Abstract 11597: Characterization of Epinephrine Use During Extracorporeal Cardiopulmonary Resuscitation

Circulation ◽  
2021 ◽  
Vol 144 (Suppl_2) ◽  
Author(s):  
Nicholas Kucher ◽  
Alexandra Marquez ◽  
Anne M Guerguerian ◽  
Michael-Alice Moga ◽  
Mariella Vargas-Gutierrez ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Total Dose ◽  
Ecmo Support ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
Vasodilator Therapy ◽  
Pump Speed ◽  
Inotrope Score ◽  
Clinically Significant ◽  
The Impact

Introduction: Guidelines recommend dosing Epinephrine (Epi) at regular intervals during pediatric cardiac arrest, including patients requiring extracorporeal membrane oxygenation (ECMO). The impact of Epi-induced vasoconstriction on systemic afterload and veno-arterial ECMO support is poorly understood. Hypothesis: Higher total dose of Epi and shorter interval between Epi dose and ECMO flow during cardiac arrest will increase systemic afterload and interfere with ECMO support. Methods: This is an ancillary study to a single-center, retrospective observational study of patients 0-18 years old who required ECMO cannulation during resuscitation over a six-year period. Patients were excluded if ECMO was initiated prior to arrest or if the resuscitation record was incomplete. The primary exposure was time from last dose of Epi to initiation of ECMO flows; secondary exposures included cumulative Epi dose delivered and indexed to arrest time. Mean arterial pressure (MAP) and systemic vasodilator therapy were used as surrogates for systemic afterload; ECMO pump speed and vasoactive-inotrope score (VIS) were used as measures of ECMO support. Results: A total 92 events in 87 patients analyzed. The patient cohort was 53% female with median (IQR) age of 122 (30-478) days, weight 4.4 (3.3 - 8.7) kg, and 43% single ventricle physiology. On average, Epi was given 7 (4 - 10) times during a 35 (27 - 44) min arrest, for a total dose of 65 (37 - 101) mcg/kg; the last dose was given 6 (2 -16) min prior to the initiation of ECMO flows. In the 6 hours following initiation of ECMO, MAP increased from 42 (36 - 56) mmHg to 57 (47 - 70) mmHg, (p<0.0001). Shorter interval between last Epi dose and ECMO initiation trended with higher MAP after 1 hour of support (estimate -0.43, p=0.06) and associated with increased of vasodilators within 6 hours of ECMO (vasodilators used (1 - 6) vs not used 9 (3 - 16) min, p=0.05). No other associations were found between Epi delivery, MAP, vasodilator use, pump speed or VIS. Conclusion: There is limited evidence to support that regular dosing of Epi throughout a cardiac arrest is associated with clinically significant increases in afterload after ECMO cannulation. Additional studies are needed to validate findings against ECMO flows and clinically relevant outcomes.

scholarly journals Lactate Clearance Predicts Good Neurological Outcomes in Cardiac Arrest Patients Treated with Extracorporeal Cardiopulmonary Resuscitation

2019 ◽  
Vol 8 (3) ◽  
pp. 374 ◽  
Author(s):  
Christian Jung ◽  
Sandra Bueter ◽  
Bernhard Wernly ◽  
Maryna Masyuk ◽  
Diyar Saeed ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Cardiopulmonary Resuscitation ◽  
Cox Regression ◽  
Lactate Concentration ◽  
Lactate Clearance ◽  
Serum Lactate ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
Neurological Outcomes ◽  
Baseline Characteristics ◽  
The Impact

Background: We evaluated critically ill patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR) due to cardiac arrest (CA) with respect to baseline characteristics and laboratory assessments, including lactate and lactate clearance for prognostic relevance. Methods: The primary endpoint was 30-day mortality. The impact on 30-day mortality was assessed by uni- and multivariable Cox regression analyses. Neurological outcome assessed by Glasgow Outcome Scale (GOS) was pooled into two groups: scores of 1–3 (bad GOS score) and scores of 4–5 (good GOS score). Results: A total of 93 patients were included in the study. Serum lactate concentration (hazard ratio (HR) 1.09; 95% confidence interval (CI) 1.04–1.13; p < 0.001), hemoglobin, (Hb; HR 0.87; 95% CI 0.79–0.96; p = 0.004), and catecholamine use were associated with 30-day-mortality. In a multivariable model, only lactate clearance (after 6 h; OR 0.97; 95% CI 0.94–0.997; p = 0.03) was associated with a good GOS score. The optimal cut-off of lactate clearance at 6 h for the prediction of a bad GOS score was at ≤13%. Patients with a lactate clearance at 6 h ≤13% evidenced higher rates of bad GOS scores (97% vs. 73%; p = 0.01). Conclusions: Whereas lactate clearance does not predict mortality, it was the sole predictor of good neurological outcomes and might therefore guide clinicians when to stop ECPR.

Abstract 259: Outcomes of Targeted Temperature Management in Patients with Out-of-hospital Refractory Ventricular Fibrillation/ventricular Tachycardia Cardiac Arrest

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_4) ◽  
Author(s):  
Kellen Albrecht ◽  
Jason Bartos ◽  
Demetris Yannopoulos
Keyword(s):  
Cardiac Arrest ◽  
Brain Death ◽  
Initial Temperature ◽  
Bleeding Risk ◽  
Targeted Temperature Management ◽  
Adult Patients ◽  
Temperature Management ◽  
Passive Cooling ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
The Impact

Background: Current guidelines recommend use of targeted temperature management (TTM) with goal between 32 and 36°C for all comatose adult patients with ROSC after cardiac arrest. However, refractory cardiac arrest with prolonged hypoperfusion, may cause passive cooling below goal temperature. The impact of this passive cooling and subsequent cooling strategies remains unknown. This study aims to describe the association between passive intra-arrest cooling and survival in patients suffering refractory VF/VT cardiac arrest treated with the University of Minnesota extracorporeal cardiopulmonary resuscitation (ECPR) protocol. Methods: Between December 2015 and October 2019, consecutive adult patients with refractory VF/VT arrest requiring ongoing CPR were transported by EMS to the CCL where ECPR, coronary angiography, and PCI were performed, as appropriate. TTM was initiated with goal temperature of 34°C unless clinically significant bleeding occurred, where a goal of 36°C was used. Patient and arrest characteristics, temperature data, and survival were collected retrospectively. Results: Data was gathered for 153 consecutive patients transferred for ECPR; 12 were excluded due to death in CCL prior to TTM. Of the remaining patients, 63 (41%) survived to discharge, where 55 (36%) had CPC scores of 1-2. Among deceased patients, 25 died from acute brain death while 47 died from other causes. Patients with CPC 1-2 had an initial temperature of 34.1°C versus 32.7°C in patients developing acute brain death (p=0.002). Survivors had shorter (p=0.0001) CPR time (52 minutes) versus deceased patients (65 minutes). If the initial temperature was below goal, patients were actively warmed to goal due to bleeding risk with ECPR. Survival to hospital discharge with CPC 1-2 was associated with lower peak warming rate compared with acute brain death (0.37°C/hr vs 0.69°C/hr; p=0.014) Conclusions: Survivors with CPC 1-2 after refractory VF/VT cardiac arrest and ECPR have preserved initial temperatures compared to more severe passive cooling in patients with acute brain death. This may be due to shorter duration of CPR. However, patients with acute brain death were noted to have higher peak rate of rewarming during TTM.

Extracorporeal Membrane Oxygenation for Pediatric Cardiac Arrest

2015 ◽  
Vol 35 (1) ◽  
pp. 60-69 ◽  
Author(s):  
Jennie Ryan
Keyword(s):  
Cardiac Arrest ◽  
Cardiopulmonary Resuscitation ◽  
Extracorporeal Membrane Oxygenation ◽  
Life Support ◽  
Survival Rates ◽  
Underlying Disease ◽  
The Body ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
Membrane Oxygenation ◽  
The Impact

Extracorporeal cardiopulmonary resuscitation (ECPR) remains a promising treatment for pediatric patients in cardiac arrest unresponsive to traditional cardiopulmonary resuscitation. With venoarterial extracorporeal support, blood is drained from the right atrium, oxygenated through the extracorporeal circuit, and transfused back to the body, bypassing the heart and lungs. The use of artificial oxygenation and perfusion thus provides the body a period of hemodynamic stability, while allowing resolution of underlying disease processes. Survival rates for ECPR patients are higher than those for traditional cardiopulmonary resuscitation (CPR), although neurological outcomes require further investigation. The impact of duration of CPR and length of treatment with extracorporeal membrane oxygenation vary in published reports. Furthermore, current guidelines for the initiation and use of ECPR are limited and may lead to confusion about appropriate use of this support. Many ethical concerns arise with this advanced form of life support. More often than not, the dilemma is not whether to withhold ECPR, but rather when to withdraw it. Although clinicians must decide if ECPR is appropriate and when further intervention is futile, the ultimate burden of choice is left to the patient’s caregivers. Offering support and guidance to the patient’s family as well as the patient is essential.

scholarly journals Association between Extracorporeal Membrane Oxygenation (ECMO) and Mortality in the Patients with Cardiac Arrest: A Nation-Wide Population-Based Study with Propensity Score Matched Analysis

2020 ◽  
Vol 9 (11) ◽  
pp. 3703
Author(s):  
Su Jin Kim ◽  
Kap Su Han ◽  
Eui Jung Lee ◽  
Si Jin Lee ◽  
Ji Sung Lee ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Health Insurance ◽  
Propensity Score ◽  
Extracorporeal Membrane Oxygenation ◽  
National Health Insurance ◽  
National Health ◽  
Hospital Costs ◽  
Ecmo Support ◽  
Membrane Oxygenation ◽  
The Impact

We attempted to determine the impact of extracorporeal membrane oxygenation (ECMO) on short-term and long-term outcomes and find potential resource utilization differences between the ECMO and non-ECMO groups, using the National Health Insurance Service database. We selected adult patients (≥20 years old) with non-traumatic cardiac arrest from 2007 to 2015. Data on age, sex, insurance status, hospital volume, residential area urbanization, and pre-existing diseases were extracted from the database. A total of 1.5% (n = 3859) of 253,806 patients were categorized into the ECMO group. The ECMO-supported patients were more likely to be younger, men, more covered by national health insurance, and showed, higher usage of tertiary level and large volume hospitals, and a lower rate of pre-existing comorbidities, compared to the non-ECMO group. After propensity score-matching demographic data, hospital factors, and pre-existing diseases, the odds ratio (ORs) of the ECMO group were 0.76 (confidence interval, (CI) 0.68–0.85) for 30-day mortality and 0.66 (CI 0.58–0.79) for 1-year mortality using logistic regression. The index hospitalization was longer, and the 30-day and 1-year hospital costs were greater in the matched ECMO group. Although ECMO support needed longer hospitalization days and higher hospital costs, the ECMO support reduced the risk of 30-day and 1-year mortality compared to the non-ECMO patients.

Microvascular perfusion in cardiac arrest: a review of microcirculatory imaging studies

Perfusion ◽  
2017 ◽  
Vol 33 (1) ◽  
pp. 8-15 ◽  
Author(s):  
Petra Krupičková ◽  
Zuzana Mormanová ◽  
Tomáš Bouček ◽  
Tomáš Belza ◽  
Jana Šmalcová ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Therapy Monitoring ◽  
Developed Countries ◽  
Dark Field ◽  
Therapeutic Interventions ◽  
Orthogonal Polarization ◽  
Sidestream Dark Field ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
Orthogonal Polarization Spectral ◽  
The Impact

Cardiac arrest represents a leading cause of mortality and morbidity in developed countries. Extracorporeal cardiopulmonary resuscitation (ECPR) increases the chances for a beneficial outcome in victims of refractory cardiac arrest. However, ECPR and post-cardiac arrest care are affected by high mortality rates due to multi-organ failure syndrome, which is closely related to microcirculatory disorders. Therefore, microcirculation represents a key target for therapeutic interventions in post-cardiac arrest patients. However, the evaluation of tissue microcirculatory perfusion is still demanding to perform. Novel videomicroscopic technologies (Orthogonal polarization spectral, Sidestream dark field and Incident dark field imaging) might offer a promising way to perform bedside microcirculatory assessment and therapy monitoring. This review aims to summarise the recent body of knowledge on videomicroscopic imaging in a cardiac arrest setting and to discuss the impact of extracorporeal reperfusion and other therapeutic modalities on microcirculation.

Abstract 214: Cardiac Arrest and Extracorporeal Cardiopulmonary Resuscitation Impairs Left Ventricle Hemodynamic Function in a Ventricular Fibrillation Cardiac Arrest Model in Rats

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_4) ◽  
Author(s):  
Alexandra Maria Warenits ◽  
Matthias Müller ◽  
Ingrid Anna Maria Magnet ◽  
Florian Ettl ◽  
Ouafa Hamza ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Cardiac Output ◽  
Ventricular Fibrillation ◽  
Cardiopulmonary Resuscitation ◽  
Left Ventricular ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
Hemodynamic Stress ◽  
Hemodynamic Function ◽  
The Right ◽  
The Impact

Introduction: Extracorporeal Cardiopulmonary Resuscitation (ECPR) may achieve ROSC after prolonged CA when conventional cardiopulmonary resuscitation fails. We investigated the impact of ECPR on cardiac hemodynamic recovery and hypothesized, that left ventricular hemodynamic function is impaired in resuscitated hearts. Methods: Adult male Sprague-Dawley rats (500 g, n=36) were subjected to 6 or 8 min of ventricular fibrillation CA, thereafter resuscitated with ECPR (open reservoir, roller pump, membrane oxygenator, draining catheter in the right jugular vein, inflow catheter in the right femoral artery; custom made bypass system), mechanical ventilation and drugs (epinephrine, bicarbonate, heparin). After defibrillation and ROSC, rats survived for 14 days and were compared to 7 sham animals. The hearts were isolated and mounted onto an erythrocyte-perfused, isolated working heart (WH) system. Cardiac output, left ventricular systolic pressure (LVSP), coronary flow and pressure-volume (P-V) relationships (by increasing the afterload in 10 mmHg increments) were measured. Myocardium of all rats was evaluated pathohistological in hematoxylin-eosin staining. Results: ROSC was achieved in 18 animals after 6 min of CA, of which 10 survived 14 d and 7 were investigated in WH, in 8 min CA group 15 achieved ROSC of which 5 survived to 14 d and 2 were investigated in WH and compared to the hearts of 7 sham animals. At defined afterload (60 mm Hg; baseline) there was no difference in cardiac hemodynamics between sham and 6 min CA group. In contrast, 8 min CA rats showed a tendency towards decrease in cardiac output and LVSP compared to sham animals. Notably, both CA groups showed impaired P-V loop relationship and subsequently less tolerance to hemodynamic stress. Histologically all 8 min CA rats showed multiple foci of myocardial scarring. Conclusions: CA led to impaired left ventricular hemodynamics in 8 min CA rats resuscitated with ECPR. In addition, hearts were more vulnerable to hemodynamic stress after successful resuscitation. For investigating the effects of future therapy approaches during and after resuscitation from CA on the heart function, isolated WH might be a promising approach in resuscitation research.

Prospective observational study of mechanical cardiopulmonary resuscitation, extracorporeal membrane oxygenation and early reperfusion for refractory cardiac arrest in Sydney: the 2CHEER study

2020 ◽  
Vol 22 (1) ◽  
pp. 26-34
Author(s):  
Mark Dennis ◽  
◽  
Hergen Buscher ◽  
David Gattas ◽  
Brian Burns ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Cardiopulmonary Resuscitation ◽  
Extracorporeal Membrane Oxygenation ◽  
Survival Rates ◽  
Ecmo Support ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
Early Reperfusion ◽  
Coronary Syndrome ◽  
Membrane Oxygenation ◽  
Refractory Cardiac Arrest

BACKGROUND: Patients with prolonged cardiac arrest that is not responsive to conventional cardiopulmonary resuscitation have poor outcomes. The use of extracorporeal membrane oxygenation (ECMO) in refractory cardiac arrest has shown promising results in carefully selected cases. We sought to validate the results from an earlier extracorporeal cardiopulmonary resuscitation (ECPR) study (the CHEER trial). METHODS: Prospective, consecutive patients with refractory in-hospital (IHCA) or out-of-hospital cardiac arrest (OHCA) who met predefined inclusion criteria received protocolised care, including mechanical cardiopulmonary resuscitation, initiation of ECMO, and early coronary angiography (if an acute coronary syndrome was suspected). RESULTS: Twenty-five patients were enrolled in the study (11 OHCA, 14 IHCA); the median age was 57 years (interquartile range [IQR], 39–65 years), and 17 patients (68%) were male. ECMO was established in all patients, with a median time from arrest to ECMO support of 57 minutes (IQR, 38–73 min). Percutaneous coronary intervention was performed on 18 patients (72%). The median duration of ECMO support was 52 hours (IQR, 24–108 h). Survival to hospital discharge with favourable neurological recovery occurred in 11/25 patients (44%, of which 72% had IHCA and 27% had OHCA). When adjusting for lactate, arrest to ECMO flow time was predictive of survival (odds ratio, 0.904; P = 0.035). CONCLUSION: ECMO for refractory cardiac arrest shows promising survival rates if protocolised care is applied in conjunction with predefined selection criteria.

The Analyses of Learning Strategies in English as a Second Language: Theoretical Classification and Measurement Test

2020 ◽  
Vol 4 (2) ◽  
pp. 118-129
Author(s):  
Asti Gumartifa ◽  
◽  
Indah Windra Dwie Agustiani
Keyword(s):  
Language Learning ◽  
Learning Outcomes ◽  
Learning Strategies ◽  
Learning Process ◽  
English Learners ◽  
English Language ◽  
Point Of View ◽  
Effective Learning ◽  
The Impact

Gaining English language learning effectively has been discussed all years long. Similarly, Learners have various troubles outcomes in the learning process. Creating a joyful and comfortable situation must be considered by learners. Thus, the implementation of effective learning strategies is certainly necessary for English learners. This descriptive study has two purposes: first, to introduce the classification and characterization of learning strategies such as; memory, cognitive, metacognitive, compensation, social, and affective strategies that are used by learners in the classroom and second, it provides some questionnaires item based on Strategy of Inventory for Language Learning (SILL) version 5.0 that can be used to examine the frequency of students’ learning strategies in the learning process. The summary of this study explains and discusses the researchers’ point of view on the impact of learning outcomes by learning strategies used. Finally, utilizing appropriate learning strategies are certainly beneficial for both teachers and learners to achieve the learning target effectively.

scholarly journals Modulation of Gut Microbiota and Oxidative Status by β-Carotene in Late Pregnant Sows

2020 ◽  
Vol 7 ◽  
Author(s):  
Xupeng Yuan ◽  
Jiahao Yan ◽  
Ruizhi Hu ◽  
Yanli Li ◽  
Ying Wang ◽  
...  
Keyword(s):  
Gut Microbiota ◽  
Dietary Supplementation ◽  
Basal Diet ◽  
Fecal Microbiota ◽  
Control Group ◽  
Metabolic Activities ◽  
The Impact ◽  
Positive Effect ◽  
Β Carotene

Recent evidences suggest that gut microbiota plays an important role in regulating physiological and metabolic activities of pregnant sows, and β-carotene has a potentially positive effect on reproduction, but the impact of β-carotene on gut microbiota in pregnant sows remains unknown. This study aimed to explore the effect and mechanisms of β-carotene on the reproductive performance of sows from the aspect of gut microbiota. A total of 48 hybrid pregnant sows (Landrace × Yorkshire) with similar parity were randomly allocated into three groups (n = 16) and fed with a basal diet or a diet containing 30 or 90 mg/kg of β-carotene from day 90 of gestation until parturition. Dietary supplementation of 30 or 90 mg/kg β-carotene increased the number of live birth to 11.82 ± 1.54 and 12.29 ± 2.09, respectively, while the control group was 11.00 ± 1.41 (P = 0.201). Moreover, β-carotene increased significantly the serum nitric oxide (NO) level and glutathione peroxidase (GSH-Px) activity (P &lt; 0.05). Characterization of fecal microbiota revealed that 90 mg/kg β-carotene increased the diversity of the gut flora (P &lt; 0.05). In particular, β-carotene decreased the relative abundance of Firmicutes including Lachnospiraceae AC2044 group, Lachnospiraceae NK4B4 group and Ruminococcaceae UCG-008, but enriched Proteobacteria including Bilophila and Sutterella, and Actinobacteria including Corynebacterium and Corynebacterium 1 which are related to NO synthesis. These data demonstrated that dietary supplementation of β-carotene may increase antioxidant enzyme activity and NO, an important vasodilator to promote the neonatal blood circulation, through regulating gut microbiota in sows.

scholarly journals Clonal approaches to understanding the impact of mutations on hematologic disease development

Blood ◽  
2019 ◽  
Vol 133 (13) ◽  
pp. 1436-1445 ◽  
Author(s):  
Jyoti Nangalia ◽  
Emily Mitchell ◽  
Anthony R. Green
Keyword(s):  
Somatic Mutations ◽  
Clonal Selection ◽  
Single Cells ◽  
Driver Mutations ◽  
Great Promise ◽  
Tumor Evolution ◽  
Disease Development ◽  
Hematopoietic Tissue ◽  
The Impact

Abstract Interrogation of hematopoietic tissue at the clonal level has a rich history spanning over 50 years, and has provided critical insights into both normal and malignant hematopoiesis. Characterization of chromosomes identified some of the first genetic links to cancer with the discovery of chromosomal translocations in association with many hematological neoplasms. The unique accessibility of hematopoietic tissue and the ability to clonally expand hematopoietic progenitors in vitro has provided fundamental insights into the cellular hierarchy of normal hematopoiesis, as well as the functional impact of driver mutations in disease. Transplantation assays in murine models have enabled cellular assessment of the functional consequences of somatic mutations in vivo. Most recently, next-generation sequencing–based assays have shown great promise in allowing multi-“omic” characterization of single cells. Here, we review how clonal approaches have advanced our understanding of disease development, focusing on the acquisition of somatic mutations, clonal selection, driver mutation cooperation, and tumor evolution.

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