Mild Hypercapnia or Normocapnia after Out-of-Hospital Cardiac Arrest.

BACKGROUND: Guidelines recommend normocapnia for adults with coma who are resuscitated after out-of-hospital cardiac arrest. However, mild hypercapnia increases cerebral blood flow and may improve neurologic outcomes. METHODS: We randomly assigned adults with coma who had been resuscitated after out-of-hospital cardiac arrest of presumed cardiac or unknown cause and admitted to the intensive care unit (ICU) in a 1:1 ratio to either 24 hours of mild hypercapnia (target partial pressure of arterial carbon dioxide [Paco2], 50 to 55 mm Hg) or normocapnia (target Paco2, 35 to 45 mm Hg). The primary outcome was a favorable neurologic outcome, defined as a score of 5 (indicating lower moderate disability) or higher, as assessed with the use of the Glasgow Outcome Scale-Extended (range, 1 [death] to 8, with higher scores indicating better neurologic outcome) at 6 months. Secondary outcomes included death within 6 months. RESULTS: A total of 1700 patients from 63 ICUs in 17 countries were recruited, with 847 patients assigned to targeted mild hypercapnia and 853 to targeted normocapnia. A favorable neurologic outcome at 6 months occurred in 332 of 764 patients (43.5%) in the mild hypercapnia group and in 350 of 784 (44.6%) in the normocapnia group (relative risk, 0.98; 95% confidence interval [CI], 0.87 to 1.11; P = 0.76). Death within 6 months after randomization occurred in 393 of 816 patients (48.2%) in the mild hypercapnia group and in 382 of 832 (45.9%) in the normocapnia group (relative risk, 1.05; 95% CI, 0.94 to 1.16). The incidence of adverse events did not differ significantly between groups. CONCLUSIONS: In patients with coma who were resuscitated after out-of-hospital cardiac arrest, targeted mild hypercapnia did not lead to better neurologic outcomes at 6 months than targeted normocapnia. (Funded by the National Health and Medical Research Council of Australia and others; TAME ClinicalTrials.gov number, NCT03114033.).

Addition of Vitamin C Does Not Decrease Neuron-Specific Enolase Levels in Adult Survivors of Cardiac Arrest-Results of a Randomized Trial.

Background and Objectives: Survival with favorable neurologic outcomes after out-of-hospital cardiac arrest (OHCA) remains elusive. Post-cardiac arrest syndrome (PCAS) involves myocardial and neurological injury, ischemia-reperfusion response, and underlying pathology. Neurologic injury is a crucial determinant of survival and functional outcomes, with damage caused by free radicals among the responsible mechanisms. This study explores the feasibility of adding intravenous vitamin C to the treatment of OHCA survivors, aiming to mitigate PCAS. Vitamin C, a nutrient with antioxidative and free radical-scavenging properties, is often depleted in critically ill patients. Materials and Methods: This randomized, double-blinded trial was conducted at a tertiary-level university hospital with adult OHCA survivors. Participants received either standard care or the addition of 1.5 g of intravenous vitamin C every 12 h for eight consecutive doses. Neurologic injury was assessed using neuron-specific enolase (NSE) levels, with additional clinical and laboratory outcomes, such as enhanced neuroprognostication factors, inflammatory markers, and cardiac parameters. Results: NSE levels were non-significantly higher in patients who received vitamin C compared to the placebo group (55.05 µg/L [95% confidence interval (CI) 26.7-124.0] vs. 39.4 µg/L [95% CI 22.6-61.9], p > 0.05). Similarly, a non-significantly greater proportion of patients in the vitamin C group developed myoclonus in the first 72 h. We also observed a non-significantly shorter duration of mechanical ventilation, fewer arrhythmias, and reduced length of stay in the intensive care unit in the group of patients who received vitamin C (p = 0.031). However, caution is warranted in interpretation of our results due to the small number of participants. Conclusions: Our findings suggest that intravenous vitamin C should not be used outside of clinical trials for OHCA survivors. Due to the small sample size and conflicting results, further research is needed to determine the potential role of vitamin C in post-cardiac arrest care.

Attitudes towards the Utilization of Intraosseous Access in Prehospital and Emergency Medicine Nursing Personnel.

Background and Objectives: Insertion of an intraosseous access device enables intravascular access for critically ill patients in a prehospital and emergency department setting even when intravenous access is not possible. The aim of our study was to assess the attitudes of prehospital and emergency department nursing staff towards the utilization of intraosseous access devices. Materials and Methods: We performed quantitative research using a closed-ended structured questionnaire distributed to prehospital unit and associated emergency department nursing staff serving a population of around 200,000 inhabitants. Results: We distributed 140 questionnaires, and 106 were returned and completed. Of these, 69 (65.1%) respondents needed more than three attempts to achieve peripheral intravenous access at least once in the last year and 29 (27.4%) required central venous access because of impossible intravenous access. In the last five years, 8 (7.5%) respondents used endotracheal route for administration of medications. Despite this, only 48 (45.3%) of respondents have ever used the intraosseous route. Also, 79 (74.5%) respondents received at least some training in obtaining IO access; however, 46 (43.4%) answered that education regarding intraosseous access is not sufficient, and 92 (86.8%) answered that they wanted additional training regarding intraosseous access. Conclusions: Prehospital and emergency department nursing staff are aware of the importance of intraosseous access and understand the need for additional education and certification in this field.

Tissue adhesives for peripheral intravenous catheter securement: A prospective randomized controlled pilot trial.

BACKGROUND: In some patients securing the peripheral intravenous cannula (PIVC) with a standard adhesive dressing can be difficult because of sweat or other body fluids. The aim of our study was to evaluate the use of tissue adhesives alone as a means to secure PIVCs inserted in the emergency department. METHODS: We performed a prospective interventional pilot study from November 2019 to May 2020 in a medical emergency department of an urban tertiary hospital. Patients were randomized to two groups: tissue adhesives (TA) or adhesive dressing (AD) group. After randomization we followed them until day 4. RESULTS: There were no significant differences between TA and AD groups in the rate of unplanned removal of PIVCs in the first 72 h (57.1% vs. 45.8%, p = 0.29), the rate of unplanned removal of PIVCs in the ED (0% vs. 2.1%, p = 1.00), the rate of unplanned removal of PIVC in the first 24 h (42.8% vs. 35.4%, p = 0.52), as well as in the rate of phlebitis (7.1% vs. 14.6%, p = 0.34) and the rate of any blood-stream infection (0% vs. 0%, p = 1.00). CONCLUSION: We did not observe any significant differences when PIVCs inserted in the emergency department were secured with tissue adhesives alone, compared to standard adhesive dressings. We observed a high rate of unplanned removal of PIVCs, necessitating further research to determine more reliable ways of securing PIVCs.

Successful use of combined blood purification techniques in splenectomised patient with septic shock in streptococcus pneumoniae infection - a case report.

BACKGROUND: Septic cardiomyopathy represents cardiac impairment in sepsis and is a part of systemic involvement in sepsis. Cytokine storm is responsible for septic shock and for myocardial dysfunction of potentially reversible septic cardiomyopathy. Several case reports and case series demonstrated successful removal of circulating cytokines by combined blood purification techniques. In this way, septic shock and survival of septic patients improved. However, the evidences for reversal of myocardial dysfunction are rare. CASE PRESENTATION: We present a patient with a history of chemotherapy for coat cell lymphoma, splenectomy and autologous bone marrow transplantation, who suffered severe pneumococcal sepsis, septic shock and septic cardiomyopathy, resistant to pharmacological therapy. Combined blood purification techniques 36 h after the start of treatment successfully decreased Interleukin-6 level, lactacidosis, the need for vasopressors to maintain normotension, improved systolic function of the left ventricle and clinical outcome. CONCLUSIONS: Our case suggests that combined blood purification techniques initiated even 36 h after the start of treatment successfully removed inflammatory cytokines, reversed circulatory failure and improved left ventricular systolic function in pneumococcal sepsis.

GPIIb-IIIa Receptor Inhibitors in Acute Coronary Syndrome Patients Presenting With Cardiogenic Shock and/or After Cardiopulmonary Resuscitation.

BACKGROUND: Data on the use of GPIIb-IIIa receptor inhibitors (GPI) in acute coronary syndrome (ACS) patients presenting with cardiogenic shock and/or after cardiopulmonary resuscitation is sparse. The aim of the study was to establish the possible influence of the adjunctive use of GPI on 30-day and 1-year mortality in these high-risk patients. METHODS: Acute coronary syndrome patients (261), who presented with cardiogenic shock and/or were cardiopulmonary resuscitated on admission, were analysed. Groups receiving (170 patients) and not receiving (91 patients) GPI were compared regarding 30-day and 1-year mortality. RESULTS: The unadjusted all-cause 30-day and 1-year mortality were similar in patients receiving GPI and those not receiving GPI [79 patients (46.5%) vs 50 patients (54.9%) at 30 days; ns, 91 patients (53.5%) vs. 55 (61.1%) at 1 year; ns]. After the adjustment for baseline and clinical characteristics, the adjunctive usage of GPI was identified as an independent prognostic factor in lower 30-day mortality (adjusted OR: 0.41; 95%CI: 0.20 to 0.84; p=0.015) and 1-year mortality (HR 0.62; 95%CI 0.39-0.97; p=0.037). Age, left main PCI and major bleeding, were also identified as independent prognostic factors in worse 30-day and 1-year mortality. In addition, Thrombolysis in Myocardial Infarction (TIMI) flow 0/1 pre-percutaneous coronary intervention (PCI) predicted a worse 1-year outcome. Novel oral P2Y12 receptor antagonists predicted better 30-day and 1-year survival. CONCLUSION: Our study suggests that the adjunctive usage of GPI may be beneficial in this high-risk group of patients in whom a delayed onset of action of oral antiplatelet therapy would be expected.

Therapeutic hypothermia and inhalation anesthesia in a patient with severe pneumococcal meningitis and secondary cardiac arrest.

Therapeutic hypothermia was associated with increased mortality in patients with severe bacterial meningitis in a large randomized trial. It still remains a treatment strategy for comatose survivors of cardiac arrest. There are several potential advantages of inhalational anesthetics as long-term sedation agents compared to intravenous sedation, however, uncontrollable increases of intracranial pressure were observed in neurocritical patients. Here we present a patient with severe bacterial meningitis and secondary cardiac arrest where therapeutic hypothermia and inhalational anesthesia were successfully used. A 59-year old female with a history of a vestibular Schwannoma surgery on the left side was admitted with signs of meningitis. Within minutes after admission, she further deteriorated with respiratory arrest, followed by cardiac arrest. She remained comatose after return of spontaneous circulation. The standard treatment of severe meningitis (steroids, antibiotics, insertion of intracranial pressure probe and external ventricular drainage) along with therapeutic hypothermia and inhalational anesthesia were implemented. Intracranial pressure remained stable and daily neurological examination was possible without being confounded by concurrent sedation. She was discharged home without neurological sequelae after 27days. In selected patients with meningitis, therapeutic hypothermia may still present a treatment option, and the long-term use of inhalational anesthetics could be appropriate with concomitant intracranial pressure monitoring.

The introduction of an esophageal heat transfer device into a therapeutic hypothermia protocol: A prospective evaluation.

BACKGROUND: Temperature management is a recommended part of post-resuscitation care of comatose survivors of cardiac arrest. A number of methods exist for temperature management, all of which have limitations. We aimed to evaluate the performance and ease of use of a new esophageal heat transfer device (EHTD; Advanced Cooling Therapy, Chicago, IL, USA) for temperature management of adult survivors of cardiac arrest. METHODS: We performed a prospective study from March to June 2015. Our standard protocol uses servo-controlled water blankets supplemented with ice-cold saline in order to attain goal temperature (32°C-34°C) within 1 hour. We substituted the EHTD for our usual water blankets, then recorded temperature over time and adverse effects. MAIN FINDINGS: A total of 14 patients were treated, with mean age 65.1±13.7 years, and median weight 75.5 (70; 83) kg. Initial temperature was 35.3±1.2°C. Mean cooling rate during the induction phase was 1.12±0.62°C/h, time to target temperature was 60 (41; 195) min and the volume of iced fluids infused was 1607±858 ml (as compared with 2-2.5L historically). The percentage of time outside target temperature range during the maintenance phase was 6.5% (0.0; 29.0). Rewarming rate was 0.22 (0.18; 0.31)°C/h. No major adverse effects were observed. CONCLUSION: Using the EHTD, our patient population attained goal temperatures in one hour, the volume of ice-cold saline required to attain this cooling rate was decreased by one-third, and experienced a low percentage of time outside target temperature range and no major adverse effects.

Difference Between Bladder and Esophageal Temperatures in Mild Induced Hypothermia.

BACKGROUND: Mild induced hypothermia is an established treatment strategy for comatose survivors of cardiac arrest. The goal of the induction phase of mild induced hypothermia is to cool the patient's core body temperature to 32°-34°C. OBJECTIVE: The main goal of this study was to compare temperature changes measured in the esophagus and urinary bladder in survivors of cardiac arrest undergoing mild induced hypothermia using cold saline infusion. METHODS: We performed a prospective study in a 12-bed adult medical intensive care unit at a tertiary level hospital in comatose adult survivors of nontraumatic cardiac arrest admitted from January to April 2012. Paired temperature readings from bladder and esophageal probes were recorded every 5 min for 95 min (20 readings). Cold fluid infusion was terminated when the measured temperature from either of the probes reached 33.9°C. Factorial repeated-measures analysis of variance was used to determine the effect of time and site of measurement on temperature readings. RESULTS: Measurements were performed in 8 patients. Target temperature was achieved in 33 ± 15 min in the esophagus and in 63 ± 15 min in the bladder (p = 0.006). We discovered a significant interaction effect (p < 0.001) between time and site of measurement, indicating that temperature changes differently depending on the site of measurement, with esophageal temperatures decreasing faster than temperatures measured in urinary bladder. CONCLUSIONS: Our results indicate that esophageal temperature measurements show a faster response rate compared to temperature measured in the bladder when cold saline infusion is used to induce mild hypothermia.

SeptiFast real-time PCR for detection of bloodborne pathogens in patients with severe sepsis or septic shock.

Several studies have been performed investigating the role of a real-time multiplex polymerase chain reaction assay LightCycler SeptiFast with inconsistent results. In prospective evaluation of adult patients with severe sepsis or septic shock SeptiFast assay and blood culture results were compared regarding concordance, the impact of SeptiFast assay on antimicrobial therapy adjustment, time to results and the role of SeptiFast assay as a marker of disease severity. 63 blood sample sets were collected from 57 patients. 51 (80.9%) results were concordant negative and 7 (11.1%) concordant posi- tive. In one (1.6%) sample set blood culture was positive and SeptiFast assay negative, in three (4.8%) sample sets with negative blood cultures pathogens were detected by SeptiFast assay and in one (1.6%)patient an additional pathogen was detected by SeptiFast assay. If blood culture is considered as "gold standard", 1 (1.6%) SeptiFast false negative and 4 (6.3%) false positive results were identified (sensitivity 87.5%, specificity 92.6%, negative predictive value 97.8%). Antibiotic treatment was adjusted according to SeptiFast assay in 4 (6.3%) cases. Time to final results was significantly shorter with SeptiFast assay (32 +/- 23 h vs. 97 +/- 28 h, p < 0.0001). Positive SeptiFast assay was not associated with higher mortality, C-reactive protein orprocalcitonin (p = 0.74, p = 0.44 and p = 0.12, respectively). According to our results SeptiFast assay can be used as a valuable add-on to blood culture in diagnostic workup ofpatients with severe sepsis and septic shock but it cannot replace the blood culture.

Adverse Events during Prone Positioning of Patients with COVID-19 during a Surge in Hospitalizations-Results of an Observational Study.

This study aimed to determine the prevalence of adverse events in mechanically ventilated adults with COVID-19 who have undergone prone positioning. A total of 100 patients were included retrospectively; 60% were males, the mean age was 64.8 ± 9.1 years, and hospital mortality was 47%. In all, we recorded 118 removals of catheters and tubes in 66 patients; 29.6% were removals of a nasogastric tube, 18.6% of an arterial line, 14.4% of a urinary catheter, and 12.7% of a central venous catheter. Reintubation or repositioning of a tracheotomy tube was required in 19 patients (16.1%), and cardiopulmonary resuscitation in 2 patients (1.7%). We recorded a total of 184 pressure ulcers in 79 patients (on anterior face in 38.5%, anterior thorax in 23.3% and any extremity anteriorly in 15.2%). We observed that body weight (p = 0.021; ß = 0.09 (CI95: 0.01-0.17)) and the cumulative duration of prone positioning (p = 0.005; ß = 0.06 (CI95: 0.02-0.11)) were independently associated with the occurrence of any adverse event. The use of prone positioning in our setting was associated with a greater number of adverse events than previously reported. Body weight and cumulative duration of prone positioning were associated with the occurrence of adverse events; however, other factors during a COVID-19 surge, such as working conditions, staffing, and staff education, could also have contributed to a high prevalence of adverse events.

The Effect of Body Temperature Changes on the Course of Treatment in Patients With Pneumonia and Sepsis: Results of an Observational Study.

BACKGROUND: Traditionally, patients who are critically ill with infection and fever have been treated with antipyretics or even physically cooled. Presumed benefits of the reduction of body temperature are mostly based on decreased metabolic demands. However, it has been shown that decreasing body temperature in patients who are critically ill is not associated with improvement in treatment outcomes. Additionally, there is some data to support the use of temperature modulation (therapeutic hyperthermia) as an adjuvant treatment strategy in patients with infection. OBJECTIVE: This study aims to determine the effect of body temperature on the course of intensive care unit (ICU) treatment of patients who are mechanically ventilated with pneumonia, sepsis, and positive tracheal aspirates on admission. METHODS: We performed a single-center retrospective study. Core body temperature was measured in all patients. We analyzed associations between average temperatures in the first 48 hours after admission to ICU and ICU treatment parameters. Additionally, patients were divided into three groups: patients with negative tracheal aspirates 1 week after ICU admission (P-N group), patients with a different pathogen in tracheal aspirates 1 week after ICU admission (P-HAP group), and patients with a persisting pathogen in tracheal aspirates 1 week after ICU admission (P-P group). Differences in body temperature and interventions aimed at temperature modulation were determined. RESULTS: We observed a significantly higher average temperature in the first 48 hours after admission to ICU in patients who survived to hospital discharge compared to nonsurvivors (mean 37.2 °C, SD 1 °C vs mean 36.9 °C, SD 1.6 °C; P=.04). We observed no associations between average temperatures in the first 48 hours after ICU admission and days of mechanical ventilation in the first 7 days of treatment (ρ=-0.090; P=.30), the average maximum daily requirement for noradrenaline in the first 7 days of treatment (ρ=-0.029; P=.80), average maximum FiO2 in the first 7 days of ICU treatment (ρ=0.040; P=.70), and requirement for renal replacement therapy in the first 7 days of ICU treatment (mean 37.3 °C, SD 1.4 °C vs mean 37.0 °C, SD 1.3 °C; P=.23). In an additional analysis, we observed a significantly greater use of paracetamol in the P-N group (mean 1.0, SD 1.1 g vs mean 0.4, SD 0.7 g vs mean 0.4, SD 0.8 g; P=.009), a trend toward greater use of active cooling in the first 24 hours after ICU admission in the P-N group (n=11, 44% vs n=14, 33.3% vs n=16, 32%; P=.57), and no other significant differences in parameters of ICU treatment between patient groups. CONCLUSIONS: We observed better survival in patients who developed higher body temperatures in the first 48 hours after admission to the ICU; however, we observed no changes in other treatment parameters. Similarly, we observed greater use of paracetamol in patients with negative tracheal aspirates 1 week after ICU admission. Our results support the strategy of temperature tolerance in patients who are intubated with pneumonia and sepsis.

Therapeutic hyperthermia for the treatment of infection-a narrative review.

Modulating body temperature, mostly through the use of antipyretics, is a commonly employed therapeutic intervention in medical practice. However, emerging evidence suggests that hyperthermia could serve as an adjuvant therapy for patients with infection. We performed a narrative review to explore the application of therapeutic hyperthermia in the treatment of infection. A number of studies have been performed in the pre-antibiotic era, enrolling patients with neurosyphilis and gonococcal infections, with reported cure rates at around 60%-80%. We have outlined the potential molecular and immunological mechanisms explaining the possible beneficial effects of therapeutic hyperthermia. For some pathogens increased temperature exerts a direct negative effect on virulence; however, it is presumed that temperature driven activation of the immune system is probably the most important factor affecting microbial viability. Lastly, we performed a review of modern-era studies where modulation of body temperature has been used as a treatment strategy. In trials of therapeutic hypothermia in patients with infection worse outcomes have been observed in the hypothermia group. Use of antipyretics has not been associated with any improvement in clinical outcomes. In modern-era therapeutic hyperthermia achieved by physical warming has been studied in one pilot trial, and better survival was observed in the hyperthermia group. To conclude, currently there is not enough data to support the use of therapeutic hyperthermia outside clinical trials; however, available studies are in favor of at least a temperature tolerance strategy for non-neurocritical patients.

Computational modeling of targeted temperature management in post-cardiac arrest patients.

Our core body temperature is held around [Formula: see text]C by an effective internal thermoregulatory system. However, various clinical scenarios have a more favorable outcome under external temperature regulation. Therapeutic hypothermia, for example, was found beneficial for the outcome of resuscitated cardiac arrest patients due to its protection against cerebral ischemia. Nonetheless, practice shows that outcomes of targeted temperature management vary considerably in dependence on individual tissue damage levels and differences in therapeutic strategies and protocols. Here, we address these differences in detail by means of computational modeling. We develop a multi-segment and multi-node thermoregulatory model that takes into account details related to specific post-cardiac arrest-related conditions, such as thermal imbalances due to sedation and anesthesia, increased metabolic rates induced by inflammatory processes, and various external cooling techniques. In our simulations, we track the evolution of the body temperature in patients subjected to post-resuscitation care, with particular emphasis on temperature regulation via an esophageal heat transfer device, on the examination of the alternative gastric cooling with ice slurry, and on how anesthesia and the level of inflammatory response influence thermal behavior. Our research provides a better understanding of the heat transfer processes and therapies used in post-cardiac arrest patients.

Better Control of Body Temperature Is Not Associated with Improved Hemodynamic and Respiratory Parameters in Mechanically Ventilated Patients with Sepsis.

The need for temperature modulation (mostly cooling) in critically ill patients is based on the expected benefits associated with decreased metabolic demands. However, evidence-based guidelines for temperature management in a majority of critically ill patients with fever are still lacking. The aim of our retrospective single-site observational study was to determine the differences in ICU treatment between patients in whom their temperature remained within the target temperature range for ≥25% of time (inTT group) and patients in whom their temperature was outside the target temperature range for <24% of time (outTT group). We enrolled 76 patients undergoing invasive mechanical ventilation for respiratory failure associated with sepsis. We observed no significant differences in survival, mechanical ventilation settings and duration, vasopressor support, renal replacement therapy and other parameters of treatment. Patients in the inTT group were significantly more frequently cooled with the esophageal cooling device, received a significantly lower cumulative dose of acetaminophen and significantly more frequently developed a presence of multidrug-resistant pathogens. In our study, achieving a better temperature control was not associated with any improvement in treatment parameters during ICU stay. A lower prevalence of multidrug-resistant pathogens in patients with higher body temperatures opens a question of a pro-pyrexia approach with an aim to achieve better patient outcomes.

A Patient with Severe Leptospirosis Treated with Cytokine Removal and High-Dose Corticosteroids.

Leptospirosis is an ubiquitous zoonosis with significant morbidity and mortality. Approximately 10 percent of human infections evolve into a severe form, with a sepsis-like disease, multiorgan failure, and significant mortality rate. The cornerstone of treatment of severe disease is antibiotic therapy, with the aims of preventing complications, reducing the duration of disease, and ultimately reducing mortality. The initiation of antibiotic chemotherapy can precipitate a febrile inflammatory reaction, also known as a Jarisch-Herxheimer reaction. We present a case report of a patient with severe leptospirosis, complicated by multiorgan failure with severe circulatory failure of distributive and cardiogenic etiology, possibly as a consequence of the Jarisch-Herxheimer reaction. The patient was treated with antimicrobial therapy and other supportive measures along with high-dose corticosteroid therapy, long-term mechanical ventilation, high-dose vasopressor therapy, and continuous veno-venous hemodiafiltration with extracorporeal cytokine removal.With this case, we would like to report on a patient presenting with two neglected diseases in our part of Europe, who was treated with novel therapeutic strategies.

The Role of Environmental PM2.5 in Admission Acute Heart Failure in ST-Elevation Myocardial Infarction patients - An Observational Retrospective Study.

BACKGROUND: Air pollution with increased concentrations of fine (<2.5 µm) particulate matter (PM2.5) increases the risk of cardiovascular morbidity and mortality. Even short-term increase of PM2.5 may help trigger ST-elevation myocardial infarction (STEMI) and heart failure (HF) in susceptible individuals, even in areas with good air quality. PURPOSE: To evaluate the role of PM2.5 levels ≥20 µg/m3 in admission acute HF in STEMI patients. MATERIALS AND METHODS: In 290 STEMI patients with the leading reperfusion strategy primary percutaneous coronary intervention (PPCI), we retrospectively studied independent predictors of admission acute HF and included admission demographic and clinical data as well as ambient PM2.5 levels ≥20 µg/m3. We defined admission acute HF in STEMI patients as classes II-IV by Killip Kimball classification. RESULTS: Acute admission HF was observed in 34.5% of STEMI patients. PPCI was performed in 87.1% of acute admission HF patients and in 94.7% non-HF patients (p= 0.037). Significant independent predictors of acute admission HF were prior diabetes (OR 2.440, 95% CI 1.100 to 5.400, p=0.028), admission LBBB (OR 10.190, 95% CI 1.160 to 89.360, p=0.036), prior resuscitation (OR 2.530, 95% CI 1.010 to 6.340, p=0.048), admission troponin I≥5µg/l (OR 3.390, 95% CI 1.740 to 6.620, p<0.001), admission eGFR levels (0.61, 95% CI 0.52 to 0.72, p < 0.001), and levels of PM2.5 ≥20 µg/m3 (OR 2.140, 95% CI 1.005 to 4.560, p=0.049) one day before admission. CONCLUSION: Temporary short-term increase in PM2.5 levels (≥20 µg/m3) one day prior to admission in an area with mainly good air quality was among significant independent predictors of acute admission HF in STEMI patients.

The Automated External Defibrillator: Heterogeneity of Legislation, Mapping and Use across Europe. New Insights from the ENSURE Study.

INTRODUCTION: The rapid use of an automated external defibrillator (AED) is crucial for increased survival after an out-of-hospital cardiac arrest (OHCA). Many factors could play a role in limiting the chance of an AED use. We aimed to verify the situation regarding AED legislation, the AED mapping system and first responders (FRs) equipped with an AED across European countries. METHODS: We performed a survey across Europe entitled "European Study about AED Use by Lay Rescuers" (ENSURE), asking the national coordinators of the European Registry of Cardiac Arrest (EuReCa) program to complete it. RESULTS: Nineteen European countries replied to the survey request for a population covering 128,297,955 inhabitants. The results revealed that every citizen can use an AED in 15 countries whereas a training certificate was required in three countries. In one country, only EMS personnel were allowed to use an AED. An AED mapping system and FRs equipped with an AED were available in only 11 countries. The AED use rate was 12-59% where AED mapping and FR systems were implemented, which was considerably higher than in other countries (0-7.9%), reflecting the difference in OHCA survival. CONCLUSIONS: Our survey highlighted a heterogeneity in AED legislation, AED mapping systems and AED use in Europe, which was reflected in different AED use and survival.