Effects of the intensity of prehospital treatment on short-term outcomes in patients with acute heart failure: the SEMICA-2 study.

OBJECTIVE: Little is known about treatments provided by advanced life support (ALS) ambulance teams to patients with acute heart failure (AHF) during the prehospital phase, and their influence on short-term outcome. We evaluated the effect of prehospital care in consecutive patients diagnosed with AHF in Spanish emergency departments (EDs). METHODS: We selected patients from the EAHFE registry arriving at the ED by ALS ambulances with available follow-up data. We recorded specific prehospital ALS treatments (supplemental oxygen, diuretics, nitroglycerin, non-invasive ventilation) and patients were grouped according to whether they received low- (LIPHT; 0/1 treatments) or high-intensity prehospital therapy (HIPHT; > 1 treatment) for AHF. We also recorded 46 covariates. The primary endpoint was all-cause 7-day mortality, and secondary endpoints were prolonged hospitalisation (> 10 days) and in-hospital and 30-day mortality. Unadjusted and adjusted odds ratios were calculated to compare the groups. RESULTS: We included 1493 patients [mean age 80.7 (10) years; women 54.8%]. Prehospital treatment included supplemental oxygen in 71.2%, diuretics in 27.9%, nitroglycerin in 13.5%, and non-invasive ventilation in 5.3%. The LIPHT group included 1041 patients (70.0%) with an unadjusted OR for 7-day mortality of 1.770 (95% CI 1.115-2.811; p = 0.016), and 1.939 (95% CI 1.114-3.287, p = 0.014) after adjustment for 16 discordant covariables. The adjusted ORs for all secondary endpoints were always > 1 in the LIPHT group, but none reached statistical significance. CONCLUSIONS: Patients finally diagnosed with AHF at then ED that have received LIPHT by the ALS ambulance teams have a poorer short-term outcome, especially during the first 7 days.

Pulmonary Valve Opening With Two Rotary Left Ventricular Assist Devices for Biventricular Support.

Right ventricular failure is a common complication associated with rotary left ventricular assist device (LVAD) support. Currently, there is no clinically approved long-term rotary right ventricular assist device (RVAD). Instead, clinicians have implanted a second rotary LVAD as RVAD in biventricular support. To prevent pulmonary hypertension, the RVAD must be operated by either reducing pump speed or banding the outflow graft. These modes differ in hydraulic performance, which may affect the pulmonary valve opening (PVO) and subsequently cause fusion, valvular insufficiency, and thrombus formation. This study aimed to compare PVO with the RVAD operated at reduced speed or with a banded outflow graft. Baseline conditions of systemic normal, hypo, and hypertension with severe biventricular failure were simulated in a mock circulation loop. Biventricular support was provided with two rotary VentrAssist LVADs with cardiac output restored to 5 L/min in banded outflow and reduced speed conditions, and systemic and pulmonary vascular resistances (PVR) were manipulated to determine the range of conditions that allowed PVO without causing left ventricular suction. Finally, RVAD sine wave speed modulation (±550 rpm) strategies (co- and counter-pulsation) were implemented to observe the effect on PVO. For each condition, outflow banding had higher PVR (97 ± 20 dyne/s/cm5 higher) for when the pulmonary valve closed compared to reduced speed. In addition, counter-pulsation demonstrated greater PVO than co-pulsation and constant speed. For the purpose of reducing the risks of pulmonary valve insufficiency, fusion, and thrombotic event, this study recommends a RVAD with a steeper H-Q gradient by banding and further exploration of RVAD speed modulation.

[Extracorporeal gas exchange procedures. Differentiated therapy when conventional ventilation reaches the limits]. / Extrakorporale Gasaustauschverfahren. Differenzierte Therapie, wenn die konventionelle Beatmung ihre Grenzen erreicht.

In recent years the range of products for extracorporeal lung support has substantially expanded. In principle systems generating high blood flow and thus enabling oxygenation and decarboxylation, corresponding to classical extracorporeal membrane oxygenation (ECMO), can be distinguished from low-flow systems, enabling decarboxylation only. Technical progress and new data have led to a novel insight into the role of ECMO as an invasive, ultimate therapy in refractory life-threatening lung failure towards a broader range of applications even in spontaneously breathing and awake patients. Indications for extracorporeal decarboxylation, initially thought to enable most protective ventilator settings, have been extended to forms of hypercapnic lung failure and towards avoidance of intubation and mechanical ventilation itself in patients with isolated hypercapnia and failure of non-invasive ventilation. It has to be emphasized however, that due to a still sparse amount of literature and potentially deleterious complications associated with extracorporeal lung support, these kinds of therapies should be reserved for specialized and experienced centers.

Efficacy and safety of percutaneous life support during high-risk percutaneous coronary intervention, refractory cardiogenic shock and in-laboratory cardiopulmonary arrest.

BACKGROUND: High-risk percutaneous coronary interventions (PCI), refractory cardiogenic shock and in-lab cardiac arrest are all associated with significant mortality. Percutaneous left ventricular assist devices (pLVAD) and CPS (cardiopulmonary support) have been used to support such patients. However, the extent to which the use of these devices can improve outcomes in this patient subset is not known. METHODS: We evaluated clinical features, efficacy and safety outcomes in a retrospective cohort of 39 patients, treated either with pLVAD or CPS for support of high-risk PCI, cardiogenic shock or in-lab cardiac arrest. The Tandem-Heart and a new versatile Multifunctional Percutaneous Heart (MPH) system, with both CPS and LVAD capability, were used and assessed. RESULTS: 19 patients received the TandemHeart and 20 received the MPH system. The MPH system was used as a pLVAD in 12 and to provide CPS in 8 patients. Procedural efficacy was 100%. Emergent institution of CPS, in the setting of cardiac arrest, was able to support 7 out of 8 patients and resulted in a 50% survival to hospital discharge rate. Overall, in-hospital death and 30-day major adverse cardiac event rates were 28.2% and 35.9%, respectively. The risk of vascular complications and bleeding was relatively small. CONCLUSIONS: pLVADs are effective in supporting patients during high-risk cardiac (coronary and structural heart) interventions, with a low risk of device-related complications. Further, the expeditious use of CPS in the catheterization laboratory can improve survival in a selected subset of patients with refractory cardiogenic shock and cardiac arrest.

Does early postresuscitation stress hyperglycemia affect 72-hour neurologic outcome? Preliminary observations in the Swine model.

BACKGROUND: Hyperglycemia is common in the early period following resuscitation from cardiac arrest and has been shown to be a predictor of neurologic outcome in retrospective studies. OBJECTIVE: To evaluate neurologic outcome and early postarrest hyperglycemia in a swine cardiac arrest model. METHODS: Electrically induced ventricular fibrillation cardiac arrest was induced in 22 anesthetized and instrumented swine. After 7 minutes, cardiopulmonary resuscitation (CPR) and Advanced Cardiac Life Support were initiated. Twenty-one animals were resuscitated and plasma glucose concentration was measured at intervals for 60 minutes after resuscitation. The animals were observed for 72 hours and the neurologic score was determined at 24-hour intervals. RESULTS: Ten animals had a peak plasma glucose value ≥ 226 mg/dL during the initial 60 minutes after resuscitation. The neurologic scores at 72 hours in these animals (mean score = 0, mean overall cerebral performance category = 1) were the same as those in the animals with a peak plasma glucose value <226 mg/dL. The end-tidal carbon dioxide (CO(2)) values measured during CPR, times to restoration of spontaneous circulation, and epinephrine doses were not significantly different between the animals with a peak glucose concentration ≥ 226 mg/dL and those with lower values. The sample size afforded a power of 95% to detect a 50-point difference from the lowest score (0 points) of the porcine neurologic outcome scale. CONCLUSION: In this standard porcine model of witnessed out-of-hospital cardiac arrest, early postresuscitation stress hyperglycemia did not appear to affect neurologic outcome. During the prehospital phase of treatment and transport, treatment of hyperglycemia by emergency medical services providers may not be warranted.

Nosocomial and community-acquired infection rates of patients treated by prehospital advanced life support compared with other admitted patients.

OBJECTIVES: Nosocomial infections are a large burden to both patients and health care organizations, causing hospitals to take measures in an attempt to reduce microorganism transmission. Patients treated by emergency medical services are one population that has not been studied regarding infection rates. This study examines admitted patients treated by advanced life support (ALS) and their likelihood of having community-acquired and nosocomial infections. METHODS: A retrospective cohort study was conducted of 154 318 admitted patients between 2003 and 2007. Subjects identified as having either community-acquired or nosocomial infections were grouped based on infection type and ALS treatment. The proportion of infected patients among total hospital admissions in each of these groups was calculated and compared using odds ratios (ORs). RESULTS: A total of 5418 patients had at least 1 infection while admitted (3653 nosocomial, 1765 community). The probability of an ALS patient getting a nosocomial infection was 3.20% versus 2.28% for non-ALS patients (OR, 1.42; 95% confidence interval [CI], 1.28-1.57). There was no significant difference in community-acquired infections between ALS and non-ALS-treated groups (1.22% vs 1.14%; OR, 1.08; 95% CI, 0.92-1.26). CONCLUSIONS: Despite having similar rates of community-acquired infections, patients admitted after ALS treatment had significantly greater risk for nosocomial infections. Because causality is not established, it remains unknown whether paramedic interventions contributed to the increased rate. Quite possibly, these patients are more susceptible to virulent organisms; however, prospective research is needed to identify causal relationships. Thus, treatment by ALS can be used as an identifier of patients at an increased risk of acquiring nosocomial infections.

Postcardiotomy extracorporeal life support in adults: the optimal duration of bridging to recovery.

Extracorporeal life support (ECLS) is a temporary support of postcardiotomy cardiogenic shock (PCS). Mortality of postcardiotomy ECLS often results from inability to recognize appropriate patients and bridge them to the next therapy before complications. A two-gated strategy for the second bridge transferring was suggested. From January 2003 to January 2008, 72 patients (mean 60 years) received ECLS for PCS. Indicators of cardiac recovery were identified from the physiological responses to ECLS. The optimal ECLS duration for myocardial recovery was defined as the supporting time of survivors. Forty-one patients weaned off ECLS and 29 survived to discharge. The mean duration of ECLS was 130 hours. Twenty- eight of the 29 survivors weaned off ECLS within 7 days. ECLS >100 hours and a refractory phenomenon of persistent hypotension (mean arterial pressure < 70 mm Hg) with a high adrenergic demand (inotropic equivalent score > 35) under a sufficient ECLS (flow > 50 ml x kg x min, SvO(2) > 80%) >24 hours were independent risk factors of ECLS nonweaning. The benefits of adult postcardiotomy ECLS are controversial after a 7-day support. Bridging should be considered in suitable patients having ECLS >7 days or showing instabilities under an adequate ECLS >24 hours. Continuing ECLS poses a higher risk of mortality.

Sternal fracture and osteomyelitis: an unusual complication of a precordial thump.

Out of hospital cardiac arrest is generally managed by cardiopulmonary resuscitation (CPR) and defibrillation. The precordial thump can also be used in the initial management of witnessed cardiac arrest whilst awaiting direct current cardioversion. However, complications are associated with a precordial thump. We report a case of an out-of-hospital cardiac arrest due to ventricular fibrillation that was treated initially with a precordial thump, which resulted in a sternal fracture and the development of sternal osteomyelitis.

Management of continuous venous gas emboli during extracorporeal life support utilizing the Kolobow gas trap.

Extracorporeal life support (ECLS) with a roller pump system uses a closed cardiopulmonary bypass (CPB) circuit not equipped with a venous reservoir. Hence, gas emboli cannot escape the ECLS circuit, predisposing to clot formation, membrane failure and potential gas embolism. Rarely, some patients may develop a continuous release of gas into the venous circulation from multiple sources. Two pediatric ECLS cases are presented with continuous venous gas embolism. A 'gas trap' was devised by creating a column of fluid erected vertically on the venous line. This allowed gas to rise within the column, separating it from the ECLS circuit, thus, preventing gas from lodging in the membrane.

Overcoming ACLS dogma: how quickly should we change?

The ECC Guidelines 2000 considered interesting new evidence about a pre-defibrillation period of prescribed CPR to increase the probability that the postshock rhythm would be perfusing rather than asystole. If victims of out-of-hospital cardiac arrest have not received bystander CPR before the arrival of the defibrillator, a period of preshock CPR could enhance the value of the shocks. At the end of the year 2000 there was insufficient evidence to recommend any other approach than shock as soon as possible and perform CPR at all other times.