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2.
Crit Care ; 23(1): 391, 2019 Dec 03.
Artigo em Inglês | MEDLINE | ID: mdl-31796127

RESUMO

PURPOSE: Recent doubts regarding the efficacy may have resulted in a loss of interest for targeted temperature management (TTM) in comatose cardiac arrest (CA) patients, with uncertain consequences on outcome. We aimed to identify a change in TTM use and to assess the relationship between this change and neurological outcome. METHODS: We used Utstein data prospectively collected in the Sudden Death Expertise Center (SDEC) registry (capturing CA data from all secondary and tertiary hospitals located in the Great Paris area, France) between May 2011 and December 2017. All cases of non-traumatic OHCA patients with stable return of spontaneous circulation (ROSC) were included. After adjustment for potential confounders, we assessed the relationship between changes over time in the use of TTM and neurological recovery at discharge using the Cerebral Performance Categories (CPC) scale. RESULTS: Between May 2011 and December 2017, 3925 patients were retained in the analysis, of whom 1847 (47%) received TTM. The rate of good neurological outcome at discharge (CPC 1 or 2) was higher in TTM patients as compared with no TTM (33% vs 15%, P < 0.001). Gender, age, and location of CA did not change over the years. Bystander CPR increased from 55% in 2011 to 73% in 2017 (P < 0.001) and patients with a no-flow time longer than 3 min decreased from 53 to 38% (P < 0.001). The use of TTM decreased from 55% in 2011 to 37% in 2017 (P < 0.001). Meanwhile, the rate of patients with good neurological recovery remained stable (19 to 23%, P = 0.76). After adjustment, year of CA occurrence was not associated with outcome. CONCLUSIONS: We report a progressive decrease in the use of TTM in post-cardiac arrest patients over the recent years. During this period, neurological outcome remained stable, despite an increase in bystander-initiated resuscitation and a decrease in "no flow" duration.

4.
N Engl J Med ; 381(19): 1831-1842, 2019 11 07.
Artigo em Inglês | MEDLINE | ID: mdl-31693806

RESUMO

BACKGROUND: Patients who are treated with targeted temperature management after out-of-hospital cardiac arrest with shockable rhythm are at increased risk for ventilator-associated pneumonia. The benefit of preventive short-term antibiotic therapy has not been shown. METHODS: We conducted a multicenter, double-blind, randomized, placebo-controlled trial involving adult patients (>18 years of age) in intensive care units (ICUs) who were being mechanically ventilated after out-of-hospital cardiac arrest related to initial shockable rhythm and treated with targeted temperature management at 32 to 34°C. Patients with ongoing antibiotic therapy, chronic colonization with multidrug-resistant bacteria, or moribund status were excluded. Either intravenous amoxicillin-clavulanate (at doses of 1 g and 200 mg, respectively) or placebo was administered three times a day for 2 days, starting less than 6 hours after the cardiac arrest. The primary outcome was early ventilator-associated pneumonia (during the first 7 days of hospitalization). An independent adjudication committee determined diagnoses of ventilator-associated pneumonia. RESULTS: A total of 198 patients underwent randomization, and 194 were included in the analysis. After adjudication, 60 cases of ventilator-associated pneumonia were confirmed, including 51 of early ventilator-associated pneumonia. The incidence of early ventilator-associated pneumonia was lower with antibiotic prophylaxis than with placebo (19 patients [19%] vs. 32 [34%]; hazard ratio, 0.53; 95% confidence interval, 0.31 to 0.92; P = 0.03). No significant differences between the antibiotic group and the control group were observed with respect to the incidence of late ventilator-associated pneumonia (4% and 5%, respectively), the number of ventilator-free days (21 days and 19 days), ICU length of stay (5 days and 8 days if patients were discharged and 7 days and 7 days if patients had died), and mortality at day 28 (41% and 37%). At day 7, no increase in resistant bacteria was identified. Serious adverse events did not differ significantly between the two groups. CONCLUSIONS: A 2-day course of antibiotic therapy with amoxicillin-clavulanate in patients receiving a 32-to-34°C targeted temperature management strategy after out-of-hospital cardiac arrest with initial shockable rhythm resulted in a lower incidence of early ventilator-associated pneumonia than placebo. No significant between-group differences were observed for other key clinical variables, such as ventilator-free days and mortality at day 28. (Funded by the French Ministry of Health; ANTHARTIC ClinicalTrials.gov number, NCT02186951.).


Assuntos
Combinação Amoxicilina e Clavulanato de Potássio/uso terapêutico , Antibacterianos/uso terapêutico , Parada Cardíaca Extra-Hospitalar/complicações , Pneumonia Associada à Ventilação Mecânica/prevenção & controle , Adulto , Idoso , Combinação Amoxicilina e Clavulanato de Potássio/efeitos adversos , Antibacterianos/efeitos adversos , Método Duplo-Cego , Feminino , Humanos , Injeções Intravenosas , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/mortalidade , Pneumonia Associada à Ventilação Mecânica/etiologia , Pneumonia Associada à Ventilação Mecânica/microbiologia , Resultado do Tratamento , Desmame do Respirador
5.
N Engl J Med ; 381(24): 2327-2337, 2019 12 12.
Artigo em Inglês | MEDLINE | ID: mdl-31577396

RESUMO

BACKGROUND: Moderate therapeutic hypothermia is currently recommended to improve neurologic outcomes in adults with persistent coma after resuscitated out-of-hospital cardiac arrest. However, the effectiveness of moderate therapeutic hypothermia in patients with nonshockable rhythms (asystole or pulseless electrical activity) is debated. METHODS: We performed an open-label, randomized, controlled trial comparing moderate therapeutic hypothermia (33°C during the first 24 hours) with targeted normothermia (37°C) in patients with coma who had been admitted to the intensive care unit (ICU) after resuscitation from cardiac arrest with nonshockable rhythm. The primary outcome was survival with a favorable neurologic outcome, assessed on day 90 after randomization with the use of the Cerebral Performance Category (CPC) scale (which ranges from 1 to 5, with higher scores indicating greater disability). We defined a favorable neurologic outcome as a CPC score of 1 or 2. Outcome assessment was blinded. Mortality and safety were also assessed. RESULTS: From January 2014 through January 2018, a total of 584 patients from 25 ICUs underwent randomization, and 581 were included in the analysis (3 patients withdrew consent). On day 90, a total of 29 of 284 patients (10.2%) in the hypothermia group were alive with a CPC score of 1 or 2, as compared with 17 of 297 (5.7%) in the normothermia group (difference, 4.5 percentage points; 95% confidence interval [CI], 0.1 to 8.9; P = 0.04). Mortality at 90 days did not differ significantly between the hypothermia group and the normothermia group (81.3% and 83.2%, respectively; difference, -1.9 percentage points; 95% CI, -8.0 to 4.3). The incidence of prespecified adverse events did not differ significantly between groups. CONCLUSIONS: Among patients with coma who had been resuscitated from cardiac arrest with nonshockable rhythm, moderate therapeutic hypothermia at 33°C for 24 hours led to a higher percentage of patients who survived with a favorable neurologic outcome at day 90 than was observed with targeted normothermia. (Funded by the French Ministry of Health and others; HYPERION ClinicalTrials.gov number, NCT01994772.).


Assuntos
Reanimação Cardiopulmonar , Coma/complicações , Parada Cardíaca/terapia , Hipotermia Induzida , Idoso , Temperatura Corporal , Encefalopatias/etiologia , Feminino , Seguimentos , Parada Cardíaca/complicações , Parada Cardíaca/mortalidade , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/terapia , Método Simples-Cego
6.
Crit Care ; 23(1): 285, 2019 Aug 23.
Artigo em Inglês | MEDLINE | ID: mdl-31443696

RESUMO

BACKGROUND: Although targeted temperature management (TTM) is recommended in comatose survivors after cardiac arrest (CA), the optimal method to deliver TTM remains unknown. We performed a meta-analysis to evaluate the effects of different TTM methods on survival and neurological outcome after adult CA. METHODS: We searched on the MEDLINE/PubMed database until 22 February 2019 for comparative studies that evaluated at least two different TTM methods in CA patients. Data were extracted independently by two authors. We used the Newcastle-Ottawa Scale and a modified Cochrane ROB tools for assessing the risk of bias of each study. The primary outcome was the occurrence of unfavorable neurological outcome (UO); secondary outcomes included overall mortality. RESULTS: Our search identified 6886 studies; 22 studies (n = 8027 patients) were included in the final analysis. When compared to surface cooling, core methods showed a lower probability of UO (OR 0.85 [95% CIs 0.75-0.96]; p = 0.008) but not mortality (OR 0.88 [95% CIs 0.62-1.25]; p = 0.21). No significant heterogeneity was observed among studies. However, these effects were observed in the analyses of non-RCTs. A significant lower probability of both UO and mortality were observed when invasive TTM methods were compared to non-invasive TTM methods and when temperature feedback devices (TFD) were compared to non-TFD methods. These results were significant particularly in non-RCTs. CONCLUSIONS: Although existing literature is mostly based on retrospective or prospective studies, specific TTM methods (i.e., core, invasive, and with TFD) were associated with a lower probability of poor neurological outcome when compared to other methods in adult CA survivors (CRD42019111021).

8.
Resuscitation ; 142: 168-174, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31211949

RESUMO

PURPOSE: To evaluate the predictive value of EEG reactivity assessment and confounders for neurological outcome after cardiac arrest. METHODS: All consecutive patients admitted in a tertiary cardiac arrest center between 2007 and 2016 still alive 48 h after admission with at least one EEG recorded during coma. EEG reactivity was defined as a reproducible waveform change in amplitude or frequency following standardized stimulation. Each EEG was classified based on American Clinical Neurophysiology Society nomenclatures and classified in highly malignant (including status epilepticus), malignant, or benign EEG. We assessed the predictive values of EEG reactivity and sedation effect for neurologic outcome at ICU discharge using the Cerebral Performance Category scale (with CPC 1-2 assumed as favorable outcome and CPC 3-4-5 considered as poor outcome). RESULTS: Among 428 patients, a poor outcome was observed in 80% patients. The median time to EEG recording was 3 (1-4) days and 51% patients had a non-reactive EEG. The positive predictive value (PPV) of a non-reactive EEG to predict an unfavorable outcome was 97.1% (IC95% 93.6-98.9), increasing to 98.3% (IC95 94.1-99.8) when the EEG had been performed without sedation. In multivariate analysis, a non-reactive EEG was associated with poor outcome (OR 12.6 IC95% 4.7-33.6; p < 0.001). In multivariate analysis, concomitant sedation was not statistically associated with EEG non-reactivity. The PPV of a benign EEG to predict favorable outcome was 49.7% (IC95% 41.5-57.9), increasing to 66.2% (IC95% 54.3-76.8) when EEG was recorded earlier, with ongoing sedation. CONCLUSIONS: After cardiac arrest, absence of EEG reactivity was predictive of unfavorable outcome. By contrast, a benign EEG was slightly predictive of a favorable outcome. Reactivity assessment may have important implications in the neuroprognostication process after cardiac arrest and could be influenced by sedation.

9.
Epilepsy Behav ; 101(Pt B): 106298, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31133509

RESUMO

Status epilepticus (SE) is associated with high mortality and morbidity rates, notably in its refractory and super-refractory forms. This narrative review discusses recent data on the potential benefits of targeted temperature management. In studies of patients with cerebral injury due to various factors, therapeutic hypothermia had variable effects on survival and functional outcomes. Sources of this variability may include the underlying etiology, whether hypothermia was used for prophylaxis or treatment, the degree and duration of hypothermia, and the hypothermia application modalities. Data from animal studies strongly suggest benefits from therapeutic hypothermia in SE. In humans, beneficial effects have been described in anecdotal case reports and small case series, but the level of evidence is low. A randomized controlled trial found no evidence that moderate hypothermia (32-34 °C) was neuroprotective in critically ill patients with convulsive SE. Nevertheless, some promising effects were noted, suggesting that therapeutic hypothermia might have a role as an adjuvant to anticonvulsant drug therapy in patients with refractory or super-refractory SE. This article is part of a Special Issue entitled "Status Epilepticus". This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".

11.
Resuscitation ; 138: 222-232, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30885824

RESUMO

BACKGROUND: Early prognostication is a major challenge after out-of-hospital cardiac arrest (OHCA). AIMS: We hypothesized that a genome-wide analysis of blood gene expression could offer new prognostic tools and lines of research. METHODS: Sixty-nine patients were enrolled from an ancillary study of the clinical trial NCT00999583 that tested the effect of erythropoietin (EPO) after OHCA. Blood samples were collected in comatose survivors of OHCA at hospital admission and 1 and 3 days after resuscitation. Gene expression profiles were analyzed (Illumina HumanHT-12 V4 BeadChip; >34,000 genes). Patients were classified into two categories representing neurological favorable outcome (cerebral performance category [CPC] = 1-2) vs unfavorable outcome (CPC > 2) at Day 60 after OHCA. Differential and functional enrichment analyses were performed to compare transcriptomic profiles between these two categories. RESULTS: Among the 69 enrolled patients, 33 and 36 patients were treated or not by EPO, respectively. Among them, 42% had a favorable neurological outcome in both groups. EPO did not affect the transcriptomic response at Day-0 and 1 after OHCA. In contrast, 76 transcripts differed at Day-0 between patients with unfavorable vs favorable neurological outcome. This signature persisted at Day-1 after OHCA. Functional enrichment analysis revealed a down-regulation of adaptive immunity with concomitant up-regulation of innate immunity and inflammation in patients with unfavorable vs favorable neurological outcome. The transcription of many genes of the HLA family was decreased in patients with unfavorable vs favorable neurological outcome. Concomitantly, neutrophil activation and inflammation were observed. Up-stream regulators analysis showed the implication of numerous factors involved in cell cycle and damages. A logistic regression including a set of genes allowed a reliable prediction of the clinical outcomes (specificity = 88%; Hit Rate = 83%). CONCLUSIONS: A transcriptomic signature involving a counterbalance between adaptive and innate immune responses is able to predict neurological outcome very early after hospital admission after OHCA. This deserves confirmation in a larger population.

12.
Neurocrit Care ; 30(2): 440-448, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30267280

RESUMO

BACKGROUND: Early diagnostic orientation for differentiating pneumonia from pneumonitis at the early stage after aspiration would be valuable to avoid unnecessary antibiotic therapy. We assessed the accuracy of procalcitonin (PCT) in diagnosing aspiration pneumonia (AP) in intensive care unit (ICU) patients requiring mechanical ventilation after out-of-hospital coma. METHODS: Prospective observational 2-year cohort study in a medical-surgical ICU. PCT, C-reactive protein (CRP) and white blood cell count (WBC) were measured at admission (H0) and 6 h (H), H12, H24, H48, H96, and H120 after inclusion. Lower respiratory tract microbiological investigations performed routinely in patients with aspiration syndrome were the reference standard for diagnosing AP. Performance of PCT, CRP, and WBC up to H48 in diagnosing AP was compared based on the areas under the ROC curves (AUC) and likelihood ratios (LR+ and LR-) computed for the best cutoff values. RESULTS: Of 103 patients with coma, 45 (44%) had AP. Repeated PCT assays demonstrated a significant increase in patients with AP versus without AP from H0 to H120. Among the three biomarkers, PCT showed the earliest change. ROC-AUC values were poor for all three biomarkers. Best ROC-AUC values for diagnosing AP were for CRP at H24 [0.73 (95%CI 0.61-0.84)] and PCT at H48 [0.73 (95%CI 0.61-0.84)]. LR+ was best for PCT at H24 (3.5) and LR- for CRP and WBC at H24 (0.4 and 0.4, respectively). CONCLUSIONS: Early and repeated assays of PCT, CRP, and WBC demonstrated significant increases in all three biomarkers in patients with versus without AP. All three biomarkers had poor diagnostic performance for ruling out AP. Whereas PCT had the fastest kinetics, PCT assays within 48 h after ICU admission do not help to diagnose AP in ICU patients with coma.


Assuntos
Coma/terapia , Cuidados Críticos/normas , Técnicas de Diagnóstico Neurológico/normas , Pneumonia Aspirativa/sangue , Pneumonia Aspirativa/diagnóstico , Pró-Calcitonina/sangue , Respiração Artificial/efeitos adversos , Adulto , Biomarcadores/sangue , Coma/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pneumonia Aspirativa/etiologia , Estudos Prospectivos , Sensibilidade e Especificidade
13.
J Intensive Care Med ; 34(5): 391-396, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-28343416

RESUMO

BACKGROUND:: Cuff leak test was developed to predict the occurrence of post-extubation stridor (PES). This study evaluated the diagnostic performance of this test in unselected critically ill patients. METHODS:: Multicenter prospective study including unselected ventilated patients at the time of their first planned extubation. The diagnostic performance of 4 different cuff leak tests was assessed. RESULTS:: Post-extubation stridor occurred in 34 (9.4%) of 362 included patients. Compared to patients without PES, patients with PES required more frequently reintubation (6 [17.6%] vs 26 [7.9%], P = .041), prolonged duration of ventilation (6 [3-13] vs 5 [2-9] days, P = .029), and longer intensive care unit (ICU) stay (12 [6-17.5] vs 7.5 [4-13] days, P = .018). However, ICU mortality was similar in both groups (1 [2.9%] vs 23 [7.0%], P = .61). The 4 cuff leak tests display poor diagnostic accuracy: sensitivities ranging from 27% to 46%, specificities from 70% to 88%, positive predictive values from 14% to 19%, and negative predictive values from 92% to 93%. CONCLUSION:: Post-extubation stridor occurs in less than 10% of unselected critically ill patients. The several cuff leak tests display limited diagnostic performance for the detection of PES. Given the high rate of false positives, routine cuff leak test may expose to undue prolonged mechanical ventilation.


Assuntos
Extubação/efeitos adversos , Equipamentos para Diagnóstico/estatística & dados numéricos , Sons Respiratórios/diagnóstico , Adulto , Idoso , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Reprodutibilidade dos Testes , Respiração Artificial , Testes de Função Respiratória/instrumentação , Sensibilidade e Especificidade , Fatores de Tempo
14.
PLoS One ; 13(11): e0207174, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30427906

RESUMO

BACKGROUND: Pain is a universal issue and is of particular concern in mechanically ventilated patients, as they require intensive nursing care and multiple invasive procedures, while being unable to communicate verbally. The aim of this study was to assess the effect of music on pain experienced by mechanically ventilated patients during morning bed bathing. METHODS: Of the 60 mechanically ventilated patients enrolled in this single-center pilot study between March 2013 and October 2015, the first 30 received no music and the next 30 the music intervention, during the morning bed bath. The Behavioral Pain Scale (BPS) score was determined during and at the end of the bath then 30, 60, and 120 minutes after the bath. BPS score changes over time were assessed and the proportions of bath times spent with a BPS score ≥5 and with the maximal BPS score were determined. RESULTS: At baseline, no patient had pain (defined as a BPS score <5) and the median BPS score was 3 [IQR, 3;3] in both groups (P = 0.43). After bed bath initiation, 88% of patients experienced pain. The maximum BPS value during the bath was lower in the music group (5 [5;6.7] vs. 7 [5;7]). Proportions of total bath time spent with BPS≥5 and with the maximum BPS were significantly lower in the music group than in the control group (2.0 [0.3;4.0] vs. 10 [4.3;18.0]; P < .0001 and 1.5 [0;3.0] vs. 3.5 [2.0;6.0]; P = .005; respectively). Two hours after the end of the bath, the BPS values had returned to baseline in both groups. CONCLUSION: In our population, music significantly decreased pain intensity and duration during the morning bed bath in mechanically ventilated patients. These results warrant further assessment in a large multicenter randomized controlled trial. TRIAL REGISTRATION: ClinicalTrials.gov NCT02883959.


Assuntos
Banhos/efeitos adversos , Musicoterapia/métodos , Manejo da Dor/métodos , Respiração Artificial/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Pessoas Acamadas , Cuidados Críticos , Feminino , França , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Dor/etiologia , Dor/fisiopatologia , Medição da Dor , Projetos Piloto , Estudos Prospectivos
15.
Seizure ; 61: 170-176, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30176574

RESUMO

PURPOSE: Few outcome data are available about morbidity associated with endotracheal intubation modalities in critically ill patients with convulsive status epilepticus. We compared etomidate versus sodium thiopental for emergency rapid sequence intubation in patients with out-of-hospital convulsive status epilepticus. METHODS: Patients admitted to our intensive care unit in 2006-2015 were studied retrospectively. The main outcome measure was seizure and/or status epilepticus recurrence within 12 h after rapid sequence intubation. RESULTS: We included 97 patients (60% male; median age, 59 years [IQR, 48-70]). Median time from seizure onset to first antiepileptic drug was 60 min [IQR, 35-90]. Reasons for intubation were coma in 95 (98%), acute respiratory distress in 18 (19%), refractory convulsive status epilepticus in 9 (9%), and shock in 6 (6%) patients; 50 (52%) patients had more than one reason. The hypnotic drugs used were etomidate in 54 (56%) and sodium thiopental in 43 (44%) patients. Seizure and/or status epilepticus recurred in 13 (56%) patients in the etomidate group and 11 patients (44%) in the sodium thiopental group (adjusted common odds ratio [aOR], 0.98; 95%CI, 0.36-2.63; P = 0.97). The two groups were not significantly different for proportions of patients with hemodynamic instability after intubation (aOR, 0.60; 95%CI, 0.23-1.58; P = 0.30) or with difficult endotracheal intubation (OR, 1.28; 95% CI 0.23 to 7.21; P=0.77). CONCLUSIONS: Our findings argue against a difference in seizure and/or status epilepticus recurrences rates between critically ill patients with convulsive status epilepticus given etomidate vs. sodium thiopental as the induction agent for emergency intubation.


Assuntos
Etomidato/uso terapêutico , Hipnóticos e Sedativos/uso terapêutico , Intubação/métodos , Estado Epiléptico/terapia , Tiopental/uso terapêutico , Idoso , Resultados de Cuidados Críticos , Feminino , Escala de Coma de Glasgow , Hemodinâmica/efeitos dos fármacos , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Estado Epiléptico/epidemiologia , Resultado do Tratamento
16.
Resuscitation ; 132: 147-155, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30086373

RESUMO

PURPOSE: To explore diagnostic pitfalls and treatment issues in out-of-hospital cardiac arrest of neurological cause (OHCA-NC). METHODS: Retrospective analysis of all consecutive patients from the Paris Sudden Death Expertise Centre (France) registry from May 2011 to September 2015 presenting with a sustained return of spontaneous circulation (ROSC) at hospital admission and a final diagnosis of OHCA-NC. Description of the early diagnostic check-up performed to identify the cause of cardiac arrest. Logistic multivariate regression to identify factors associated with immediate coronary angiography (iCAG) in OHCA-NC patients. RESULTS: Among 3542 patients with ROSC, a final diagnosis of OHCA-NC was established in 247 (7%). The early diagnostic check-up consisted in a total of 207 (84%) immediate cranial CT-scan, 66 (27%) iCAG and 25 (10%) chest CT-scan. The brain CT-scan allowed identifying a neurovascular cause in 116 (47%) patients. An iCAG was performed as the first line exam in 57 (23%) patients, in whom a final diagnosis of neurovascular cause for OHCA-NC was later identified in 41 patients. By multivariate analysis, decision for iCAG was independently associated with ST-segment elevation on post-ROSC electrocardiogram (OR, 5.94; 95%CI, 2.14-18.28; P = 0.0009), whereas an obvious cause of cardiac arrest on scene was negatively associated with iCAG (OR, 0.14; 95%CI, 0.02-0.51; P = 0.01). CONCLUSIONS: OHCA-NC is a rare event that is mainly related to neurovascular causes. The initial ECG pattern may be a confounder regarding triage for early diagnostic check-up. Further studies are required to explore the potential harmfulness associated with decision to perform an iCAG in this population.


Assuntos
Encéfalo/diagnóstico por imagem , Parada Cardíaca Extra-Hospitalar/etiologia , Idoso , Transtornos Cerebrovasculares/complicações , Transtornos Cerebrovasculares/diagnóstico , Angiografia Coronária/estatística & dados numéricos , Eletrocardiografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Exame Neurológico/estatística & dados numéricos , Parada Cardíaca Extra-Hospitalar/mortalidade , Paris/epidemiologia , Sistema de Registros , Estudos Retrospectivos , Tomografia Computadorizada por Raios X
18.
Resuscitation ; 130: 61-66, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29981819

RESUMO

BACKGROUND: While S-100B protein and Neuron-Specific Enolase (NSE) dosages have been extensively investigated for neurological prognostication after cardiac arrest (CA), there is no data about their ability to detect a cerebrovascular cause of CA. We assessed the utility of plasma S-100B protein and NSE measurements for early diagnosis of primary neurological cause in resuscitated CA patients. PATIENTS AND METHODS: Case control study based on two prospectively acquired CA databases. Patients with a primary cerebrovascular etiology were compared with randomly selected CA of non-neurological cause. S-100B protein and NSE were measured at ICU admission in all patients. RESULTS: CA was due to a cerebrovascular etiology in 18 patients (subarachnoid hemorrhage, n = 15; ischemic stroke, n = 3), with an ICU mortality of 100%. Comparative group was constituted with 66 patients (cardiac etiology n = 45, respiratory etiology n = 21), with an ICU mortality of 71%. Admission S-100B protein concentration was 2.0 [0.63-7.15] µg/L in the cerebrovascular group and 0.45 [0.24-1.95] in the non-cerebrovascular group (p < 0.001). In contrast, NSE concentration was similar in cerebrovascular and non-cerebrovascular etiologies (35 [25-103] µg/L vs. 27 [19-47] respectively, p = 0.16). Area under ROC curves for S-100B protein and NSE to predict cerebrovascular cause of CA was 0.75 [95% CI: 0.64-0.87] and 0.61 [95% CI: 0.45-0.76], respectively. CONCLUSIONS: Even if S-100B protein dosage performs slightly better than NSE, early dosages of these biomarkers are poorly predictive of a cerebrovascular etiology of CA. Our results suggest that early measurement of brain biomarkers should not be recommended to tailor the imaging strategy employed to investigate the CA cause.


Assuntos
Parada Cardíaca Extra-Hospitalar , Fosfopiruvato Hidratase/sangue , Subunidade beta da Proteína Ligante de Cálcio S100/sangue , Acidente Vascular Cerebral , Idoso , Biomarcadores/sangue , Estudos de Casos e Controles , Diagnóstico Precoce , Feminino , França/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/etiologia , Parada Cardíaca Extra-Hospitalar/mortalidade , Parada Cardíaca Extra-Hospitalar/terapia , Valor Preditivo dos Testes , Prognóstico , Curva ROC , Acidente Vascular Cerebral/sangue , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/diagnóstico
19.
Crit Care Med ; 46(8): e751-e760, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29742585

RESUMO

OBJECTIVES: Cardiac arrest is a catastrophic event that may arise during the management of convulsive status epilepticus. We aimed to report the clinical characteristics, outcomes, and early predictors of convulsive status epilepticus-related cardiac arrest. DESIGN: Retrospective multicenter study. SETTING: Seventeen university or university affiliated participating ICUs in France and Belgium. PATIENTS: Consecutive patients admitted to the participating ICUs for management of successfully resuscitated out-of-hospital cardiac arrest complicating the initial management of convulsive status epilepticus between 2000 and 2015. Patients were compared with controls without cardiac arrest identified in a single-center registry of convulsive status epilepticus patients, regarding characteristics, management, and outcome. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We included 49 cases with convulsive status epilepticus-cardiac arrest and 235 controls. In the cases, median time from medical team arrival to cardiac arrest was 25 minutes (interquartile range, 5-85 min). First recorded rhythm was asystole in 25 patients (51%) and pulseless electrical activity in 13 patients (27%). A significantly larger proportion of patients had a favorable 1-year outcome (Glasgow Outcome Scale score of 5) among controls (90/235; 38%) than among cases (10/49; 21%; p = 0.02). By multivariate analysis, independent predictors of cardiac arrest were pulse oximetry less than 97% on scene (odds ratio, 2.66; 95% CI, 1.03-7.26; p = 0.04), drug poisoning as the cause of convulsive status epilepticus (odds ratio, 4.13; 95% CI, 1.27-13.53; p = 0.02), and complications during early management (odds ratio, 11.98; 95% CI, 4.67-34.69; p < 0.0001). Having at least one comorbidity among cardiac, respiratory, and neurologic (other than epilepsy) conditions predicted absence of cardiac arrest (odds ratio, 0.28; 95% CI, 0.10-0.80; p = 0.02). CONCLUSIONS: In patients managed for convulsive status epilepticus, relative hypoxemia, on-scene management complications, and drug poisoning as the cause of convulsive status epilepticus were strong early predictors of cardiac arrest, suggesting areas for improvement.


Assuntos
Parada Cardíaca/epidemiologia , Parada Cardíaca/terapia , Estado Epiléptico/epidemiologia , Estado Epiléptico/terapia , Adulto , Idoso , Reanimação Cardiopulmonar , Doenças Cardiovasculares/epidemiologia , Comorbidade , Eletroencefalografia , Feminino , Humanos , Hipóxia/epidemiologia , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Doenças do Sistema Nervoso/epidemiologia , Respiração Artificial/métodos , Doenças Respiratórias/epidemiologia , Estudos Retrospectivos , Índice de Gravidade de Doença , Fatores de Tempo , Vasoconstritores/administração & dosagem
20.
Resuscitation ; 128: 204-210, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29555261

RESUMO

PURPOSE: Although guidelines on post-resuscitation care recommend the use of short-acting agents for sedation during targeted temperature management (TTM) after cardiac arrest (CA), the potential advantages of this strategy have not been clinically demonstrated. METHODS: We compared two sedation regimens (propofol-remifentanil, period P2, vs midazolam-fentanyl, period P1) among comatose TTM-treated CA survivors. Management protocol, apart from sedation and neuromuscular blockers use, did not change between the two periods. Baseline severity was assessed with Cardiac-Arrest-Hospital-Prognosis (CAHP) score. Time to awakening was measured starting from discontinuation of sedation at the end of rewarming. Awakening was defined as delayed when it occurred after more than 48 h. RESULTS: 460 patients (134 in P2, 326 in P1) were included. CAHP score did not significantly differ between P2 and P1 (P = 0.93). Sixty percent of patients awoke in both periods (81/134 vs. 194/326, P = 0.85). Median time to awakening was 2.5 (IQR 1-9) hours in P2 vs. 17 (IQR 7-60) hours in P1. Awakening was delayed in 6% of patients in P2 vs. 29% in P1 (p < 0.001). After adjustment, P2 was associated with significantly lower odds of delayed awakening (OR 0.08, 95% CI 0.03-0.2; P < 0.001). Patients in P2 had significantly more ventilator-free days (25 vs. 24 days; P = 0.007), and lower catecholamine-free days within day 28. Survival and favorable neurologic outcome at discharge did not differ across periods. CONCLUSIONS: During TTM following resuscitation from CA, sedation with propofol-remifentanil was associated with significantly earlier awakening and more ventilator-free days as compared with midazolam-fentanyl.


Assuntos
Anestésicos Intravenosos/administração & dosagem , Fentanila/administração & dosagem , Hipotermia Induzida/métodos , Midazolam/administração & dosagem , Propofol/administração & dosagem , Remifentanil/administração & dosagem , Adulto , Idoso , Anestésicos Intravenosos/farmacologia , Coma/etiologia , Coma/terapia , Sedação Profunda , Quimioterapia Combinada , Feminino , Fentanila/farmacologia , Humanos , Infusões Intravenosas/métodos , Masculino , Midazolam/farmacologia , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/complicações , Parada Cardíaca Extra-Hospitalar/terapia , Propofol/farmacologia , Estudos Prospectivos , Sistema de Registros , Remifentanil/farmacologia , Tremor por Sensação de Frio/efeitos dos fármacos , Vigília/efeitos dos fármacos
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