Refractory ventricular fibrillation secondary to hyperkalemia resuscitated with extracorporeal membrane oxygenation: A case report.

The routine use of extracorporeal cardiopulmonary resuscitation (ECPR) is not recommended for patients with cardiac arrest. However, ECPR is considered for selected patients with cardiac arrest of reversible cause. Extracorporeal membrane oxygenation (ECMO) provides temporary cardiopulmonary support and adequate perfusion to the end organs, thereby shortening ischemic organ time and minimizing complications. One indication for ECPR therapy is prolonged ventricular fibrillation despite optimal conventional CPR. Here, we report a successful recovery case from ECPR, in which the patient suffered from refractory ventricular fibrillation and was predisposed to severe hyperkalemia. Ventricular fibrillation failed to respond despite prolonged conventional CPR and defibrillation management for 32 min. After successfully initiating ECPR 54 min after cardiac arrest, spontaneous circulation returned sooner. He demonstrated clear consciousness after treatment and was discharged without any neurological disability on day 11.

Pan-Genotypic Direct-Acting Antiviral Agents for Undetermined or Mixed-Genotype Hepatitis C Infection: A Real-World Multi-Center Effectiveness Analysis.

Although the pan-genotypic direct-acting antiviral regimen was approved for treating chronic hepatitis C infection regardless of the hepatitis C virus (HCV) genotype, real-world data on its effectiveness against mixed-genotype or genotype-undetermined HCV infection are scarce. We evaluated the real-world safety and efficacy of two pan-genotypic regimens (Glecaprevir/Pibrentasvir and Sofosbuvir/Velpatasvir) for HCV-infected patients with mixed or undetermined HCV genotypes from the five hospitals in the Changhua Christian Care System that commenced treatment between August 2018 and December 2020. This retrospective study evaluated the efficacy and safety of pan-genotypic direct-acting antiviral (DAA) treatment in adults with HCV infection. The primary endpoint was the sustained virological response (SVR) observed 12 weeks after completing the treatment. Altogether, 2446 HCV-infected patients received the pan-genotypic DAA regimen, 37 (1.5%) patients had mixed-genotype HCV infections and 110 (4.5%) patients had undetermined HCV genotypes. The mean age was 63 years and 55.8% of our participants were males. Nine (6.1%) patients had end-stage renal disease and three (2%) had co-existing hepatomas. We lost one patient to follow-up during treatment and one more patient after treatment. A total of four patients died. However, none of these losses were due to treatment-related side effects. The rates of SVR12 for mixed-genotype and genotype-undetermined infections were 97.1% and 96.2%, respectively, by per-protocol analyses, and 91.9% and 92.7% respectively, by intention-to-treat population analyses. Laboratory adverse events with grades ≥3 included anemia (2.5%), thrombocytopenia (2.5%), and jaundice (0.7%). Pan-genotypic DAAs are effective and well-tolerated for mixed-genotype or genotype-undetermined HCV infection real-world settings.

Real-World Experience of Chronic Hepatitis C-Related Compensated Liver Cirrhosis Treated with Glecaprevir/Pibrentasvir: A Multicenter Retrospective Study.

BACKGROUND: Glecaprevir/pibrentasvir is a protease inhibitor-containing pangenotypic direct-acting antiviral regimen that has been approved for the treatment of chronic hepatitis C. The present study aimed to evaluate the safety and efficacy of glecaprevir/pibrentasvir in patients with compensated cirrhosis in a real-world setting. METHODS: We evaluated the real-world safety and efficacy of glecaprevir/pibrentasvir in patients with compensated cirrhosis from five hospitals in the Changhua Christian Care System, who underwent treatment between August 2018 and October 2020. The primary endpoint was a sustained virological response observed 12 weeks after completion of the treatment. RESULTS: Ninety patients, including 70 patients who received the 12-week therapy and 20 patients who received the 8-week therapy, were enrolled. The mean age of the patients was 65 years, and 57.8% of the patients were males. Sixteen (17.8%) patients had end-stage renal disease, and 15 (16.7%) had co-existing hepatoma. The hepatitis C virus genotypes 1 (40%) and 2 (35.6%) were most common. The common side effects included anorexia (12.2%), pruritus (7.8%), abdominal discomfort (7.8%), and malaise (7.8%). Laboratory adverse grade ≥3 events included anemia (6.3%), thrombocytopenia (5.1%), and jaundice (2.2%). The overall sustained virological response rates were 94.4% and 97.7% in the intention-to-treat and per-protocol analyses, respectively. CONCLUSIONS: the glecaprevir/pibrentasvir treatment regimen was highly effective and well tolerated among patients with compensated cirrhosis in the real-world setting.

Strategy for the Micro-Elimination of Hepatitis C among Patients with Diabetes Mellitus-A Hospital-Based Experience.

Hepatitis C virus (HCV) infection can induce insulin resistance, and patients with diabetes mellitus (DM) have a higher prevalence of HCV infection. Patient outcomes improve after HCV eradication in DM patients. However, HCV micro-elimination targeting this population has not been approached. Little is known about using electronic alert systems for HCV screening among patients with DM in a hospital-based setting. We implemented an electronic reminder system for HCV antibody screening and RNA testing in outpatient departments among patients with DM. The screening rates and treatment rates at different departments before and after system implementation were compared. The results indicated that the total HCV screening rate increased from 49.3% (9505/19,272) to 78.2% (15,073/19,272), and the HCV-RNA testing rate increased from 73.4% to 94.2%. The anti-HCV antibody seropositive rate was 5.7%, and the HCV viremia rate was 62.7% in our patient population. The rate of positive anti-HCV antibodies and HCV viremia increased with patient age. This study demonstrates the feasibility and usefulness of an electronic alert system for HCV screening and treatment among DM patients in a hospital-based setting.

Diagnosis and management of jejunoileal diverticular haemorrhage: An update on the experience in a single centre.

INTRODUCTION: Jejunoileal diverticular haemorrhage is a rare disease that is difficult to diagnose and treat. Despite advances in endoscopic technology, recommendations on diagnosis and management for jejunoileal diverticular haemorrhage have remained unchanged and these new options have not been compared against traditional surgical management. MATERIALS AND METHODS: We retrospectively reviewed the diagnosis, management, and outcome for jejunoileal diverticular haemorrhage cases at our institution over the past 20 years. Data were organized and analysed by chi-square test, student t-test and Kaplan-Meier survival analysis. RESULTS: The most utilised diagnostic procedure was computed tomography, followed by enteroscopy, angiography, small bowel flow-through and surgery. Primary treatments included, in a decreasing order, medical therapy, surgery, endoscopy and radiology. Surgical treatment was not associated with rebleeding, but it did result in longer hospital stays and larger blood transfusions than non-surgical treatments. The bleeding-related mortality rate was very low. Notably, there was also little change in the diagnosis and treatment between decades. CONCLUSION: We presented our experience with the diagnosis and management of jejunoileal diverticular haemorrhage, as well as long-term follow-up after treatments that have not been reported previously. Surgical treatment continues to dominate management for jejunoileal diverticular haemorrhage, but we support increasing the role of endoscopy for select patient groups.

Can we predict patient outcome before extracorporeal membrane oxygenation for refractory cardiac arrest?

BACKGROUND: Refractory cardiac arrest resistant to conventional cardiopulmonary resuscitation (C-CPR) has a poor outcome. Although previous reports showed that extracorporeal cardiopulmonary resuscitation (E-CPR) can improve the clinical outcome, there are no clinically applicable predictors of patient outcome that can be used prior to the implementation of E-CPR. We aimed to evaluate the use of clinical factors in patients with refractory cardiac arrest undergoing E-CPR to predict patient outcome in our institution. METHODS: This is a single-center retrospective study. We report 112 patients presenting with refractory cardiac arrest resistant to C-CPR between January 2012 and November 2017. All patients received E-CPR for continued life support when a cardiogenic etiology was presumed. Clinical factors associated with patient outcome were analyzed. Significant pre-ECMO clinical factors were extracted to build a patient outcome risk prediction model. RESULTS: The overall survival rate at discharge was 40.2, and 30.4% of patients were discharged with good neurologic function. The six-month survival rate after hospital discharge was 36.6, and 25.9% of patients had good neurologic function 6 months after discharge. We stratified the patients into low-risk (n = 38), medium-risk (n = 47), and high-risk groups (n = 27) according to the TLR score (low-flow Time, cardiac arrest Location, and initial cardiac arrest Rhythm) that we derived from pre-ECMO clinical parameters. Compared with the medium-risk and high-risk groups, the low-risk group had better survival at discharge (65.8% vs. 42.6% vs. 0%, p < 0.0001) and at 6 months (60.5% vs. 38.3% vs. 0%, p = 0.0001). The low-risk group also had a better neurologic outcome at discharge (50% vs. 31.9% vs. 0%, p = 0.0001) and 6 months after discharge (44.7% vs. 25.5% vs. 0%, p = 0.0003) than the medium-risk and high-risk groups. CONCLUSIONS: Patients with refractory cardiac arrest receiving E-CPR can be stratified by pre-ECMO clinical factors to predict the clinical outcome. Larger-scale studies are required to validate our observations.

Successful resuscitation with extracorporeal membrane oxygenation support for refractory ventricular fibrillation caused by left main coronary artery occlusion.

Refractory ventricular fibrillation with cardiac arrest caused by occlusion of the left main coronary artery may rapidly become fatal. In this report, we describe the case of a 70-year-old male who presented to emergency department with chest pain. Electrocardiogram showed ST-segment elevation in leads aVR and aVL and ST-segment depression in leads v3, v4, v5, v6, 2, 3, and aVF. Occlusion of the left main coronary artery was suspected. While waiting for percutaneous coronary intervention, the patient experienced sudden refractory ventricular fibrillation with cardiac arrest. In the emergency department, resuscitation of a patient with refractory ventricular fibrillation caused by occlusion of the left main coronary artery and ongoing cardiopulmonary resuscitation is a clinical challenge. Resuscitation with extracorporeal membrane oxygenation support was initiated approximately 35 min after prolonged conventional cardiopulmonary resuscitation. Emergency coronary angiography showed almost total occlusion of the left main coronary artery. Percutaneous coronary intervention with a stent restored coronary perfusion. The patient was discharged on day 6 without serious sequelae or neurological deficits.

Massive Pulmonary Embolism Mimicking Acute Myocardial Infarction: Successful use of extracorporeal membrane oxygenation support as bridge to diagnosis.

Prolonged cardiac arrest with pulseless electrical activity (PEA) results in death if its aetiology cannot be corrected immediately. We describe the case of a 75-year-old man with chest pain and his electrocardiogram (ECG) revealing ST-segment elevation in leads II, III, and aVf. Inferior wall myocardial infarction was subsequently diagnosed. Before performing emergency coronary angiography, however, a sudden cardiac arrest with PEA developed and the patient was placed on advanced cardiac life support. Oxygenation support for the extracorporeal membrane was initiated approximately 65min after prolonged cardiopulmonary resuscitation. Emergency coronary arteriogram showed no obstructive lesions in the right coronary artery. This result, however, was not consistent with the ECG findings, and thus, a massive pulmonary embolism was suspected. Subsequent pulmonary artery angiography showed severe emboli in bilateral branches of the pulmonary arteries. Catheter-directed thrombolysis with urokinase was administered, which ultimately failed, and surgical embolectomy was performed with extracorporeal membrane oxygenation support. After the above intervention, the patient was discharged on hospital day 60 without any sequelae or neurological deficits.

Managing cardiac arrest with refractory ventricular fibrillation in the emergency department: Conventional cardiopulmonary resuscitation versus extracorporeal cardiopulmonary resuscitation.

AIM: Refractory ventricular fibrillation, resistant to conventional cardiopulmonary resuscitation (CPR), is a life threatening rhythm encountered in the emergency department. Although previous reports suggest the use of extracorporeal CPR can improve the clinical outcomes in patients with prolonged cardiac arrest, the effectiveness of this novel strategy for refractory ventricular fibrillation is not known. We aimed to compare the clinical outcomes of patients with refractory ventricular fibrillation managed with conventional CPR or extracorporeal CPR in our institution. METHOD: This is a retrospective chart review study from an emergency department in a tertiary referral medical center. We identified 209 patients presenting with cardiac arrest due to ventricular fibrillation between September 2011 and September 2013. Of these, 60 patients were enrolled with ventricular fibrillation refractory to resuscitation for more than 10 min. The clinical outcome of patients with ventricular fibrillation received either conventional CPR, including defibrillation, chest compression, and resuscitative medication (C-CPR, n = 40) or CPR plus extracorporeal CPR (E-CPR, n = 20) were compared. RESULTS: The overall survival rate was 35%, and 18.3% of patients were discharged with good neurological function. The mean duration of CPR was longer in the E-CPR group than in the C-CPR group (69.90 ± 49.6 min vs 34.3 ± 17.7 min, p = 0.0001). Patients receiving E-CPR had significantly higher rates of sustained return of spontaneous circulation (95.0% vs 47.5%, p = 0.0009), and good neurological function at discharge (40.0% vs 7.5%, p = 0.0067). The survival rate in the E-CPR group was higher (50% vs 27.5%, p = 0.1512) at discharge and (50% vs 20%, p = 0. 0998) at 1 year after discharge. CONCLUSIONS: The management of refractory ventricular fibrillation in the emergency department remains challenging, as evidenced by an overall survival rate of 35% in this study. Patients with refractory ventricular fibrillation receiving E-CPR had a trend toward higher survival rates and significantly improved neurological outcomes than those receiving C-CPR.

Prolonged pulseless electrical activity: successful resuscitation using extracorporeal membrane oxygenation.

Pulseless electrical activity (PEA) can rapidly transform into sudden cardiac death, if the etiology cannot be identified and corrected immediately. The clinical challenge is how to resuscitate the patient with prolonged PEA. We present a case of a 51-year-old man with PEA due to acute myocardial infarction caused by total occlusion of the main coronary artery, which was refractory to prolonged conventional cardiopulmonary resuscitation. Extracorporeal membrane oxygenation was initiated approximately 75 minutes after prolonged cardiopulmonary resuscitation; this achieved a sustained return of spontaneous circulation, which permitted adequate time for subsequent coronary intervention. He was discharged on day 16 without any further sequelae or neurologic deficits.

Cecal pneumatosis intestinalis in obstructing sigmoid cancer: emergency metallic stenting.

An 85-year-old man presented with acute abdomen. Abdominal computed tomography revealed obstructing sigmoid colon cancer with pneumatosis intestinalis of the ascending colon. A surgeon was consulted for colonic obstruction with impending sepsis, who declined surgery considering the patient's advanced age. After discussion, the patient consented for emergent endoscopic metallic colonic stent placement. Complete obstruction of the lumen was observed at the sigmoid colon, followed by successful metallic colonic stent placement through the obstructed area. Normal stool passage was achieved after this, and the patient survived the 9-month follow-up period. Acute colonic obstruction from obstructive colon cancer requires emergency management, wherein the presence of pneumatosis intestinalis poses a high risk of cecal perforation. Emergency endoscopic colonic metallic stent placement provides an alternative therapy, particularly when surgery is not feasible, as described here.

Prolonged cardiac arrest: successful resuscitation with extracorporeal membrane oxygenation.

Extracorporeal membrane oxygenation support can extend the duration of cardiopulmonary resuscitation (CPR), but prolonged CPR may develop multiple organ failure, and neurologic death is a major complication. We present a case of a 35-year-old woman with fulminant myocarditis secondary to H1N1 influenza A infection, in which cardiac arrest was refractory to prolonged conventional CPR. Extracorporeal membrane oxygenation was initiated 250 minutes after prolonged CPR. Extracorporeal membrane oxygenation provided cardiopulmonary life support for prolonged CPR, achieving a sustained return of spontaneous circulation, which allowed further treatment and made a good recovery with intact cerebral performance.

Cardiac arrest with refractory ventricular fibrillation: a successful resuscitation using extracorporeal membrane oxygenation.

Extracorporeal membrane oxygenation (ECMO) is a form of a mechanical cardiopulmonary life-support system and an adjunct to prolonged cardiac resuscitation. The ECMO results in good outcomes for patients with in-hospital cardiac arrest. We present a case of a 52-year-old man with out-of-hospital cardiac arrest caused by refractory ventricular fibrillation. The patient was referred to our emergency department with suspected acute coronary syndrome. Cardiac arrest with ventricular fibrillation was refractory to conventional cardiopulmonary resuscitation. In this case, the ECMO­cardiopulmonary resuscitation provided cardiopulmonary life support for out-of-hospital cardiac arrest, achieving a sustained return of spontaneous circulation that allowed prompt percutaneous coronary intervention and a good recovery.