 64 (25–75 IQR:52-72). Compared to a NLR < 6 (n = 442), adjusted hazard ratio for long-term mortality was significantly higher in patients with a NLR ≥ 6 (n = 447; 1.52 (95%CI 1.03–2.24)) and in patients with abnormal differential (n = 299; 3.16 (95%CI 2.02-4.97)). Epinephrine application during resuscitation did not explain the effect of NLR on mortality. Conclusion In this large retrospective cohort study of altogether >1000 OHCA patients, hospital admission NLR < 6 compared to abnormal differential or NLR ≥ 6 was associated with mortality independently from epinephrine application.
Current guidelines recommend targeted temperature management to improve neurological outcome after cardiac arrest. Evidence regarding an ideal sedative/analgesic regimen including skeletal muscle ...paralysis is limited.
Patients were randomized to either a continuous administration of rocuronium (continuous-NMB-group) or to a continuous administration of saline supplemented by rocuronium bolus administration if demanded (bolus-NMB-group).
The primary outcome was the number of shivering episodes. Secondary outcomes included survival and neurological status one year after cardiac arrest, time to awakening, length of stay as well as required cumulative dose of rocuronium, midazolam and fentanyl.
Sixty-three patients (32 continuous-NMB-group; 31 bolus-NMB-group) were enrolled. Differences in baseline characteristics were not significant. Shivering episodes were detected in 94% of the patients in the bolus-NMB-group compared to 25% of the patients receiving continuous rocuronium infusion (p<0.01). The continuous-NMB-group received significant lower doses of midazolam (4.3±0.8mg/kg vs. 5.1±0.9mg/kg, p<0.01) and fentanyl (62±14μg/kg vs. 71±7μg/kg, p<0.01), but higher cumulative doses of rocuronium (7.8±1.8mg/kg vs. 2.3±1.6mg/kg, p<0.01). Earlier awakening (2 IQR 2;3 vs. 4 IQR 2;7.5 days, p=0.04) and decreased length of stay at the ICU (6 IQR 3;5.9 vs. 10 IQR 5;15 days, p=0.03) were observed in the continuous-NMB-group. There were no significant differences in survival and quality of life 12 months after cardiac arrest.
Continuous neuromuscular blockade during the first day after resuscitation reduced shivering, midazolam and fentanyl requirement, time to awakening and discharge from intensive care unit. There were no differences in overall survival, cooling rate and time to target temperature.
Abstract Background The outcome of patients after out-of-hospital cardiac arrest (OHCA) is poor and gets worse after prolonged resuscitation. Recently introduced attempts like an early installed ...emergency extracorporeal life support (E-ECLS) in patients with persisting cardiac arrest at the emergency department (ED) are tried. The “Vienna Cardiac Arrest Registry” (VICAR) was introduced August 2013 to collect Utstein-style data. The aim of this observational study was to identify the incidence of patients which fulfil “load&go”-criteria for E-ECLS at the ED. Methods VICAR was retrospectively analyzed for following criteria: age <75 years; witnessed OHCA; basic life support; ventricular fibrillation/ventricular tachycardia; no return-of-spontaneous-circulation (ROSC) within 15 min of advanced-life-support, which were supposed as potential optimal criteria for “load&go” plus successful E-ECLS treatment at the ED. The observation period was from August 1, 2013 to July 31, 2014. Results Over 948 OHCA patients registered during the study period; data were exploitable for 864 patients. Of all patients, “load&go”-criteria were fulfilled by 55 (6%). However, 96 (11%) were transported with on-going CPR to the ED. Of these 96 patients, only 16 (17%) met the “load&go”-criteria. Similarly, among the 96 patients, 12 adults were treated with E-ECLS at the ED, with only 5 meeting the criteria. Among these 12 patients, favourable neurological outcome (CPC 1/2) was obtained in 1 patient without criteria. Conclusion Further promotion of these criteria within the ambulance crews is needed. May be these criteria could serve as a decision support for emergency physicians/paramedics, which patients to transport with on-going CPR to the ED for E-ECLS.
Targeted temperature management (TTM) is part of standard post-resuscitation care. TTM may downregulate cytochrome enzyme activity and thus impact drug metabolism. This study compared the ...pharmacokinetics (PK) of pantoprazole, a probe drug of CYP2C19-dependent metabolism, at different stages of TTM following cardiac arrest.
This prospective controlled study was performed at the Medical University of Vienna and enrolled 16 patients following cardiac arrest. The patients completed up to three study periods (each lasting 24 h) in which plasma concentrations of pantoprazole were quantified: (P1) hypothermia (33 °C) after admission, (P2) normothermia after rewarming (36 °C, intensive care), and (P3) normothermia during recovery (normal ward, control group). PK was analysed using non-compartmental analysis and nonlinear mixed-effects modelling.
16 patients completed periods P1 and P2; ten completed P3. The median half-life of pantoprazole was 2.4 h (quartiles: 1.8–4.8 h) in P1, 2.8 h (2.1–6.8 h, p = 0.046 vs. P1, p = 0.005 vs. P3) in P2 and 1.2 h (0.9 – 2.3 h, p = 0.007 vs. P1) in P3. A two-compartment model described the PK data best. Typical values for clearance were estimated separately for each study period, indicating 40% and 29% reductions during P1 and P2, respectively, compared to P3. The central volume of distribution was estimated separately for P2, indicating a 64% increase compared to P1 and P3.
CYP2C19-dependent drug metabolism is downregulated during TTM following cardiac arrest. These results may influence drug choice and dosing of similarly metabolized drugs and may be helpful for designing studies in similar clinical situations.
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•We included cardiac arrest patients during therapeutic hypothermia at 33 °C, after rewarming (ICU) and after recovery.•The pharmacokinetics of pantoprazole, a CYP2C19 probe drug, during these treatment stages were compared.•During hypothermia and after rewarming (ICU), the metabolism of pantoprazole was reduced compared with normal ward stay.•The initial hypothermia and the systemic inflammatory response after cardiac arrest may impair CYP2C19 activity.
Abstract Aim of the study To determine the incidence of out-of-hospital cardiac arrest and the survival rate of those patients who received CPR in the city of Vienna. Methods A cohort of patients ...with out-of-hospital cardiac arrests and who were treated by the Vienna Ambulance Service between January 1, 2009, and December 31, 2010, were followed up until either death or hospital discharge. The associations of survival and neurological outcome with their potential predictors were analysed using simple logistic regression models. Odds ratios were estimated for each factor. Results During the observation period, a total of 7030 (206.8/100,000 inhabitants/year) patients without signs of circulation were assessed by teams of the Vienna Ambulance Service, and 1448 adult patients were resuscitated by emergency medical service personnel. A sustained return of spontaneous circulation was reported in 361 (24.9%) of the treated patients, and in all 479 (33.0%) of the patients were taken to the emergency department. A total of 164 (11.3%) of the patients were discharged from the hospital alive, and 126 (8.7%) of the patients showed cerebral performance categories of 1 or 2 at the time of discharge. Younger age, an arrest in a public area, a witnessed arrest and a shockable rhythm were associated with a higher probability of survival to hospital discharge. Conclusion Survival rates for out-of-hospital cardiac arrests remain low. Efforts should be focused on rapidly initiating basic life support, early defibrillation, and high-quality CPR by emergency medical services and state-of-the art post-resuscitation care.
Abstract Objective To investigate the feasibility of a refined aortic flush catheter and pump system to induce emergency preservation and resuscitation before extracorporeal cardiopulmonary ...resuscitation in a normovolemic cardiac arrest swine model simulating near real size/weight conditions of adults. Methods In this feasibility study, 8 female Large White breed pigs weighing 70 to 80 kg underwent ventricular fibrillation cardiac arrest for 15 minutes, followed by 4°C aortic flush (150 mL/kg for the brain; 50 mL/kg for the spine) via a new hardware ensued by resuscitation with extracorporeal cardiopulmonary resuscitation. Results Brain temperature was lowered from 39.9°C (interquartile range IQR 39.6-40.3) to 24.0°C (IQR 20.8-28.9) in 12 minutes (IQR 11-16) with a median cooling rate of 1.3°C (IQR 0.7-1.6) per minute. A median of 776 mL (IQR 673-840) per minute with a median pump pressure of 1487 mm Hg (IQR 1324-1545) were pumped to the brain. Conclusions With the new hardware, we were able to cool the brain within a few minutes in a large pig cardiac arrest model. The exact position; the design, diameter, and length of the flush catheter; and the brain perfusion pressure seem to be critical to effectively reduce brain temperature. Redistribution of peripheral blood could lead to sterile inflammation again and might be avoided.
Optimal Exploitation of Nonrenewable Resources Kunow, Angela; Rosche, Sandy; Tammer, Christiane ...
Journal of optimization theory and applications,
12/2015, Letnik:
167, Številka:
3
Journal Article
Recenzirano
Since the oil-crisis in the seventies of the last century humans have become aware of the finite availability of scarce resources and the influence of today’s exploitation on future wealth. Thus ...following the demand to integrate lasting (sustained) effects of human acting into economic models presupposes long-term thinking in form of a generation contract. Only dynamic modeling matches the prerequisites of solving these problems. Therefore, we develop a model of dynamic exploitation for oil-exploitation and use the maximum principle to generate algorithm to find an approximate solution. We use this algorithm to solve an example and give interpretation of the results.
Background
Organ failure increases mortality in patients with liver cirrhosis. Data about resuscitated cardiac arrest patients with liver cirrhosis are missing. This study aims to assess aetiology, ...survival and functional outcome in patients after successful cardiopulmonary resuscitation (CPR) with and without liver cirrhosis.
Methods
Analysis of prospectively collected cardiac arrest registry data of consecutively hospital-admitted patients following successful CPR was performed. Patient’s characteristics, admission diagnosis, severity of disease, course of disease, short- and long-term mortality as well as functional outcome were assessed and compared between patients with and without cirrhosis.
Results
Out of 1068 patients with successful CPR, 47 (4%) had liver cirrhosis. Acute-on-chronic liver failure (ACLF) was present in 33 (70%) of these patients on admission, and four patients developed ACLF during follow-up. Mortality at 1 year was more than threefold increased in patients with liver cirrhosis (OR 3.25; 95% CI 1.33–7.96). Liver cirrhosis was associated with impaired neurological outcome (OR for a favourable cerebral performance category: 0.13; 95% CI 0.04–0.36). None of the patients with Child–Turcotte–Pugh (CTP) C cirrhosis survived 28 days with good neurological outcome. Overall nine (19%) patients with cirrhosis survived 28 days with good neurological outcome. All patients with ACLF grade 3 died within 28 days.
Conclusion
Cardiac arrest survivors with cirrhosis have worse outcome than those without. Although one quarter of patients with liver cirrhosis survived longer than 28 days after successful CPR, patients with CTP C as well as advanced ACLF did not survive 28 days with good neurological outcome.
Background: Mild therapeutic hypothermia (MTH) is a treatment adjunct in ST-segment elevation myocardial infarction (STEMI) that deserves investigation. Copeptin―a surrogate marker for vasopressin―is ...an early biomarker in STEMI. Data from cardiac arrest patients suggest a reduction of copeptin levels through MTH; however, copeptin levels have not been investigated in MTH during STEMI. Methods: We analyzed patients treated with MTH during STEMI in a sub-study of the STATIM trial (Testori, Heart 2019). Patients were randomized to normothermia or MTH with out-of-hospital initiation. Seven copeptin samples were collected from each patient. Primary endpoint was the difference in copeptin levels between the groups. As secondary endpoints, we defined differences in the kinetics between the sampling timepoints and the correlation between copeptin and the infarct size in relation to left ventricular myocardium. Results: We included 99 patients (MTH n = 47, control n = 52) in our intention to treat analysis. No differences in copeptin values at first medical contact between the MTH and normothermia groups were found. MTH showed no effect on copeptin levels, neither during cooling phase nor through the course. Copeptin peaked at first medical contact and hospital admission in both groups. No differences in kinetics between the timepoints were found. Copeptin showed no correlation with infarct size, neither at first medical contact nor hospital admission. Conclusions: Copeptin levels were not influenced by MTH in STEMI, suggesting the use of this biomarker also during temperature management. Furthermore, copeptin levels were not usable as a surrogate marker for infarct size at any timepoint.
The exact contribution of neutrophils to post-resuscitative brain damage is unknown. We aimed to investigate whether neutrophil extracellular trap (NET) formation in the early phase after return of ...spontaneous circulation (ROSC) may be associated with poor 30 day neurologic function in cardiac arrest survivors. This study prospectively included adult (≥18 years) out-of-hospital cardiac arrest (OHCA) survivors with cardiac origin, who were subjected to targeted temperature management. Plasma levels of specific (citrullinated histone H3, H3Cit) and putative (cell-free DNA (cfDNA) and nucleosomes) biomarkers of NET formation were assessed at 0 and 12 h after admission. The primary outcome was neurologic function on day 30 after admission, which was assessed using the five-point cerebral performance category (CPC) score, classifying patients into good (CPC 1-2) or poor (CPC 3-5) neurologic function. The main variable of interest was the effect of H3Cit level quintiles at 12 h on 30 day neurologic function, assessed by logistic regression. The first quintile was used as a baseline reference. Results are given as crude odds ratio (OR) with 95% confidence interval (95% CI). Sixty-two patients (79% male, median age: 57 years) were enrolled. The odds of poor neurologic function increased linearly, with 0 h levels of cfNDA (crude OR 1.8, 95% CI: 1.2-2.7,
= 0.007) and nucleosomes (crude OR 1.7, 95% CI: 1.0-2.2,
= 0.049), as well as with 12 h levels of cfDNA (crude OR 1.6, 95% CI: 1.1-2.4,
= 0.024), nucleosomes (crude OR 1.7, 95% CI: 1.1-2.5,
= 0.020), and H3Cit (crude OR 1.6, 95% CI: 1.1-2.3,
= 0.029). Patients in the fourth (7.9, 95% CI: 1.1-56,
= 0.039) and fifth (9.0, 95% CI: 1.3-63,
= 0.027) H3Cit quintile had significantly higher odds of poor 30 day neurologic function compared to patients in the first quintile. Increased plasma levels of H3Cit, 12 h after admission, are associated with poor 30 day neurologic function in adult OHCA survivors, which may suggest a contribution of NET formation to post-resuscitative brain damage and therefore provide a therapeutic target in the future.
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