Neuromuscular blocking agents during targeted temperature management for out-of-hospital cardiac arrest patients.

BACKGROUND: Neuromuscular blocking agents (NMBAs) can control shivering during targeted temperature management (TTM) of patients with cardiac arrest. However, the effectiveness of NMBA use during TTM on neurologic outcomes remains unclear. We aimed to evaluate the association between NMBA use during TTM and favorable neurologic outcomes after out-of-hospital cardiac arrest (OHCA). MATERIALS AND METHODS: A multicenter, prospective, observational cohort study from 2019 to 2021. It included OHCA patients who received TTM after hospitalization. We conducted overlap weight propensity-score analyses after multiple imputation to evaluate the effect of NMBAs during TTM. The primary outcome was a favorable neurological outcome, defined as a cerebral performance category of 1 or 2 at discharge. Subgroup analyses were conducted based on initial monitored rhythm and brain computed tomography findings. RESULTS: Of the 516 eligible patients, 337 received NMBAs during TTM. In crude analysis, the proportion of patients with favorable neurological outcome was significantly higher in the NMBA group (38.3% vs. 16.8%; risk difference (RD): 21.5%; 95% confidence interval (CI): 14.0% to 29.1%). In weighted analysis, a significantly higher proportion of patients in the NMBA group had a favorable neurological outcome compared to the non-NMBA group (32.7% vs. 20.9%; RD: 11.8%; 95% CI: 1.2% to 22.3%). In the subgroup with an initial shockable rhythm and no hypoxic encephalopathy, the NMBA group showed significantly higher proportions of favorable neurological outcomes. CONCLUSIONS: The use of NMBAs during TTM was significantly associated with favorable neurologic outcomes at discharge for OHCA patients. NMBAs may have benefits in selected patients with initial shockable rhythm and without poor prognostic computed tomography findings.

Association between changes in disease severity and physical function after surviving a critical illness: A multicentre retrospective observational study.

BACKGROUND: Whilst disease severity can significantly impact functional outcomes, the ability to predict the scale of this impact has not been consistent. AIM: We aimed to investigate whether changes in disease severity within the first 48 h of ICU admission are more strongly associated with physical dysfunction than a single-time assessment of disease severity at ICU admission. METHODS: A multicentre retrospective study in seven tertiary ICUs in Japan, including all consecutive adult ICU patients (>48 h ICU stay) between September 2019 and February 2020. The primary outcome was physical function defined as the Barthel Index, which is an ordinal scale (0-100: larger indicates better function) to measure physical independence and performance. The association between Barthel Index score at hospital discharge and the Sequential Organ Failure Assessment (SOFA) scores, measured at ICU admission, the highest recorded score within 48 h of ICU admission, and the level of change between these two timepoints were investigated in multivariable analysis. RESULTS: A total of 199 patients were included. Median SOFA score at ICU admission and the highest recorded score within the first 48 h were 6 (interquartile range: 5-10) and 8 (interquartile range: 6-11), respectively. A quarter of patients had a Barthel Index score of 60 or less at hospital discharge. The highest SOFA score within 48 h of ICU admission and the level of change in SOFA scores between ICU admission and the highest recorded score within 48 h were significantly associated with lower Barthel Index scores at hospital discharge. No significant association was identified with regard to Barthel Index scores and SOFA score at ICU admission. An increase in SOFA score of 1 or more within the first 48 h of ICU admission was the threshold to predict a Barthel Index score of 60 or less at hospital discharge. Larger changes in SOFA scores over the first 48 h of ICU admission were also significantly associated with smaller changes in Barthel Index scores from ICU discharge to hospital discharge. CONCLUSIONS: The level of change in SOFA score between ICU admission and the highest recorded score within the first 48 h of ICU stay can more accurately predict the presence of physical dysfunction at hospital discharge than a single-time assessment of disease severity at ICU admission. The larger worsening in SOFA potentially indicates lower recovery after a critical illness.

Evaluating the impact of ELSO guideline adherence on favorable neurological outcomes among patients requiring extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest.

AIM: Selecting the appropriate candidates for extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA) is challenging. Previously, the Extracorporeal Life Support Organization (ELSO) guidelines suggested the example of inclusion criteria. However, it is unclear whether patients who meet the inclusion criteria of the ELSO guidelines have more favorable outcomes. We aimed to evaluate the relationship between the outcomes and select inclusion criteria of the ELSO guidelines. METHODS: We conducted a post-hoc analysis of a multicenter prospective study conducted between 2019 and 2021. Adult patients with OHCA treated with ECPR were included. The primary outcome was a favorable neurological outcome (Cerebral Performance Category of 1 or 2) at 30 days. An ELSO criteria score was assigned based on four criteria: (i) age < 70 years; (ii) witness; (iii) bystander CPR; and (iv) low-flow time (<60 min). Subgroup analysis based on initial cardiac rhythm was performed. RESULTS: Among 9,909 patients, 227 with OHCA were included. The proportion of favorable neurological outcomes according to the number of ELSO criteria met were: 0.0% (0/3), 0 points; 0.0% (0/23), 1 point; 3.0% (2/67), 2 points; 7.3% (6/82), 3 points; and 16.3% (7/43), 4 points. A similar tendency was observed in patients with an initial shockable rhythm. However, no such relationship was observed in those with an initial non-shockable rhythm. CONCLUSION: Patients who adhered more closely to specific inclusion criteria of the ELSO guidelines demonstrated a tendency towards a higher rate of favorable neurological outcomes. However, the relationship was heterogeneous according to initial rhythm.

Association between gasping and survival among out-of-hospital cardiac arrest patients undergoing extracorporeal cardiopulmonary resuscitation: The SOS-KANTO 2017 study.

Aim: This study aimed to assess the association between gasping and survival among out-of-hospital cardiac arrest (OHCA) patients requiring extracorporeal cardiopulmonary resuscitation (ECPR). Methods: This prospective, multicenter, observational study was conducted between 2019 and 2021. We categorized adult patients requiring ECPR into those with or without gasping prior to hospital arrival. The primary outcome was the 30-day survival. We performed multivariable logistic regression analyses fitted with generalized estimating equations and subgroup analyses based on the initial rhythm and age. Results: Of the 9,909 patients with OHCA requiring ECPR, 332 were enrolled in the present study, including 92 (27.7%) and 240 (72.3%) with and without gasping, respectively. The 30-day survival was higher in patients with gasping than in those without gasping (35.9% [33/92] vs. 16.2% [39/240]). In the logistic regression analysis, gasping was significantly associated with improved 30-day survival (adjusted odds ratio: 3.01; 95% confidence interval, 1.64-5.51). Subgroup analyses demonstrated similar trends in patients with an initial non-shockable rhythm and older age. Conclusions: Gasping was associated with improved survival in OHCA patients requiring ECPR, even those with an initial non-shockable rhythm and older age. Clinicians may select the candidates for ECPR appropriately based on the presence of gasping.

Veno-venous extracorporeal membrane oxygenation for acute respiratory distress syndrome caused by nitrogen dioxide inhalation: A case report.

Background: Nitrogen dioxide (NO2) is known to cause lung injury, but there is no established treatment for acute respiratory distress syndrome (ARDS) caused by NO2 inhalation. Case Presentation: A 35-year-old man was accidentally exposed to NO2 fumes and presented to the emergency department. On admission, his oxygen saturation was 87% on ambient air and he was diagnosed with ARDS caused by NO2 inhalation and immediately intubated; however, hypoxemia and hypercapnia were not ameliorated. Hence, veno-venous extracorporeal membrane oxygenation (V-V ECMO) was introduced and the ventilator settings were set for lung-protective ventilation. Methylprednisolone was also administered. After the initiation of these treatments, oxygenation gradually improved. Therefore, ECMO was weaned off on day 11 and he was extubated on day 12. Conclusion: Lung injury caused by NO2 inhalation can cause ARDS, and lung-protective ventilation with V-V ECMO induction, as well as glucocorticoid administration, may be effective for this condition.

Post-intensive care syndrome follow-up system after hospital discharge: a narrative review.

BACKGROUND: Post-intensive care syndrome (PICS) is the long-lasting impairment of physical functions, cognitive functions, and mental health after intensive care. Although a long-term follow-up is essential for the successful management of PICS, few reviews have summarized evidence for the efficacy and management of the PICS follow-up system. MAIN TEXT: The PICS follow-up system includes a PICS follow-up clinic, home visitations, telephone or mail follow-ups, and telemedicine. The first PICS follow-up clinic was established in the U.K. in 1993 and its use spread thereafter. There are currently no consistent findings on the efficacy of PICS follow-up clinics. Under recent evidence and recommendations, attendance at a PICS follow-up clinic needs to start within three months after hospital discharge. A multidisciplinary team approach is important for the treatment of PICS from various aspects of impairments, including the nutritional status. We classified face-to-face and telephone-based assessments for a PICS follow-up from recent recommendations. Recent findings on medications, rehabilitation, and nutrition for the treatment of PICS were summarized. CONCLUSIONS: This narrative review aimed to summarize the PICS follow-up system after hospital discharge and provide a comprehensive approach for the prevention and treatment of PICS.

Instruments to assess post-intensive care syndrome assessment: a scoping review and modified Delphi method study.

BACKGROUND: The assessment of post-intensive care syndrome (PICS) is challenging due to the numerous types of instruments. We herein attempted to identify and propose recommendations for instruments to assess PICS in intensive care unit (ICU) survivors. METHODS: We conducted a scoping review to identify PICS follow-up studies at and after hospital discharge between 2014 and 2022. Assessment instruments used more than two times were included in the modified Delphi consensus process. A modified Delphi meeting was conducted three times by the PICS committee of the Japanese Society of Intensive Care Medicine, and each score was rated as not important (score: 1-3), important, but not critical (4-6), and critical (7-9). We included instruments with ≥ 70% of respondents rating critical and ≤ 15% of respondents rating not important. RESULTS: In total, 6972 records were identified in this scoping review, and 754 studies were included in the analysis. After data extraction, 107 PICS assessment instruments were identified. The modified Delphi meeting reached 20 PICS assessment instrument recommendations: (1) in the physical domain: the 6-min walk test, MRC score, and grip strength, (2) in cognition: MoCA, MMSE, and SMQ, (3) in mental health: HADS, IES-R, and PHQ-9, (4) in the activities of daily living: the Barthel Index, IADL, and FIM, (5) in quality of life: SF-36, SF-12, EQ-5D-5L, 3L, and VAS (6), in sleep and pain: PSQI and Brief Pain Inventory, respectively, and (7) in the PICS-family domain: SF-36, HADS, and IES-R. CONCLUSION: Based on a scoping review and the modified Delphi method, 20 PICS assessment instruments are recommended to assess physical, cognitive, mental health, activities of daily living, quality of life, sleep, and pain in ICU survivors and their families.

Prevalence and Risk Factor Analysis of Post-Intensive Care Syndrome in Patients with COVID-19 Requiring Mechanical Ventilation: A Multicenter Prospective Observational Study.

INTRODUCTION: Post-intensive care syndrome (PICS) is an emerging problem in critically ill patients and the prevalence and risk factors are unclear in patients with severe coronavirus disease 2019 (COVID-19). This multicenter prospective observational study aimed to investigate the prevalence and risk factors of PICS in ventilated patients with COVID-19 after ICU discharge. METHODS: Questionnaires were administered twice in surviving patients with COVID-19 who had required mechanical ventilation, concerning Barthel Index, Short-Memory Questionnaire, and Hospital Anxiety and Depression Scale scores. The risk factors for PICS were examined using a multivariate logistic regression analysis. RESULTS: The first and second PICS surveys were obtained at 5.5 and 13.5 months (mean) after ICU discharge, with 251 and 209 patients completing the questionnaires and with a prevalence of PICS of 58.6% and 60.8%, respectively, along with the highest percentages of cognitive impairment. Delirium (with an odds ratio of (OR) 2.34, 95% CI 1.1-4.9, and p = 0.03) and the duration of mechanical ventilation (with an OR of 1.29, 95% CI 1.05-1.58, and p = 0.02) were independently identified as the risk factors for PICS in the first PICS survey. CONCLUSION: Approximately 60% of the ventilated patients with COVID-19 experienced persistent PICS, especially delirium, and required longer mechanical ventilation.

Risk factors for bleeding complications during venovenous extracorporeal membrane oxygenation as a bridge to recovery.

BACKGROUND: Bleeding complications during venovenous extracorporeal membrane oxygenation (V-V ECMO) can be critical. However, there is limited information on the associated risk factors. This study investigated the risk factors for bleeding complications during V-V ECMO as a bridge to recovery. METHODS: This single-center retrospective study enrolled 59 patients (bleeding and non-bleeding groups) who received V-V ECMO from 2012 to 2020, to evaluate whether peak activated partial thromboplastin time (APTT) value, lowest platelet count, and mobilization to sitting on the edge of the bed during V-V ECMO were risk factors for bleeding complications, defined according to the Extracorporeal Life Support Organization guidelines. Age, sex, body mass index, Sequential Organ Failure Assessment score, and ECMO duration before bleeding complications were covariates in the multivariate logistic regression analysis. RESULTS: Thirty-one (53%) participants experienced 36 bleeding complications; the ECMO cannulation site, gastrointestinal tract, and nasopharyngeal region were the most common bleeding sites. The use of transfusion products and length of ECMO and intensive care unit stay were significantly and medical costs were non-significantly increased in the bleeding group. Peak APTT (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.05, p < 0.01) was significantly associated whereas the lowest platelet count (OR 0.96, 95% CI 0.82-1.13, p = 0.66) was unassociated with bleeding complications during ECMO. Achieving mobilization (OR 0.14, 95% CI 0.02-1.17, p = 0.07) decreased the trend of risk for bleeding complications. CONCLUSIONS: Peak APTT might be an independent modifiable factor for bleeding complications during V-V ECMO. The protective effect of mobilization during V-V ECMO requires further investigation.