The Role of Extracorporeal Membrane Oxygenation ECMO in Accidental Hypothermia and Rewarming in Out-of-Hospital Cardiac Arrest Patients-A Literature Review.

Accidental hypothermia, defined as an unintentional drop of the body core temperature below 35 °C, is one of the causes of cardiocirculatory instability and reversible cardiac arrest. Currently, extracorporeal life support (ECLS) rewarming is recommended as a first-line treatment for hypothermic cardiac arrest patients. The aim of the ECLS rewarming is not only rapid normalization of core temperature but also maintenance of adequate organ perfusion. Veno-arterial extracorporeal membrane oxygenation (ECMO) is a preferred technique due to its lower anticoagulation requirements and potential to prolong circulatory support. Although highly efficient, ECMO is acknowledged as an invasive treatment option, requiring experienced medical personnel and is associated with the risk of serious complications. In this review, we aimed to discuss the clinical aspects of ECMO management in severely hypothermic cardiac arrest patients.

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Recommendations on the use of prehabilitation, i.e. comprehensive preparation of the patient for surgery.

Prehabilitation is a comprehensive preparation of a patient for primarily surgical treatments. Its aim is to improve the patient'sgeneral condition so as to reduce the risk of complications and ensure the fastest possible recovery to full health. Thebasic components of prehabilitation include: improvement of nutritional status, appropriate exercises to improve functioning,psychological support, and help in eliminating addictions. Other important aspects of prehabilitation are: increasinghemoglobin levels in patients with anemia, achieving good glycemic control in patients with diabetes, treatment or stabilizationof any concurrent disorders, or specialist treatment associated with a specific procedure (endoprostheses, ostomyprocedure). This article organizes and outlines the indications for prehabilitation, its scope, duration, and the method to conductit. Experts of various specialties related to prehabilitation agree that it should be an element of surgery preparationwhenever possible, especially in patients with co-existing medical conditions who have been qualified for major procedures.Prehabilitation should be carried out by interdisciplinary teams, including family physicians and various specialists in thetreatment of comorbidities. Prehabilitation requires urgent systemic and reimbursement solutions.

Early postoperative hemodynamic instability after heart transplantation - incidence and metabolic indicators.

BACKGROUND: Primary graft dysfunction (PGD) is the main cause of death in the first 30 days after heart transplantation (HTX), accounting for approximately 40% of mortality. The study's primary aim was to assess the incidence of PGD, following the International Society for Heart and Lung Transplantation consensus, and to compare it with the incidence of significant postoperative hypotension despite administration of high-dose inotropes and vasoconstrictors. The secondary aim of the study was to determine changes in biochemical markers that accompany the phenomenon. METHODS: Forty-five patients who underwent HTX between 2010 and 2015 were enrolled in this study, and detailed hemodynamic and metabolic data from the first 48 postoperative hours were collected and analyzed. Hemodynamic instability was defined as significant postoperative hypotension (mean arterial pressure (MAP) < 60 mmHg) combined with a high inotrope score (> 10). Data for long-term mortality were obtained from the population registration office. RESULTS: PGD incidence was relatively low (17.8%); however, hemodynamic instability was common (40%). Among unstable patients, MAP was insufficient for end-organ perfusion (51.4 ± 9.5 mmHg) but no decrease in left ventricular function was observed (cardiac index, 2.65 ± 0.6 l/min/m2; left ventricular ejection fraction, 52.9 ± 15.5%). Within this group, mean systemic vascular resistance index (961 ± 288 dyn*s*m2/cm5) was low despite receiving high doses of vasoactive agent (norepinephrine 0.21 (0.06-0.27) µg/kg/min during first 24 h postoperatively and 0.21 (0.01-0.27) µg/kg/min during next 24 h postoperatively). After HTX, serum lactate levels were initially significantly higher in patients with hemodynamic instability (p = 0.002); however, impaired lactate clearance was not observed (p = 0.366), and lactate levels normalized within the first 24 h postoperatively. Postoperative hemodynamic instability altered the long-term outcome and increased 5-year mortality after HTX (p = 0.034). CONCLUSIONS: Hemodynamic instability is a more common phenomenon than PGD. Only early postoperative serum lactate levels correspond with hemodynamic instability following HTX. Postoperative hemodynamic instability is associated with poor long-term survival among HTX recipients.

Prognostic role of perioperative acid-base disturbances on the risk of Clostridioides difficile infection in patients undergoing cardiac surgery.

BACKGROUND: It is unclear whether acid-base balance disturbances during the perioperative period may impact Clostridium difficile infection (CDI), which is the third most common major infection following cardiac surgery. We hypothesized that perioperative acid-base abnormalities including lactate disturbances may predict the probability of incidence of CDI in patients after cardiac procedures. METHODS: Of the 12,235 analyzed patients following cardiac surgery, 143 (1.2%) developed CDI. The control group included 200 consecutive patients without diarrhea, who underwent cardiac procedure within the same period of observation. Pre-, intra and post-operative levels of blood gases, as well as lactate and glucose concentrations were determined. Postoperatively, arterial blood was drawn four times: immediately after surgery and successively; 4, 8 and 12 h following the procedure. RESULTS: Baseline pH was lower and PaO2 was higher in CDI patients (p < 0.001 and p = 0.001, respectively). Additionally, these patients had greater base deficiency at each of the analyzed time points (p < 0.001, p = 0.004, p = 0.012, p = 0.001, p = 0.016 and p = 0.001, respectively). Severe hyperlactatemia was also more common in CDI patients; during the cardiac procedure, 4 h and 12 h after surgery (p = 0.027, p = 0.004 and p = 0.001, respectively). Multivariate logistic regression analysis revealed that independent risk factors for CDI following cardiac surgery were as follows: intraoperative severe hyperlactatemia (OR 2.387, 95% CI 1.155-4.933, p = 0.019), decreased lactate clearance between values immediately and 12 h after procedure (OR 0.996, 95% CI 0.994-0.999, p = 0.013), increased age (OR 1.045, 95% CI 1.020-1.070, p < 0.001), emergent surgery (OR 2.755, 95% CI 1.565-4.848, p < 0.001) and use of antibiotics other than periprocedural prophylaxis (OR 2.778, 95% CI 1.690-4.565, p < 0.001). CONCLUSION: This study is the first to show that perioperative hyperlactatemia and decreased lactate clearance may be predictors for occurrence of CDI after cardiac surgery.

Clostridioides difficile infection after cardiac surgery: Assessment of prevalence, risk factors and clinical outcomes-retrospective study.

BACKGROUND: Clostridioides difficile infection (CDI) is the most common cause of hospital-acquired diarrhea. There is little available data regarding risk factors of CDI for patients who undergo cardiac surgery. The study evaluated the course of CDI in patients after cardiac surgery. METHODS: Of 6,198 patients studied, 70 (1.1%) developed CDI. The control group consisted of 73 patients in whom CDI was excluded. Perioperative data and clinical outcomes were analyzed. RESULTS: Patients with CDI were significantly older in comparison to the control group (median age 73.0 vs 67.0, P = 0.005) and more frequently received proton pump inhibitors, statins, ß-blockers and acetylsalicylic acid before surgery (P = 0.008, P = 0.012, P = 0.004, and P = 0.001, respectively). In addition, the presence of atherosclerosis, coronary disease and history of malignant neoplasms correlated positively with the development of CDI (P = 0.012, P = 0.036 and P = 0.05, respectively). There were no differences in the type or timing of surgery, aortic cross-clamp and cardiopulmonary bypass time, volume of postoperative drainage and administration of blood products between the studied groups. Relapse was more common among overweight patients with high postoperative plasma glucose or patients with higher C-reactive protein during the first episode of CDI, as well as those with a history of coronary disease or diabetes mellitus (P = 0.005, P = 0.030, P = 0.009, P = 0.049, and P = 0.025, respectively). Fifteen patients died (21.4%) from the CDI group and 7 (9.6%) from the control group (P = 0.050). Emergent procedures, prolonged stay in the intensive care unit, longer mechanical ventilation and high white blood cell count during the diarrhea were associated with higher mortality among patients with CDI (P = 0.05, P = 0.041, P = 0.004 and P = 0.007, respectively). CONCLUSIONS: The study did not reveal any specific cardiac surgery-related risk factors for development of CDI.

Postoperative Serum Lactate Levels for In-Hospital Mortality Prediction Among Heart Transplant Recipients.

BACKGROUND Hyperlactatemia is a common phenomenon following cardiac surgeries and is associated with prolonged ICU stay and higher morbidity and mortality rates, but such analyses have never focused on patients undergoing heart transplantation (HTX), in whom hyperlactatemia defined with the traditional threshold is observed in nearly every individual. The present study aimed to assess the prognostic value and clinical usefulness of postoperative serum lactate level measurements for in-hospital mortality prediction following HTX. MATERIAL AND METHODS Forty-six consecutive patients who underwent HTX in the Department of Cardiovascular Surgery and Transplantology between 2010 and 2015 were enrolled into a retrospective analysis. Serum lactate level measurements within the first 48 h after HTX were obtained from arterial blood gas analyses, that were routinely conducted every 6 h. Lactate clearance was determined for each patient individually throughout 3 different time frames: the first 24-h (Lac clear 0-24) and second 24-h period (Lac clear 24-48), and the first 48 h after surgery (Lac clear 0-48). RESULTS The ICU admission serum lactate levels differed between the deceased and survivors (7.6 vs. 4.3 mmol/L; p=0.000). Among all tested postoperative lactate level measurements, only the measurement taken upon ICU admission predicted in-hospital mortality (OR 1.94 95% CI [1.09-3.43]; p=0.024). The receiving operating characteristic (ROC) curve for in-hospital mortality was constructed for ICU admission measurement, with the optimal cut-off point estimated at 7.0 mmol/L. CONCLUSIONS Serum lactate level measurement upon ICU admission can be used as a predictive parameter for in-hospital mortality among heart transplant recipients. Values greater than 7.0 mmol/L can predict in-hospital mortality with 90% accuracy.

Successful Defibrillation at a Core Temperature of 18.2 Degrees Celsius.

Both the temperature at which defibrillation can be effectively used and how often it should be repeated in severe accidental hypothermia have not been definitely established. Current recommendations are based mainly on expert opinion and suggest withholding defibrillation after 3 shocks when the core temperature is below 30°C (86°F). However, growing evidence supports the effectiveness of defibrillation in patients with a core temperature below 30°C (86°F). We present a case of successful defibrillation of a 54-y-old, severely hypothermic patient with a core temperature of 18.2°C (64.8°F). The shock was delivered automatically by an implanted cardioverter-defibrillator shortly after the implementation of extracorporeal rewarming. The patient survived and was discharged from the hospital neurologically intact. It might be reasonable to consider defibrillation attempts in severely hypothermic patients despite current guidelines to the contrary. Increasing coronary perfusion using extracorporeal circulation may result in a better response to defibrillation.

Postoperative hyperlactatemia and serum lactate level trends among heart transplant recipients.

BACKGROUND: Advanced heart failure (HF), that affects 10% of the HF population, is associated with high mortality rate, meeting 50% at 1-year from diagnosis. For these individuals, heart transplantation (HTX) remains the ultimate and the gold-standard treatment option. Serum lactate level measurements has been proven useful for determining the outcome following other cardiac surgeries and among critically ill patients. Increased serum lactate levels are expected following HTX; however, no detailed analysis has been yet performed in this population. The research aims to estimate the prevalence of hyperlactatemia and describe early postoperative serum lactate level trends among heart transplant recipients. MATERIALS AND METHODS: Forty-six consecutive patients, who underwent HTX between 2010 and 2015, were enrolled into the retrospective analysis. Serum lactate level measurements within first 48 hours post-HTX were obtained every 6 hours from routinely conducted arterial blood gas analyses. The threshold for hyperlactatemia was considered at >1.6 mmol/L, according to upper limit of normal, based on internal laboratory standardization. The highest observed measurement within the observation, regardless of the time point of observation was determined for each patient individually and was appointed as Peak Value. RESULTS: Consecutively measured serum lactate levels differed in time (p = 0.000), with the initial increase and subsequent decrease of the values (4.3 vs. 1.9 mmol/l; p = 0.000). The increase from the baseline level to the Peak Value was statistically significant (4.3 vs. 7.0 mmol/l; p = 0.000). Various serum lactate level trends were identified, with one or more hyperlactatemia episodes. Eventually, 50% of the individuals had normal serum lactate levels at the end of the study, and hyperlactatemia was observed in the other half. CONCLUSIONS: Throughout the observation, all of the patients experienced at least one episode of hyperlactatemia, with the median Peak Value of 7.0 (4.5-8.4) mmol/L. Various serum lactate level trends can be identified in post-HTX patients. Further research is required to determine the clinical usefulness of newly reported serum lactate level trends among heart transplant recipients.

Prognostic Factors for Nonasphyxia-Related Cardiac Arrest Patients Undergoing Extracorporeal Rewarming - HELP Registry Study.

OBJECTIVE: Extracorporeal rewarming is the treatment of choice for patients who had hypothermic cardiac arrest, allowing for best neurologic outcome. The authors' goal was to identify factors associated with survival in nonasphyxia-related hypothermic cardiac arrest patients undergoing extracorporeal rewarming. DESIGN: All 38 cardiac surgery departments in Poland were encouraged to report consecutive hypothermic cardiac arrest patients treated with extracorporeal life support. All variables collected were analyzed in order to compare survivor and nonsurvivor groups. The parameters available at the initiation of extracorporeal rewarming were considered as potential predictors of survival in a logistic regression model. The primary outcome was survival to discharge from the intensive care unit. The secondary outcome was neurologic status. SETTING: Multicenter retrospective study. PARTICIPANTS: Ninety-eight cases in the final analysis. INTERVENTIONS: All patients in nonasphyxia-related hypothermic cardiac arrest rewarmed with extracorporeal life support. MEASUREMENTS AND MAIN RESULTS: The survival rate was 53.1%, and 94.2% of survivors had favorable neurologic outcome. The lowest reported core temperature with cerebral performance category scale 1 was 11.8°C. A univariate analysis identified 3 variables associated with survival, namely: age, initial arterial pH, and lactate concentration. In a multivariate analysis, 2 independent predictors of survival were age (0.957; 95% confidence interval [CI] 0.924-0.991) and lactates (0.871; 95% CI 0.789-0.961). The area under the receiver operating characteristics curve for this fitted model was 0.71; 95% CI 0.602-0.817. CONCLUSIONS: Favorable survival with good neurologic outcome in nonasphyxiated hypothermic patients treated with extracorporeal life support was reported. Age and initial lactate level are independently associated with survival.

One-day, sequential carotid artery stenting followed by cardiac surgery in patients with severe carotid and cardiac disease.

Optimal management of patients with internal carotid artery (ICA) stenosis concurrent with severe cardiac disease remains undefined. The aim of this study is to evaluate the safety and feasibility of the one-day, sequential approach by carotid artery stenting (CAS) immediately followed by cardiac surgery. The study included 70 consecutive patients with symptomatic > 50% or ⩾ 80% asymptomatic ICA stenosis coexisting with severe coronary/valve disease, who underwent one-day, sequential CAS + cardiac surgery. The majority of patients (85.7%) had CSS class III or IV angina and 10% had non-ST elevation myocardial infarction. The EuroSCORE II risk was 2.4% (IQR 1.69-3.19%). All CAS procedures were performed according to the 'tailored' algorithm with a substantial use of proximal neuroprotection devices of 44.3%. Closed-cell (75.7%) and mesh-covered (18.6%) stents were implanted in most cases. The majority of patients underwent isolated coronary artery bypass grafting (88.6%) or isolated valve replacement (7.1%). No major adverse cardiac and cerebrovascular events (MACCE) occurred at the CAS stage. There were three (4.3%) perioperative MACCE: one myocardial infarction and two deaths. All MACCE were related to cardiac surgery and were due to the high surgical risk profile of the patients. Up to 30 days, no further MACCE were observed. No perioperative or 30-day neurological complications occurred. In this patient series, one-day, sequential CAS and cardiac surgery was relatively safe and did not result in neurological complications. Thus, a strategy of preoperative CAS could be considered for patients with severe or symptomatic ICA stenosis who require urgent cardiac surgery.

[Hypothermia - e-learning course dedicated to lifeguards, border guards and policemen].

OBJECTIVE: Introduction: The paper covers the problem of pre-hospital hypothermia recognition and management among lifeguards, board guards and policemen, who took part in e-learning course Academy of Hypothermia. PATIENTS AND METHODS: Materials and methods: The subject of analysis were the results of pre-test, post-test and lesson revision tests of Academy of Hypothermia e-learning course, taken by lifeguards (WOPR), board guards (SG) and policemen (POL). RESULTS: Results: 221 participants were enrolled in a study. Lifeguards were significantly younger than other groups (mean age respectively: 34,13 years SG; 32,95 years POL and 23,31 years WOPR; p< 0,001) and median work experience (respectively: 10 years SG, 8 years POL and 2 years WOPR; p< 0,001). Pre-test analysis showed significant difference in results of board guards and lifeguards (median and q1-q3 values respectively: 61%; 43%-92% for SG and 53%; 46%-69% for WOPR, p = 0,02). Post-test analysis proved significantly better results of board guards (median and q1-q3 values: 92%; 77%-100%) in comparison to policemen (median and q1-q3 values: 85%; 69%-92%) and lifeguards (median and q1-q3 values: 85%; 69%-92%). Extra analysis was performed for lesson revision tests. The least correct answers were noted in lessons covering the topic of post trauma hypothermia and the algorithm of hypothermia casualty management. CONCLUSION: Conclusions: Lifeguards have least knowledge on accidental hypothermia than board guards and policemen. E-learning course is an effective tool for improving knowledge of hypothermia recognition and treatment.

Ten-year follow-up after combined coronary artery bypass grafting and transmyocardial laser revascularization in patients with disseminated coronary atherosclerosis.

Coronary artery disease involving heavily calcified lesions has been associated with worse short- and long-term outcomes including increased mortality. This paper aims to evaluate long-term survival benefit when CABG + transmyocardial laser revascularization (TMLR) are performed on the hearts of patients with disseminated coronary atherosclerosis (DCA). This novel retrospective study was conducted between 1997 and 2002 and followed 86 patients with ischemic heart disease and severe DCA who underwent TMLR using a Holmium:YAG laser and/or CABG. There were 46 patients who had CABG plus TMLR on at least one heart wall ("combined therapy group") and 40 patients who had CABG or TMLR separately on at least one heart wall ("single therapy group"). For the whole group, actuarial survival at 10 years was 78.3% in the combined group compared to 72.5% in the single therapy group (p = 0.535). Ten-year survival in the combined vs. single therapy group for the anterior heart walls was 100 vs. 72.2% (p = 0.027). For the lateral and posterior heart walls were 73.7 vs. 73.3% (p = 0.97) and 84.2 vs. 72% (p = 0.27), respectively. Kaplan-Meier survival analysis showed benefit only for the anterior heart wall (F Cox test, p = 0.103). Single therapy procedures on all heart walls (odds ratio 1.736, p = 0.264) or on the anterior heart wall only (odds ratio 3.286, p = 0.279) were found to be predictors of 10-year late mortality. Combined therapy (TMLR + CABG) provides benefit for perioperative mortality and long-term survival only when provided on the anterior heart wall. For patients with disseminated coronary atherosclerosis, cardiac mortality was found to be increased when followed up 6 years later, regardless of the therapy applied.

[Early complications of extracorporeal rewarming].

BACKGROUND: Application of appropriate method of rewarming is the key issue in the management of hypothermia. Severely hypothermic, life-threatened patients require advanced extracorporeal rewarming. Such procedure is not free of possible complications, yet, if the qualification for extracorporeal rewarming is correct, it guarantees restoration of hemodynamic stability, and what is the most important, leads to full neurologic recovery, even with long resuscitation times. THE AIM: The summary of complications observed during extracorporeal rewarming with ECMO in severely hypothermic patients and analysis of their prevalence in managed group. Presentation of possible etiology and means of prevention of anticipated complications and suggested strategies of their treatment. MATERIALS AND METHODS: Retrospective analysis of medical records of all 33 patients with severe accidental hypothermia, accepted for extracorporeal rewarming with venoarterial ECMO. CONCLUSIONS: Based on reviewed medical records of severely hypothermic patients subjected to extracorporeal rewarming it was possible to identify these complications of management, that are hypothermia related, and which are not to be seen in patients treated with ECMO for other reasons.

Difficulties in funding of VA-ECMO therapy for patients with severe accidental hypothermia.

BACKGROUND: Severe accidental hypothermia is defined as a core temperature below 28 Celsius degrees. Within the last years, the issue of accidental hypothermia and accompanying cardiac arrest has been broadly discussed and European Resuscitation Council (ERC) Guidelines underline the importance of Extracorporeal Rewarming (ECR) in treatment of severely hypothermic victims. The study aimed to evaluate the actual costs of ECR with VA-ECMO and of further management in the Intensive Care Unit of patients admitted to the Severe Accidental Hypothermia Centre in Cracow, Poland. METHODS: We carried out the economic analysis of 31 hypothermic adults in stage III-IV (Swiss Staging) treated with VA ECMO. Twenty-nine individuals were further managed in the Intensive Care Unit. The actual treatment costs were evaluated based on current medication, equipment, and dressing pricing. The costs incurred by the John Paul II Hospital were then collated with the National Health Service (NHS) funding, assessed based on current financial contract. RESULTS: In most of the cases, the actual treatment cost was greater than the funding received by around 10000 PLN per patient. The positive financial balance was achieved in only 4 (14%) individuals; other 25 cases (86%) showed a financial loss. CONCLUSION: Performed analysis clearly shows that hospitals undertaking ECR may experience financial loss due to implementation of effective treatment recommended by international guidelines. Thanks to new NHS funding policy since January 2017 such loss can be avoided, what shall encourage hospitals to perform this expensive, yet effective method of treatment.

Clinical course and prognostic factors of patients in severe accidental hypothermia with circulatory instability rewarmed with veno-arterial ECMO - an observational case series study.

BACKGROUND: Recently, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has become the rewarming treatment of choice in hypothermic cardiac arrest. The detailed indications for extracorporeal rewarming in non-arrested, severely hypothermic patients with circulatory instability have not been established yet. The primary purpose of the study was a preliminary analysis of all aspects of the treatment process, as well as initial identification of mortality risk factors within the group of severely hypothermic patients, treated with arteriovenous extracorporeal membrane oxygenation (VA-ECMO). The secondary aim of the study was to evaluate efficacy of VA-ECMO in initial 6-h period of treatment METHODS: From July 2013 to June 2016, thirty one hypothermic patients were accepted for extracorporeal rewarming at Severe Accidental Hypothermia Center, Cracow. Thirteen patients were identified with circulatory instability and were enrolled in the study. The evaluation took into account patients' condition on admission, the course of therapy, and changes in laboratory and hemodynamic parameters. RESULTS: Nine out of 13 analyzed patients survived (69%). Patients who died were older, had lower both systolic and diastolic pressure, and had increased creatinine an potassium levels on admission. In surviving patients, arterial blood gases parameters (pH, BE, HCO3) and lactates would normalize more quickly. Their potassium level was lower on admission as well. The values of the core temperature on admission were comparable. Although normothermia was achieved in 92% of patients, none of them had been weaned-off VA-ECMO in the first 6 h of treatment. DISCUSSION AND CONCLUSIONS: In our preliminary study more pronounced markers of cardiocirculatory instability and organ hypoperfusion were observed in non-survivors. Future studies on indications to extracorporeal rewarming in severely hypothermic, non-arrested patients should focus on the extent of hemodynamic disturbances. Short term (<6 h) treatment in severe hypothermic, non-arrested patients seems to be not clinically appropriate.