Extracorporeal cardiopulmonary resuscitation for hypothermic refractory cardiac arrests in urban areas with temperate climates.

BACKGROUND: Accidental hypothermia designates an unintentional drop in body temperature below 35 °C. There is a major risk of ventricular fibrillation below 28 °C and cardiac arrest is almost inevitable below 24 °C. In such cases, conventional cardiopulmonary resuscitation is often inefficient. In urban areas with temperate climates, characterized by mild year-round temperatures, the outcome of patients with refractory hypothermic out-of-hospital cardiac arrest (OHCA) treated with extracorporeal cardiopulmonary resuscitation (ECPR) remains uncertain. METHODS: We conducted a retrospective monocentric observational study involving patients admitted to a university hospital in Paris, France. We reviewed patients admitted between January 1, 2011 and April 30, 2022. The primary outcome was survival at 28 days with good neurological outcomes, defined as Cerebral Performance Category 1 or 2. We performed a subgroup analysis distinguishing hypothermic refractory OHCA as either asphyxic or non-asphyxic. RESULTS: A total of 36 patients were analysed, 15 of whom (42%) survived at 28 days, including 13 (36%) with good neurological outcomes. Within the asphyxic subgroup, only 1 (10%) patient survived at 28 days, with poor neurological outcomes. A low-flow time of less than 60 min was not significantly associated with good neurological outcomes (P = 0.25). Prehospital ECPR demonstrated no statistically significant difference in terms of survival with good neurological outcomes compared with inhospital ECPR (P = 0.55). Among patients treated with inhospital ECPR, the HOPE score predicted a 30% survival rate and the observed survival was 6/19 (32%). CONCLUSION: Hypothermic refractory OHCA occurred even in urban areas with temperate climates, and survival with good neurological outcomes at 28 days stood at 36% for all patients treated with ECPR. We found no survivors with good neurological outcomes at 28 days in submersed patients.

Kidneys recovered from brain dead cardiac arrest patients resuscitated with ECPR show similar one-year graft survival compared to other donors.

INTRODUCTION: Among patients treated with extracorporeal cardiopulmonary resuscitation (ECPR) as a second line of treatment for refractory out-of-hospital cardiac arrest (OHCA), some may develop brain death and become eligible for organ donation. The objective of this study was to evaluate long-term outcomes of kidney grafts recovered from these patients. MATERIAL AND METHODS: We conducted a retrospective monocentric observational study between January 1, 2011, and December 31, 2017. We exclusively included patients eligible for planned donation after brainstem death and from whom at least one organ graft was retrieved and transplanted. We compared two groups of brain dead patients: those treated with ECPR for refractory OHCA (ECPR group) and a diverse group of patients who did not receive ECPR, from which only 5/23 (22%) had OHCA (control group). The primary outcome was one-year kidney graft survival. RESULTS: We included 45 patients, 23 in the control group and 22 in the ECPR group. Although patients in the ECPR group were younger and had a lower prevalence of chronic renal disease (p = 0.01), their kidney function was more severely impaired upon admission in the ICU. A total of 68 kidney grafts were retrieved, transplanted, and studied, 34 in each study group. There was no significant difference between the two groups in terms of one-year kidney graft survival (p = 0.52). CONCLUSION: Organ transplantation from patients treated with ECPR after refractory OHCA showed one-year kidney graft survival rates comparable to those of patients not treated with ECPR.

Setting up of a hospital Covid-19 vaccination center: A descriptive study.

Background and Aims: The coronavirus pandemic challenged countries worldwide in a race against contaminations and variants. Vaccination campaigns were the answer to such an infectious spread. This descriptive study presents the organizational process of the setting up of a Covid-19 vaccination center in a French University Hospital in January 2021, the issues encountered along the way and assessment of adaptability. Methods: Three major stakeholders: SARS CoV-2 crisis referent, referring vaccination medical doctor and referring vaccination pharmacist retraced key moments and identified issues encountered during the setting up of the vaccination center and its long term maintenance, threw a series of meetings. Records of crisis and periodic meetings that took place threw out the vaccination campaign were consulted. Results: A multidisciplinary crisis steering committee with nine different professionals was created January 3. Logistics for the vaccination center opening were discussed: location, informatics, appointment-scheduling, pharmaceutical circuit, internal circuit, human resources, and information communication. The vaccination center was ready to welcome healthcare workers in less than 24 h on January 4. The first month, 2757 1st shots were administered, leading up to a total of 9167 1st shots during 6 months of activity. From January to June 2021, the multidisciplinary group dealt and adapted its processes to challenging and unexpected situations. Indeed, issues encountered with Pfizer BioNTech's and AstraZeneca's vaccine, were: supply shortages, vaccine manipulation, targeted populations, pharmacovigilance, and general communication. Conclusion: This descriptive study provides an exclusive insight on how a hospital vaccination center was organized and adapted during Covid-19 pandemic to ensure healthcare workers' security and resilience, and to protect high risk patients of severe Covid-19 infection.

Elimination of three doses of gentamicin over three consecutive days using a polyacrylonitrile-derived filter: An in vitro assessment.

INTRODUCTION: Adsorption of gentamicin in a polyacrylonitrile filter was previously evidenced in a session lasting 6 h using the NeckEpur model. We extended the study over three consecutive days to mimic the 72-h life span of a filter. METHODS: Prismaflex® monitor and ST150® filter were used in the continuous diafiltration (CDF) mode at a 2.5 L/h flowrate. The daily session started with a 6-h session of CDF. Thereafter, the 5-L central compartment was changed using a bag free of gentamicin to assess gentamicin release over the following 18 h. Experiments were repeated on Day 2 and stopped at the end of the 6-h session of CDF on Day 3. The experiment was performed in duplicate. RESULTS: At a 2.5 L/h diafiltration flowrate, the mean daily clearances of gentamicin were 5.5, 4.0, and 3.3 L/h, respectively. The mean diafiltration and adsorption ratios in the daily elimination of gentamicin were 32/68%, 58/42%, and 88/12%, respectively. During days 1 and 2, the mean amount of gentamicin released from the ST150® filter were 14 and 34 mg, respectively. CONCLUSION: The pharmacokinetics of gentamicin over 3 days is strongly altered by adsorption in the same filter with a progressive decrease of elimination by adsorption, suggesting saturation of the filter. One limitation of our study results from the mode of administration using a bolus dose instead of an infusion over 30 min. Adsorption adds a clearance to those of diafiltration. The time-dependency of gentamicin clearance precludes using a constant dosage regimen over the filter's life span.

[Adult advanced life support]. / Erweiterte lebensrettende Maßnahmen für Erwachsene: Leitlinien des European Resuscitation Council 2021.

These European Resuscitation Council Advanced Life Support guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the prevention of and ALS treatments for both in-hospital cardiac arrest and out-of-hospital cardiac arrest.

Terror in Paris: Incidence and risk factors for infections related to high-energy ammunition injuries.

BACKGROUND: We aimed to assess the incidence and the risk factors for secondary wound infections associated to high-energy ammunition injuries (HEAI) in the cohort of civilian casualties from the 2015 terrorist attacks in Paris. METHODS: This retrospective multi-centric study included casualties presenting at least one HEAI who underwent surgery during the first 48 h following hospital admission. HEAI-associated infection was defined as a wound infection occurring within the initial 30 days following trauma. Risk factors were assessed using univariate and multivariate analysis. RESULTS: Among the 200 included victims, the rate of infected wounds was 11.5%. The median time between admission and the surgical revision for secondary wound infection was 11 days [IQR 9-20]. No patient died from an infectious cause. Infections were polymicrobial in 44% of the cases. The major risk factors for secondary wound infection were ISS (p < 0.001), SAPS II (p < 0.001), MGAP (p < 0.001), haemorrhagic shock (p = 0.003), use of vasopressors (p < 0.001), blood transfusion (p < 0.001), abdominal penetrating trauma (p = 0.003), open fracture (p = 0.01), vascular injury (p = 0.001), duration of surgery (p = 0.009), presence of surgical material (p = 0.01). In the multivariate analysis, the SAPS II score (OR 1.07 [1.014-1.182], p = 0.019) and the duration of surgery (OR 1.005 [1.000-1.012], p = 0.041) were the only risk factors identified. CONCLUSION: We report an 11.5% rate of secondary wound infection following high-energy ammunition injuries. Risk factors were an immediately severe condition and a prolonged surgery.

Resuscitative endovascular balloon occlusion of the aorta vs epinephrine in the treatment of non-traumatic cardiac arrest in swine.

BACKGROUND: The administration of epinephrine in the management of non-traumatic cardiac arrest remains recommended despite controversial effects on neurologic outcome. The use of resuscitative endovascular balloon occlusion of the aorta (REBOA) could be an interesting alternative. The aim of this study was to compare the effects of these 2 strategies on return of spontaneous circulation (ROSC) and cerebral hemodynamics during cardiopulmonary resuscitation (CPR) in a swine model of non-traumatic cardiac arrest. RESULTS: Anesthetized pigs were instrumented and submitted to ventricular fibrillation. After 4 min of no-flow and 18 min of basic life support (BLS) using a mechanical CPR device, animals were randomly submitted to either REBOA or epinephrine administration before defibrillation attempts. Six animals were included in each experimental group (Epinephrine or REBOA). Hemodynamic parameters were similar in both groups during BLS, i.e., before randomization. After epinephrine administration or REBOA, mean arterial pressure, coronary and cerebral perfusion pressures similarly increased in both groups. However, carotid blood flow (CBF) and cerebral regional oxygenation saturation were significantly higher with REBOA as compared to epinephrine administration (+ 125% and + 40%, respectively). ROSC was obtained in 5 animals in both groups. After resuscitation, CBF remained lower in the epinephrine group as compared to REBOA, but it did not achieve statistical significance. CONCLUSIONS: During CPR, REBOA is as efficient as epinephrine to facilitate ROSC. Unlike epinephrine, REBOA transitorily increases cerebral blood flow and could avoid its cerebral detrimental effects during CPR. These experimental findings suggest that the use of REBOA could be beneficial in the treatment of non-traumatic cardiac arrest.

European Resuscitation Council Guidelines 2021: Adult advanced life support.

These European Resuscitation Council Advanced Life Support guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the prevention of and ALS treatments for both in-hospital cardiac arrest and out-of-hospital cardiac arrest.

Assessment of the mass casualty triage during the November 2015 Paris area terrorist attacks: towards a simple triage rule.

BACKROUND: Triage is key in the management of mass casualty incidents. OBJECTIVE: The objective of this study was to assess the prehospital triage performed during the 2015 Paris area terrorist attack. DESIGN SETTING AND PARTICIPANT: This was a retrospective cohort study that included all casualties of the attacks on 13 November 2015 in Paris area, France, that were admitted alive at the hospital within the first 24 h after the events. Patients were triaged as absolute emergency or relative emergency by a prehospital physician or nurse. This triage was then compared to the one of an expert panel that had retrospectively access to all prehospital and hospital files. OUTCOMES MEASURES AND ANALYSIS: The primary endpoints were the rate of overtriage and undertriage, defined as number of patients misclassified in one triage category, divided by the total number of patients in this triage category. MAIN RESULT: Among 337 casualties admitted to the hospital, 262 (78%) were triaged during prehospital care, with, respectively, 74 (28%) and 188 (72%) as absolute and relative emergencies. Among these casualties, the expert panel classified 96 (37%) patients as absolute emergencies and 166 (63%) as relative emergency. The rate of undertriage and overtriage was 36% [95% confidence interval (CI), 27-47%] and 8% (95% CI, 4-13%), respectively. Among undertriaged casualties, 8 (23%) were considered as being severely undertriaged. Among overtriaged casualties, 10 (77%) were considered as being severely overtriaged. CONCLUSION: A simple prehospital triage for trauma casualties during the 13 November terrorist attack in Paris could have been performed triaged in 78% of casualties that were admitted to the hospital, with a 36% rate of undertriage and 8% of overtriage. Qualitative analysis of undertriage and overtriage indicate some possibilities for further improvement.

Elimination of fluconazole during continuous renal replacement therapy. An in vitro assessment.

INTRODUCTION: Continuous renal replacement therapy (CRRT) efficiently eliminates fluconazole. However, the routes of elimination were not clarified. Adsorption of fluconazole by filters is a pending question. We studied the elimination of fluconazole in a model mimicking a session of CRRT in humans using the NeckEpur® model. Two filters were studied. METHODS: The AV1000®-polysulfone filter with the Multifiltrate Pro. Fresenius and the ST150®-polyacrylonitrile filter with the Prismaflex. Baxter-Gambro were studied. Continuous filtration used a flowrate of 2.5 L/h in post-dilution only. Session were made in duplicate. Routes of elimination were assessed using the NeckEpur® model. RESULTS: The mean measured initial fluconazole concentration (mean ± SD) for the four sessions in the central compartment (CC) was 14.9 ± 0.2 mg/L. The amount eliminated from the CC at the end of 6 h-session at a 2.5 L/h filtration flowrate for the AV1000®-polysulfone and the ST150®-polyacrylonitrile filters were 90%-93% and 96%-94%, respectively; the clearances from the central compartment (CC) were 2.5-2.6 and 2.4-2.3 L/h, respectively. The means of the instantaneous sieving coefficient were 0.94%-0.91% and 0.99%-0.91%, respectively. The percentages of the amount eliminated from the CC by filtration/adsorption were 100/0%-95/5% and 100/0%-100/0%, respectively. CONCLUSION: Neither the ST150®-polyacrylonitrile nor the AV1000®-polysulfone filters result in any significant adsorption of fluconazole.

Alteration of the pharmacokinetics of aminoglycosides by adsorption in a filter during continuous renal replacement therapy. An in vitro assessment.

OBJECTIVES: Filters used in continuous renal replacement therapy (CRRT) induce elimination by filtration, dialysis, and adsorption. The worldwide used ST150® filter adsorbs cytokines. However, adsorption is a non-specific process which might alter the pharmacokinetics of drugs. Pharmacodynamic/pharmacokinetic relationship of aminoglycosides evidences the importance of the peak concentration at the first dose. We hypothesize an in vitro study may clarify the routes of elimination of aminoglycosides using the ST150® filter. METHODS: Prismaflex® and the STX150® filter, Baxter-Gambro were used. The diafiltration mode combined flowrates of dialysis and filtration at 2.5/1.5L/h, respectively, over 6h. One ionic solute was used in the different compartments. Pharmacokinetic analyses were performed using the NeckEpur® software. RESULTS: Percentages of gentamicin, tobramycin, and amikacin eliminated from the central compartment were 97±1, 95±3, and 94±6, %, respectively. The clearances were 8.4±2.3, 5.4±5, and 4.2±0.4L/h, respectively. The contributions of dialysis, filtration, and adsorption for gentamicin, tobramycin, and amikacin were 34.3±2.1, 0±0, and 67.7±2.1; 51.1±1.6, 6.3±3.1, and 46.3±2.0, and 37.8±6.3, 46.3±2.0, and 16.0±5.7%, respectively. Among physico-chemical properties, the rate of adsorption linearly and inversely correlated with the polar surface area of aminoglycosides (Y=-0.44X+161.7; R2=0.9993). DISCUSSION: Using the ST150® filter, dialysis, filtration, and adsorption play a role depending on the chemical structure of aminoglycosides. In the diafiltration mode, elimination of gentamicin and tobramycin by filtration is not detected or weak, respectively. Adsorption should be considered as a potential adverse effect of CRRT. Polar surface area of drugs is a physico-chemical parameter which should be considered regarding adsorption of drugs in filters. The risk needs to be systematically assessed.

Pupil Reactivity in Refractory Out-of-Hospital Cardiac Arrest Treated by Extra-Corporeal Cardiopulmonary Resuscitation.

OBJECTIVE: The objective of this study was to assess the association of early pupil evaluation with death occurrence on Day 28 in patients with refractory out-of-hospital cardiac arrest (ROHCA) admitted to the intensive care unit (ICU) and treated by extra-corporeal cardiopulmonary resuscitation (eCPR). METHODS: The pupil size (miosis, intermediary or mydriasis) and bilateral pupillary light reactivity (present or absent) were monitored in sedated and paralysed patients treated by eCPR. Mortality was assessed on Day 28. RESULTS: A total of 46 consecutive patients with ROHCA were included in the study. Thirty (65%) patients died on Day 28. Twenty-seven (90%) patients had pupils non-reactive to light, and 18 (60%) had mydriasis at the ICU admission. Using logistic regression, including age, gender, no flow, low-flow, size and pupil reactivity to light, only the pupillary reactivity to light remained associated with death on Day 28 (Odds ratio=0.12, 95%CI=[0.01-0.96]). CONCLUSION: Pupils not reacting to light at the ICU admission were associated with mortality on Day 28 in patients with ROHCA. Pupillary light reactivity is a simple and easy tool that can be used to early detect a poor outcome in patients with ROHCA treated by eCPR.

Effects of early high-dose erythropoietin on acute kidney injury following cardiac arrest: exploratory post hoc analyses from an open-label randomized trial.

BACKGROUND: Acute kidney injury (AKI) is frequent in patients resuscitated from cardiac arrest (CA) and may worsen outcome. Experimental data suggest a renoprotective effect by treating these patients with a high dose of erythropoietin (Epo) analogues. We aimed to evaluate the efficacy of epoetin alpha treatment on renal outcome after CA. METHODS: We did a post hoc analysis of the Epo-ACR-02 trial, which randomized patients with a persistent coma after a witnessed out-of-hospital CA. Only patients admitted in one intensive care unit were analysed. In the intervention group, patients received five intravenous injections of Epo spaced 12 h apart during the first 48 h, started as soon as possible after resuscitation. In the control group, patients received standard care without Epo. The main endpoint was the proportion of patients with persistent AKI defined by Kidney Disease: Improving Global Outcomes criteria at Day 2. Secondary endpoints included the occurrence of AKI through Day 7, estimated glomerular filtration rate (eGFR) at Day 28, haematological indices and adverse events. RESULTS: A total of 162 patients were included in the primary analysis (74 in the Epo group, 88 in the control group). Baseline characteristics were similar in the two groups. At Day 2, 52.8% of the patients (38/72) in the intervention group had an AKI, as compared with 54.4% of the patients (46/83) in the control group (P = 0.74). There was no significant difference between the two groups regarding the proportion of patients with AKI through Day 7. Among patients with persistent AKI at Day 2, 33% (4/12) in the intervention group had an eGFR <75 mL/min/1.73 m2 compared with 25% (3/12) in the control group at Day 28 (P = 0.99). We found no significant differences in haematological indices or adverse events. CONCLUSION: After CA, early administration of Epo did not confer any renal protective effect as compared with standard therapy.

Association between Blood Pressure after Haemodynamic Resuscitation in the Prehospital Setting and 28-Day Mortality in Septic Shock.

OBJECTIVE: Septic shock results in a decreased blood pressure (BP) leading to organ failure. The haemodynamic resuscitation aims at restoring the BP to allow efficient tissue perfusion. The aim of the present study was to evaluate the association between the mean BP (MBP) reached after haemodynamic resuscitation in patients with septic shock cared for in the prehospital setting by a mobile intensive care unit (MICU) and mortality at 28 days after intensive care unit (ICU) admission. METHODS: Patients with septic shock managed by a mobile intensive care unit (MICU) and admitted in the ICU were retrospectively analysed. The association between mortality and MBP after prehospital resuscitation was studied. RESULTS: A total of 85 patients with septic shock were included in the study. The origin of sepsis was mainly pulmonary (64%). Mortality reached 35%. Haemodynamic resuscitation was performed using crystalloids (98%) with a mean infused volume indexed on a body weight of 16±11 mL kg-1 in the prehospital setting. No patient received catecholamine or antibiotic prior to hospital admission. Final prehospital MBP was 64±8 mm Hg in the overall population and 66±8 mm Hg versus 62±8 mm Hg in alive and deceased patients, respectively (p=0.02). After adjustment, final prehospital MBP [odds ratio adjusted (ORa) (95% confidence interval (CI)]=0.89 (0.80-0.99), MBP <65 mmHg [ORa (95% CI)=14.3 (3.35-77.7)] and MBP >65 mmHg [ORa (95% CI)=0.06 (0.01-0.25)] were associated with mortality. CONCLUSION: Persistent low MBP after prehospital initial resuscitation measures in patients with septic shock managed in the prehospital setting is associated with increased mortality. Further studies are needed to evaluate the impact of prehospital haemodynamic management in septic shock to further optimise prehospital care and improve outcome.

Diafiltration flowrate is a determinant of the extent of adsorption of amikacin in renal replacement therapy using the ST150®-AN69 filter: An in vitro study.

INTRODUCTION: In continuous renal replacement therapy, conduction and convection are controlled allowing prescribing dosage regimen improving survival. In contrast, adsorption is an uncontrolled property altering drug disposition. Whether adsorption depends on flowrates is unknown. We hypothesized an in vitro model may provide information in conditions mimicking continuous renal replacement therapy in humans. METHODS: ST150®-AN69 filter and Prismaflex dialyzer, Baxter-Gambro were used. Simulated blood flowrate was set at 200 mL/min. The flowrates in the filtration (continuous filtration), dialysis (continuous dialysis), and diafiltration (continuous diafiltration) were 1500, 2500, and 4000 mL/h, respectively. Routes of elimination were assessed using NeckEpur® analysis. RESULTS: The percentages of the total amount eliminated by continuous filtration, continuous dialysis, and continuous diafiltration were 82%, 86%, and 94%, respectively. Elimination by effluents and adsorption accounted for 42% ± 7% and 58% ± 5%, 57% ± 7% and 43% ± 6%, and 84% ± 6% and 16% ± 6% of amikacin elimination, respectively. There was a linear regression between flowrates and amikacin clearance: Y = 0.6 X ± 1.7 (R2 = 0.9782). Conversely, there was a linear inverse correlation between the magnitude of amikacin adsorption and flowrate: Y = -16.9 X ± 84.1 (R2 = 0.9976). CONCLUSION: Low flowrates resulted in predominant elimination by adsorption, accounting for 58% of the elimination of amikacin from the central compartment in the continuous filtration mode at 1500 mL/h of flowrate. Thereafter, the greater the flowrate, the lower the adsorption of amikacin in a linear manner. Flowrate is a major determinant of adsorption of amikacin. There was an about 17% decrease in the rate of adsorption per increase in the flowrate of 1 L/min.

Blood product needs and transfusion timelines for the multisite massive Paris 2015 terrorist attack: A retrospective analysis.

OBJECTIVE: Hemorrhage is the leading cause of death after terrorist attack, and the immediacy of labile blood product (LBP) administration has a decisive impact on patients' outcome. The main objective of this study was to evaluate the transfusion patterns of the Paris terrorist attack victims, November 13, 2015. METHODS: We performed a retrospective analysis including all casualties admitted to hospital, aiming to describe the transfusion patterns from admission to the first week after the attack. RESULTS: Sixty-eight of 337 admitted patients were transfused. More than three quarters of blood products were consumed in the initial phase (until November 14, 11:59 PM), where 282 packed red blood cell (pRBC) units were transfused along with 201 plasma and 25 platelet units, to 55 patients (16% of casualties). Almost 40% of these LBPs (134 pRBC, 73 plasma, 8 platelet units) were transfused within the first 6 hours after the attack. These early transfusions were massive transfusion (MT) for 20 (6%) of 337 patients, and the average plasma/red blood cell ratio was 0.8 for MT patients who received 366 (72%) of 508 LBPs.The median time from admission to pRBC transfusion was 57 (25-108) minutes and 208 (52-430) minutes for MT and non-MT patients, respectively. These same time intervals were 119 (66-202) minutes and 222 (87-381) minutes for plasma and 225 (131-289) minutes and 198 (167-230) minutes for platelets. CONCLUSION: Our data suggest that improving transfusion procedures in mass casualty setting should rely more on shortening the time to bring LBP to the bedside than in increasing the stockpile. LEVEL OF EVIDENCE: Epidemiological study, Therapeutic IV.