Near-infrared spectroscopy monitoring during out-of-hospital cardiac arrest: can the initial cerebral tissue oxygenation index predict ROSC?

STUDY OBJECTIVES: Near-infrared spectroscopy is a modality that can monitor tissue oxygenation index (TOI) and has potential to evaluate return of spontaneous circulation (ROSC) during cardiopulmonary resuscitation (CPR). This study's objectives were to evaluate whether TOI could be associated with ROSC and used to help guide the decision to either terminate CPR or proceed to extracorporeal CPR (ECPR). METHODS: In this observational study, we assessed the patients with out-of-hospital cardiac arrest with non-traumatic cause receiving CPR on arrival at our ED between 2013 and 2016. TOI monitoring was discontinued either on CPR termination after ROSC was reached or on patient death. Patients were classified into two groups: ROSC and non-ROSC group. RESULTS: Out of 141 patients, 24 were excluded and the remaining 117 were classified as follows: ROSC group (n=44) and non-ROSC group (n=73). ROSC group was significantly younger and more likely to have their event witnessed and bystander CPR. ROSC group showed a higher initial TOI than non-ROSC group (60.5%±17.0% vs 37.9%±13.7%: p<0.01). Area under the curve analysis was more accurate with the initial TOI than without it for predicting ROSC (0.88, 95% CI 0.82 to 0.95 vs 0.79, 95% CI 0.70 to 0.87: p<0.01). TOI cut-off value ≥59% appeared to favour survival to hospital discharge whereas TOI ≤24% was associated with non-ROSC. CONCLUSIONS: This study demonstrated an association between higher initial TOI and ROSC. Initial TOI could increase the accuracy of ROSC prognosis and may be a clinical factor in the decision to terminate CPR and select patients who are to proceed to ECPR.

Toward improved surveillance: the impact of ventilator-associated complications on length of stay and antibiotic use in patients in intensive care units.

BACKGROUND: Hospitals and quality improvement agencies are vigorously focusing on reducing rates of hospital-acquired infection. Ventilator-associated pneumonia (VAP) is notoriously difficult to diagnose and surveillance is thwarted by the subjectivity of many components of the surveillance definition. Alternative surveillance strategies are needed. Ventilator-associated complications (VAC) is a simple, objective measure of respiratory deterioration. METHODS: VAC is defined by increases in fraction of inspired oxygen (FiO(2)) by ≥ 15% or positive end-expiratory pressure (PEEP) by ≥ 2.5 cm H(2)O lasting ≥ 2 days after stable or decreasing FiO(2) or PEEP lasting ≥ 2 days. We retrospectively assessed patients on mechanical ventilation for ≥ 48 hours in our study intensive care unit (ICU) using electronic medical record data. We analyzed the association between VAC and clinical diagnoses, ICU length of stay, duration of mechanical ventilation, antibiotic use, and mortality. RESULTS: We assessed 153 patients with VAC and 390 without VAC. VAC events were associated with significantly increased ICU length of stay, duration of mechanical ventilation, and consumption of broad-spectrum antibiotics but not with longer hospital stays or ICU mortality. CONCLUSIONS: Surveillance for VAP is subjective and labor intensive. VAC is an objective measure which can be readily obtained from electronic records. It is associated with adverse outcomes and increased broad-spectrum antibiotic usage. VAC may be a useful surveillance tool. The utility of VAC prevention bundles merits assessment.

Association between regional cerebral oxygen saturation and outcome of patients with out-of-hospital cardiac arrest: An observational study.

Aim: This study aimed to evaluate the association between cerebral oxygen saturation (StO2) and return of spontaneous circulation (ROSC) in patients with out-of-hospital cardiac arrest (OHCA). Methods: We retrospectively evaluated the data of patients with OHCA to determine the association between ROSC and various StO2 parameters (initial_StO2, final_StO2, mean_StO2, and Δ_StO2 [=final_StO2-initial_StO2]). Time-domain near-infrared spectroscopy was used to determine absolute StO2 values. Results: Of the 108 patients with OHCA, 23 achieved ROSC. Although initial_StO2 values did not differ between the groups, final_StO2, mean_StO2, and Δ_StO2 were higher in the ROSC group than in the non-ROSC group. The cut-off values for initial_StO2, mean_StO2, and Δ_StO2 as predictors of ROSC were 35%, 30%, and 5%, respectively. The odds ratio for ROSC had markedly increased in the Δ_StO2 ≥ 5% subgroup (19.70 [6.06-64.11], p < 0.001). When the change in StO2 (=d_StO2) at 8 min from the initiation of StO2 measurement was assessed, the d_StO2 ≥ 5% subgroup had a higher odds ratio for ROSC than the d_StO2 < 5% subgroup (5.8 [1.78-18.85], p = 0.002), and this tendency was maintained until 20 min. In the evaluation using a two-by-two contingency table with initial_StO2 and Δ_StO2 as two parameters, 61.9% of the patients fell under the categories of initial_StO2 < 35% and Δ_StO2 < 5% and had the lowest rate of ROSC achievement (4.6%). In the Δ_StO2 ≥ 5% subgroup, approximately-two-thirds of the patients achieved ROSC irrespective of the initial_StO2 (initial_StO2 ≥ 35%, 66.7%; initial_StO2 < 35%, 60.0%). Conclusions: Initial_StO2 and Δ_StO2 were associated with the achievement of ROSC.

Predicting the aggravation of coronavirus disease-19 pneumonia using chest computed tomography scans.

Presently, coronavirus disease-19 (COVID-19) is spreading worldwide without an effective treatment method. For COVID-19, which is often asymptomatic, it is essential to adopt a method that does not cause aggravation, as well as a method to prevent infection. Whether aggravation can be predicted by analyzing the extent of lung damage on chest computed tomography (CT) scans was examined. The extent of lung damage on pre-intubation chest CT scans of 277 patients with COVID-19 was assessed. It was observed that aggravation occurred when the CT scan showed extensive damage associated with ground-glass opacification and/or consolidation (p < 0.0001). The extent of lung damage was similar across the upper, middle, and lower fields. Furthermore, upon comparing the extent of lung damage based on the number of days after onset, a significant difference was found between the severe pneumonia group (SPG) with intubation or those who died and non-severe pneumonia group (NSPG) ≥3 days after onset, with aggravation observed when ≥14.5% of the lungs exhibited damage at 3-5 days (sensitivity: 88.2%, specificity: 72.4%) and when ≥20.1% of the lungs exhibited damage at 6-8 days (sensitivity: 88.2%, specificity: 69.4%). Patients with aggravation suddenly developed hypoxemia after 7 days from the onset; however, chest CT scans obtained in the paucisymptomatic phase without hypoxemia indicated that subsequent aggravation could be predicted based on the degree of lung damage. Furthermore, in subjects aged ≥65 years, a significant difference between the SPG and NSPG was observed in the extent of lung damage early beginning from 3 days after onset, and it was found that the degree of lung damage could serve as a predictor of aggravation. Therefore, to predict and improve prognosis through rapid and appropriate management, evaluating patients with factors indicating poor prognosis using chest CT is essential.

Monitoring tissue oxygenation index using near-infrared spectroscopy during pre-hospital resuscitation among out-of-hospital cardiac arrest patients: a pilot study.

BACKGROUND: Tissue oxygenation index (TOI) using the near infrared spectroscopy (NIRS) has been demonstrated as a useful indicator to predict return of spontaneous circulation (ROSC) among out-of-hospital cardiac arrest (OHCA) patients in hospital setting. However, it has not been widely examined based on pre-hospital setting. METHODS: In this prospective observational study, we measured TOI in pre-hospital setting among OHCA patients receiving cardio-pulmonary resuscitation (CPR) during ambulance transportation between 2017 and 2018. Throughout the pre-hospital CPR procedure, TOI was continuously measured. The study population was divided into two subgroups: ROSC group and non-ROSC group. RESULTS: Of the 81 patients included in the final analysis, 26 achieved ROSC and 55 did not achieve ROSC. Patients in the ROSC group were significantly younger, had higher ∆TOI (changes in TOI) (5.8 % vs. 1.3 %; p < 0.01), and were more likely to have shockable rhythms and event witnessed than patients in the non-ROSC group. ∆TOI cut-off value of 5 % had highest sensitivity (65.4 %) and specificity (89.3 %) for ROSC. Patients with a cut-off value ≤-2.0 % did not achieve ROSC and while all OHCA patient with a cut-off value ≥ 8.0 % achieved ROSC. In addition, ROSC group had stronger positive correlation between mean chest compression rate and ∆TOI (r = 0.82) than non-ROSC group (r = 0.50). CONCLUSIONS: This study suggests that ∆ TOI could be a useful indicator to predict ROSC in a pre-hospital setting.

Efficacy of prehospital National Early Warning Score to predict outpatient disposition at an emergency department of a Japanese tertiary hospital: a retrospective study.

OBJECTIVES: The National Early Warning Score (NEWS) was originally developed to assess hospitalised patients in the UK. We examined whether the NEWS could be applied to patients transported by ambulance in Japan. DESIGN: This retrospective study assessed patients and calculated the NEWS from paramedic records. Emergency department (ED) disposition data were categorised into the following groups: discharged from the ED, admitted to the ward, admitted to the intensive care unit (ICU) or died in the ED. The predictive performance of NEWS for patient disposition was assessed using receiver operating characteristic curve analysis. Patient dispositions were compared among NEWS-based categories after adjusting for age, sex and presence of traumatic injury. SETTING: A tertiary hospital in Japan. PARTICIPANTS: Overall, 2847 patients transported by ambulance between April 2017 and March 2018 were included. RESULTS: The mean (±SD) NEWS differed significantly among patients discharged from the ED (n=1330, 3.7±2.9), admitted to the ward (n=1263, 60.3±3.8), admitted to the ICU (n=232, 9.4±4.0) and died in the ED (n=22, 110.7±2.9) (p<0.001). The prehospital NEWS C-statistics (95% CI) for admission to the ward, admission to the ICU or death in the ED; admission to the ICU or death in the ED; and death in the ED were 0.73 (0.72-0.75), 0.81 (0.78-0.83) and 0.90 (0.87-0.93), respectively. After adjusting for age, sex and trauma, the OR (95% CI) of admission to the ICU or death in the ED for the high-risk (NEWS ≥7) and medium-risk (NEWS 5-6) categories was 13.8 (8.9-21.6) and 4.2 (2.5-7.1), respectively. CONCLUSION: The findings from this Japanese tertiary hospital setting showed that prehospital NEWS could be used to identify patients at a risk of adverse outcomes. NEWS stratification was strongly correlated with patient disposition.

Can the global end-diastolic volume index guide fluid management in septic patients? A multicenter randomized controlled trial.

AIM: An index that accurately measures intravascular volume is paramount for the optimal resuscitation of sepsis. Selecting an adequate indicator to substitute for central venous pressure (CVP) has remained an issue. The objective of our study was to compare the usefulness of standard early goal-directed therapy (EGDT) with CVP (EGDT-CVP) and modified EGDT with global end-diastolic volume index (GEDI; EGDT-GEDI) for sepsis. METHODS: This was a multicenter prospective randomized controlled study. All patients with sepsis who were expected to require mechanical ventilator support for a minimum of 48 h were included. The patients were classified into an EGDT-CVP group and an EGDT-GEDI group. All participants underwent the extubation protocol. The primary outcome was the ventilator-free days over a 28-day period. RESULTS: The ventilator-free days was not significantly different between the two groups (P = 0.59). However, the EGDT-GEDI group showed a trend of shorter ventilator support duration (5.1 days [2.0-8.7 days] versus 3.9 days [2.4-5.7 days], P = 0.27) and length of stay in the intensive care unit (7.2 days [3.8-10.7 days] versus 5.1 days [3.7-8.8 days], P = 0.05) and a smaller 3-day infusion balance than the EGDT-CVP group (4,405 mL [1,092-8,163 mL] versus 3,046 mL [830-6,806 mL], P = 0.34), but the differences were not statistically significant. CONCLUSION: Although there was no significant efficacy, EGDT guided by GEDI showed a trend of shorter length of stay in the intensive care unit and lower 3-day infusion balance than the EGDT-CVP group in sepsis. The GEDI monitoring did not appear to improve the ventilator-free days over a 28-day period.

The peripheral lymphocyte count as a predictor of severe COVID-19 and the effect of treatment with ciclesonide.

We investigated whether reduced lymphocyte count, could predict the development of severe COVID-19. We also examined whether ciclesonide could prevent the development of severe COVID-19 among patients with the predictors. This was a retrospective cohort study. Of the 30 included patients, 12, 14, and 4 were allocated to severe pneumonia, non-severe pneumonia, and non-pneumonia groups, respectively. The group of the low level of lymphocyte counts of the sixth day after onset was significantly intubated approximately three days later. The incidence of the severe pneumoniae requiring intubation are significantly lower in the patients treated with ciclesonide than without it (11.18 % vs 83.33 %, p = 0.0033). The lymphocyte count after ciclesonide treatment in the non-severe pneumonia group was significantly higher (p = 0. 0156) than before. The lymphocyte count could be used to identify patients that may develop severe COVID-19. Treatment with ciclesonide may prevent the development of severe COVID-19.

The downside of aggressive volume administration in critically ill patients-"aggressive" may lead to "excessive".

Management of fluid therapy in an intensive care unit (ICU) tends to be volume restriction after initial fluid resuscitation, since it has been the consensus that volume overload is associated with complications and poor clinical outcomes. Aggressive volume administration without cautious monitoring should be avoided in the ICU, because it could lead to excessive volume administration. However, there are limited consensus on determining the completion of resuscitation phase, in other words, when to stop aggressive infusion and initiate infusion restriction.

Early-phase changes of extravascular lung water index as a prognostic indicator in acute respiratory distress syndrome patients.

BACKGROUND: The features of early-phase acute respiratory distress syndrome (ARDS) are leakage of fluid into the extravascular space and impairment of its reabsorption, resulting in extravascular lung water (EVLW) accumulation. The current study aimed to identify how the initial EVLW values and their change were associated with mortality. METHODS: This was a post hoc analysis of the PiCCO Pulmonary Edema Study, a multicenter prospective cohort study that included 23 institutions. Single-indicator transpulmonary thermodilution-derived EVLW index (EVLWi) and conventional prognostic factors were prospectively collected over 48 h after enrollment. Associations between 28-day mortality and each variable including initial (on day 0), mean, maximum, and Δ (subtracting day 2 from day 0) EVLWi were evaluated. RESULTS: We evaluated 192 ARDS patients (median age, 69 years (quartile, 24 years); Sequential Organ Failure Assessment (SOFA) score on admission, 10 (5); all-cause 28-day mortality, 31%). Although no significant differences were found in initial, mean, or maximum EVLWi, Δ-EVLWi was significantly higher (i.e., more reduction in EVLWi) in survivors than in non-survivors (3.0 vs. -0.3 mL/kg, p = 0.006). Age, maximum, and Δ-SOFA scores and Δ-EVLW were the independent predictors for survival according to the Cox proportional hazard model. Patients with Δ-EVLWi > 2.8 had a significantly higher incidence of survival than those with Δ-EVLWi ≤ 2.8 (log-rank test, χ (2) = 7.08, p = 0.008). CONCLUSIONS: Decrease in EVLWi during the first 48 h of ARDS may be associated with 28-day survival. Serial EVLWi measurements may be useful for understanding the pathophysiologic conditions in ARDS patients. A large multination confirmative trial is required.

Difference in pulmonary permeability between indirect and direct acute respiratory distress syndrome assessed by the transpulmonary thermodilution technique: a prospective, observational, multi-institutional study.

BACKGROUND: Acute respiratory distress syndrome (ARDS) is characterized by the increased pulmonary permeability secondary to diffuse alveolar inflammation and injuries of several origins. Especially, the distinction between a direct (pulmonary injury) and an indirect (extrapulmonary injury) lung injury etiology is gaining more attention as a means of better comprehending the pathophysiology of ARDS. However, there are few reports regarding the quantitative methods distinguishing the degree of pulmonary permeability between ARDS patients due to pulmonary injury and extrapulmonary injury. METHODS: A prospective, observational, multi-institutional study was performed in 23 intensive care units of academic tertiary referral hospitals throughout Japan. During a 2-year period, all consecutive ARDS-diagnosed adult patients requiring mechanical ventilation were collected in which three experts retrospectively determined the pathophysiological mechanisms leading to ARDS. Patients were classified into two groups: patients with ARDS triggered by extrapulmonary injury (ARDSexp) and those caused by pulmonary injury (ARDSp). The degree of pulmonary permeability using the transpulmonary thermodilution technique was obtained during the first three intensive care unit (ICU) days. RESULTS: In total, 173 patients were assessed including 56 ARDSexp patients and 117 ARDSp patients. Although the Sequential Organ Failure Assessment (SOFA) score was significantly higher in the ARDSexp group than in the ARDSp group, measurements of the pulmonary vascular permeability index (PVPI) were significantly elevated in the ARDSp group on all days: at day 0 (2.9 ± 1.3 of ARDSexp vs. 3.3 ± 1.3 of ARDSp, p = .008), at day 1 (2.8 ± 1.5 of ARDSexp vs. 3.2 ± 1.2 of ARDSp, p = .01), at day 2 (2.4 ± 1.0 of ARDSexp vs. 2.9 ± 1.3 of ARDSp, p = .01). There were no significant differences in mortality at 28 days, mechanical ventilation days, and hospital length of stay between the two groups. CONCLUSIONS: The results of this study suggest the existence of several differences in the increased degree of pulmonary permeability between patients with ARDSexp and ARDSp. TRIAL REGISTRATION: This report is a sub-group analysis of the study registered with UMIN-CTR (IDUMIN000003627).

Positive clinical risk factors predict a high rate of methicillin-resistant Staphylococcus aureus colonization in emergency department patients.

BACKGROUND: This study was undertaken to determine the rate of methicillin-resistant Staphylococcus aureus (MRSA) colonization predicted by clinical risk factors compared with determination by nasal swab culture and polymerase chain reaction in emergency department patients. METHODS: From November 2009 to March 2011, patients seen in the emergency department were studied prospectively. The risk of MRSA colonization was determined by clinical risk factors, and both surveillance cultures and a polymerase chain reaction assay were performed in each patient. RESULTS: A total of 277 patients was enrolled, and 31.4% (87/277) of patients had a positive surveillance culture or a MRSA polymerase chain reaction assay. The rate of colonization in patients with high-risk factors included the following: past history of colonization/infections, 60.0%; history of previous antibiotic use, 47.2%; more than 30 days hospitalization in the past 3 months, 43.9%; more than 10 days hospitalization in the past 3 months, 41.7%; and a history of hospitalization because of acute illness, 40.0%. CONCLUSION: The prevalence rate of colonization in patients with a high risk of MRSA colonization exceeded 30%. Active surveillance cultures should be considered in patients at high risk for MRSA colonization.