- Meeting Abstracts
- Open Access
37th International Symposium on Intensive Care and Emergency Medicine (part 2 of 3)
Brussels, Belgium. 21-24 March 2017
Critical Care volume 21, Article number: 56 (2017)
P171 The use of extracorporeal membrane oxygenation for ventricular septal rupture complicated by refractory cardiogenic shock
D Rob, R Špunda, J Lindner, J Šmalcová, O Šmíd, T Kovárník, A Linhart, J Bìlohlávek
First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic, Prague, Czech Republic
Introduction: Ventricular septal rupture (VSR) is an unusual mechanical complication of myocardial infarction (MI) in the era of reperfusion therapy, but the mortality rate of patients who present with cardiogenic shock (CS) remains extremely high. Whereas current American and European guidelines recommend urgent surgical repair regardless of hemodynamic status, promising outcomes have been repeatedly reported with the use of circulatory support, enabling hemodynamic stabilization and delaying repair after consolidation of the infarct scar. Therefore, we analyzed our experience with the use of Veno-Arterial Extracorporeal Membrane Oxygenation (V-A ECMO) in post-infarction VSR.
Methods: We conducted a retrospective search of institutional database of all patients presenting with post-infarction VSR from January 2007 to June 2016. Data of 33 consecutive patients were retrospectively reviewed and analyzed.
Results: In our center, 7 out of 33 patients with post-MI VSR and refractory CS (despite vasopressor and intraaortic balloon pump therapy) received V-A ECMO support. V-A ECMO improved end-organ perfusion with lower lactate levels 24 hours after implantation (7.514 vs. 1.514, p < 0.005), normalized arterial pH (7.25 vs. 7.40, p < 0.036), improved mean arterial pressure (64 mm/Hg vs. 83 mm/Hg, p < 0.001) and lowered heart rate (115/min vs. 68/min, p < 0.001) in all patients. Mean duration of ECMO support was 12 days, 5 out of 7 patients underwent surgical repair, 4 were successfully weaned from ECMO, 3 survived 30 days and 2 survived more than 1 year. The most frequent complication (5 patients) as well as the cause of death (3 patients) was bleeding.
Conclusions: Our experience suggest that V-A ECMO support in patients with VSR and refractory CS improves end-organ perfusion, provides hemodynamic stabilization and increases time for cardiovascular team decision. Bleeding complications are an important limitation of this method.
P172 Feasibility of cerebral circulatory arrest diagnosis by TCD in VA ECMO patients
MM Marinoni1, G Cianchi2, S Trapani2, ML Migliaccio2, L Gucci2, M Bonizzoli2, A Cramaro2, M Cozzolino2, S Valente2, A Peris2
1University of Florence, Florence, Italy; 2Careggi Teaching Hospital, Florence, Italy
Introduction: The aim of our study is to investigate the feasibility of Transcranial Doppler (TCD) in Veno-arterial (VA) ECMO patients for confirmation of Cerebral Circulatory Arrest (CCA) in Brain Death (BD) diagnosis.
BD can occur in VA ECMO patients  and TCD is an accepted technique for BD confirmation in many countries and also in Italy . In these patients, presence of Intra-aortic Balloon Pump (IABP) and residual cardiac contractility can influence TCD patterns.[3,4]
Methods: In this monocentric retrospective study TCD was performed in 5 patients evolved to BD. Left Ventricular Ejection Fraction (LVEF) values and the presence or absence of IABP were taken into account.
Results: Haemodynamic conditions of the sample study are summarized in Table 1. TCD diagnostic patterns of CCA were found in all patients in all cerebral arteries. In 2 patients TCD evaluation was available before and in CCA.
Conclusions: In the case of BD, TCD seems to be a reliable instrumental test for CCA diagnosis in patients on VA ECMO treatment with a pulsatile flow (native or IABP support).
1. Pokersnik JA et al. J Card Surgery 27: 246–252, 2012
2. National Transplantation Council Guidelines, 2009
3. Yang F et al. J Transl Med 12:106, 2014
4. Kavi T et al. Journal of Stroke and Cerebrovascular Diseases, 2016
P173 A dysbalance in t-cell response predicts in-house mortality in VA-ECMO patients
E Grins1, E Kort2, M Weiland3, N Manandhar Shresta2, P Davidson3, L Algotsson1, S Fitch2, G Marco2, J Sturgill2, S Lee2, M Dickinson2, T Boeve2, A Khaghani2, P Wilton2, S Jovinge2
1Scania Univ Hospital Lund, Lund, Sweden; 2Spectrum Health Hospitals, Grand Rapids, MI, United States; 3Van Andel Institute, Grand Rapids, MI, United States
Introduction: ECMO treatment has continuously been associated with high mortality. CD4/CD8 T-cell ratio has been used to monitor loss in immune function HIV patients and high ratio has been reported in allograft connected to worse outcome.
Methods: Patients (n = 51) eligible for VA ECMO treatment at Meijer Heart Centre in Grand Rapids Michigan were consented through by themselves or their Legal Representatives. Blood was drawn before the patient was cannulated.
Results: Non-survivors had higher CD4/CD8 p < 0.0266 than non-survivers. IN ROC regression CD4/CD8 ratio performed second best AUC 0.72
Conclusions: A more aggressive T-cell activation as reflected by CD4/CD8 ratio is related to mortality.
P174 ENCOURAGE…ing results for veno-arterial ECMO in myocardial infarction
AN Ahmad, R Loveridge, S Vlachos, S Patel, E Gelandt, L Morgan, S Butt, M Whitehorne, V Kakar, C Park, M Hayes, C Willars, T Hurst, T Best, A Vercueil, G Auzinger
King´s College Hospital, London, United Kingdom
Introduction: The ENCOURAGE score is a mortality risk score for acute myocardial infarction (AMI) patients treated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) using pre-ECMO parameters. 
Only 41% of patients in the ENCOURAGE dataset survived six months with 20% of them requiring VAD or heart transplant.
This study aims to evaluate our 6-month outcomes against those predicted by the score.
Methods: All consecutive patients receiving VA-ECMO post AMI between 2012 and 2016 had data prospectively collected for analysis and an ENCOURAGE score calculated, using the seven parameters that comprise the score: age, sex, BMI, GCS, creatinine, lactate and prothrombin activity.
Patient outcomes using six-month follow-up data were compared and a standardized mortality ratio (SMR) calculated.
Results: 12 patients were included. Median ENCOURAGE score was 27 (IQR 6) with 83% in the worst risk classes. Predicted survival of our cohort according to the score was 18%.
42% were initiated as eCPR, 92% were after cardiac arrest (45% OHCA, 55% IHCA), mean lactate was 11.9 (SD + - 6.7), median SOFA 16 (IQR 4).
75% were ECMO survivors and 50% were alive at six months without VAD or transplantation, all with good Cerebral Performance Category scores.
The ENCOURAGE SMR is 0.611 (95% CI 0.25-1.27).
Conclusions: Risk prediction models that use pre-ECMO criteria can be used to assess the performance of ECMO centres [2,3] and this technique can be extended to sub-group analysis.
Previous studies have suggested poorer outcomes (36% , 21% ), in line with the ENCOURAGE dataset but the service exceeds predicted outcomes, and we recommend against restrictive criteria for the use of VA-ECMO.
The UK also needs to consider destination therapy for those surviving ECMO but not ICU.
 Muller G et al. Intensive care medicine. 2016;42(3):370–8.
 Chaddock et al. EuroELSO 2016
 Loveridge et al. Crit Care 20:94. 2016
 Boqambar et al. EuroELSO 2016
 Francis et al. EuroELSO 2016
P175 Veno-arterial extracorporeal membrane oxygenation for cardiac support: a single center experience
B Adibelli, N Akovali, A Torgay, P Zeyneloglu, A Pirat, Z Kayhan
Ankara Baskent Hospital, Ankara, Turkey
Introduction: Veno-arterial extracorporeal membrane oxygenation (VA ECMO) ensures end-organ perfusion while fully replacing heart and lung function to allow time for possible heart recovery or may bridge patients to heart transplantation or ventricular assist device (VAD) implantation. We review our 4-year experience regarding VA-ECMO use for cardiac support including early, midterm outcomes and survival.
Methods: This is a retrospective analysis of patients undergoing VA-ECMO for cardiac support from January 2012 to December 2015. ECMO was performed through the femoral vessels percutaneously with ultrasound guidance in 39 of them and through the right atrium to ascending aorta in 7 of them during cardiac surgery. VA-ECMO was applied during or after cardiac surgery in 30 (65%), not related to surgery in 16 (35%) out of 46 patients. Extracorporeal CPR was done in 6 patients.
Results: A total of 46 patients were supported with VA-ECMO. Mean age of patients was 47.7 ± 20.9 years with 67.7% males. The leading diagnoses were dilated cardiomyopathy, heart failure and coronary artery disease. Mean duration of VA-ECMO support was 226.9 ± 283.4 hours. Overall, 14 (30.4%) patients were successfully weaned off ECMO and survived, 32 (69.6%) patients died due to multifactorial complications. Overall, 12 patients were bridged to heart transplantation and 8 patients to left VAD. The 30-day and 6-month survival rates were 41% and 20%, respectively. Requirement for mechanical ventilation before and after VA-ECMO implantation was significantly less in patients who survived (p < 0.05).
Conclusions: In cases of cardiomyopathy refractory to medical treatment, failure to wean off cardiopulmonary bypass and refractory shock post cardiac arrest, circulation can be supported with VA-ECMO. Our experience among 46 patients implanted with VA-ECMO for cardiac support, survival to discharge was 30%. Survival was significantly better in those patients who did not require mechanical ventilation before and after VA-ECMO implantation.
P176 Use of automated chest compression devices after out-of-hospital cardiac arrest in Sweden
SS Schmidbauer1, J Herlitz2, T Karlsson3, H Friberg1
1Skåne University Hospital, Lund, Lund, Sweden; 2PreHospen, University of Borås, The Pre-hospital Research Centre of Western Sweden, Borås, Sweden; 3Health Metrics, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
Introduction: Although shown not to increase survival rates, automated chest compression (ACC) devices are frequently utilised after out-of-hospital cardiac arrest (OHCA) in Sweden. With no implementation guidelines available, it is not known how these devices are put to use. In this retrospective observational study, we evaluated the utilisation of ACC devices in Sweden between the years 2011-2015. The association between ACC-CPR and 30-day survival was also assessed.
Methods: The Swedish Cardiopulmonary Resuscitation Registry is a prospectively recorded nationwide registry of modified Utstein-style parameters with a coverage of close to 100% of OHCA cases where resuscitation was attempted. Propensity score matching (PSM) and logistic regression with multiple imputation (MI) were used to study the association between ACC-CPR and survival.
Results: During the study period, 25898 patients were identified in the registry. After exclusions, 24316 were included in the study population. Of these, 32.4% received ACC-CPR. Overall, unadjusted 30-day-survival was 6.3% in the ACC-CPR group, 12.8% in the manual CPR group and 10.7% for the entire study population. Male gender and an initial shockable rhythm were factors associated with ACC device use, whereas crew witnessed status was associated with manual CPR. Administration of adrenaline and antiarrhythmics was also more prevalent in the ACC-CPR group, and so was intubation (Table 2).
The odds ratio for 30-day survival regarding ACC device utilisation was 0.72 (95% CI 0.62-0.84), p < .001 by means of PSM (n = 13922). Similar results were seen using stratification on the PS (n = 20633) as well as logistic regression with MI (data not shown).
Conclusions: Automated chest compression devices are frequently used after OHCA and predominantly so for patients with a more refractory condition. Their use might be associated with lower survival rates.
P177 Mechanical ventilation during CPR
R Knafelj, P Radsel
Rihard Knafelj, Ljubljana, Slovenia
Introduction: Guidelines for mechanical ventilation (MV) during cardiopulmonary resuscitation suggest low frequency (f) with normal tidal volume (Vt) avoiding hyperventilation and hyperinflation. During inhospital cardiac arrest in patients that are already mechanically ventilated, optimal ventilatory strategy is not known. We hypothesized that using CPR ventilation mode results in better Vt and (f) compared to bag ventilation, volume (V-AC) or pressure (P-AC) ventilation.CPR mode has pre-configured settings (FiO2 1.0,PEEP 5/20 cmH2O, f 12/min), alarms are deactivated, ventilation is synchronized with chest compressions
Methods: 40 tests were performed. Ventilation with V-AC (450 mL, PEEP 5 cmH2O, max pressure limit 30 cmH2O) was set (Elisa 800,HL,Germany). After chest compressions started group 1remained in V-AC, group 2 was switched to bag ventilation, group 3 to BIPAP, group 4 to CPR mode. During chest compressions changes in settings but not in mode were allowed. Vt, f of ventilation and chest compressions rate were measured in all groups
Results: During CPRf of chests compression did not differ across groups (118 ± 4, 110 ± 12, 113 ± 10, 112 ± 8 group 1, 2, 3, 4 respectively). Vt were significantly lower in groups 1, 3 and 4 (87 ± 47, 48 ± 71, 268 ± 46 mL respectively) compared to group 2 (1139 ± 133, p < 0.005) due to reached high pressure limit (group 1, 3, 4) or excessive bagging (group 2). Group 4 received higher Vt compared to group 2 and 3 (p < 0.005). Ventilation f was higher in groups 1, 2 and 3 (18 ± 3, 21 ± 4, 20 ± 3 respectively) compared to group 4 (12 ± 0p, <0.005)
Conclusions: CPR ventilation mode prevents hypo/hyperventilation and hyperinflation compared to other modes. Better guidelines compliance was demonstrated for chest compression rate. Clinical impact of newly implemented CPR ventilation mode warrants further studies.
Soar J et al. ALCS. Resuscitation.2015.95:100–47
P178 New system to control FDO2 with bag valve mask for premature infants
F Duprez1, T Bonus1, G Cuvelier2, S Mashayekhi1, M Maka1, S Ollieuz1, G Reychler3
1Epicura, Hornu, Belgium; 2Condorcet, Tournai, Belgium; 3UCL, Bruxelles, Belgium
Introduction: According to the recommendations of the European Resuscitation Council (ERC), Cardio Pulmonary Resuscitation (CPR) in premature infants must be made with a fraction of delivered oxygen (FDO[sub]2[/sub]) not exceeding 30%. Bag valve masks for premature infant (BVMp) can be used for ventilation and oxygenation during CPR. In such a case, even with a low oxygen flow rate (OFR), a BVMp delivers higher FDO[sub]2[/sub] than recommended. Indeed, with a BVMp, FDO[sub]2[/sub] rises proportionally to OFR but decreases inversely proportionally to minute ventilation (MV). Therefore, in neonatology resuscitation, controlling and maintaining the FDO[sub]2[/sub] below 30% is very difficult, even with a low OFR. To meet the ERC recommendations, we developed a new system aimed at delivering adequate FDO[sub]2[/sub] with a BVMp: the DupRey system. This system uses the Venturi effect to provides a stable air-oxygen mixture to a BVMp. The present study was aimed at evaluating the actual O[sub]2[/sub] fraction delivered between bag valve masks for premature infant used conventionally or used with the DupRey system.
Methods: On a bench study, a BVMp (Laerdal™ for premature infant type 850150) was connected to a test lung (Maquet™ VA800 - compliance 0,02 L/cm H[sub]2[/sub]O - resistance 20 cm H[sub]2[/sub]O/L/sec. With the BVMp, two MV (0.7 L/min and 1 L/min) were generated. A metronome gave the frequency of insufflations. The BVMp was tested both with and without oxygen reservoir (OR) and the pop off valve was closed. Two OFR: 0.6 and 1 L/min were analyzed and compared to the DupRey with Venturi 24% and 28% (OFR: 5 L/min). OFR were analyzed by a thermal mass flow meter Vogtlyn™ Red Y. The FDO[sub]2[/sub] and MV measurements were made using an analog iWorx® acquisition system (GA207 gas analyzer associated with digital IWx 214) and LabScribe II ® software.
Statistical: One Way Repeated Measures Analysis of Variance followed by Holm Sidak method.
Results: Statistical differences (p < .001) were found between A5-A6 / B5-B6 and all other columns. However, no statistical differences were found between: B2 and A2, A6 and B6, B5 and A5.
Conclusions: For an oxygen flow ranging from 0.6 to 1 L/min and two MV analyzed, a Bag Valve Masks for premature infant with an OR delivers very high FDO[sub]2[/sub] (>86%). Without OR, at same OFRs, FDO[sub]2[/sub] decreases but they maintain high values (>44%). The DupRey delivers FDO[sub]2[/sub] < to 30% regardless MV. The DupRey system is easily accessible for medical teams who do not have access to modern technology.
WyllieJ. ERC Guidelines for Resuscitation 2015: Resuscitation. 2015 Oct. 95: 249–63.
P179 Could echocardiography have prognostic value in patients after successful resuscitation?
R Mosaddegh, S Abbasi, S Talaee
Iran University of Medical Sciences, Tehran, Iran
Introduction: After successful cardio pulmonary resuscitation, many patients have poor outcome, because of current illness that causes cardiopulmonary arrest, or complications of resuscitation or any other problem. Researchers want to know if echocardiography have prognostic value in these patients.
Methods: In this case series the researchers enroll 50 patients with successful resuscitation in three general hospitals. Echocardiography was done for all patients without considering the duration of resuscitation in 24 hours after ROSC and ventricular and septal wall motion was observed for hypokinesia, akinesia or dyskinesia. Ejection Fraction (EF), E-Point Septal Separation (EPSS), Inferior Vena Cava (IVC) diameter and presence of Hepatic Portal Vein Gas (HPVG) and 24 hour's survival was measured. The relation between outcome and these echocardiographic findings were observed then.
Results: Twenty eight participants were survived and 22 were died. The median age of participants was 55.52 (SD: ±23.57) years. The mean EF for all participants was 26.74 ± 18.26 percent. The mean EF was 27.82 (SD ± 15.79) in survivors and 25.89 (SD ± 20.23) without statistically significant difference (P < 0.05). Ventricular wall motion, HPVG presence and IVC diameter has no statistically significant difference in both survivors and non survivors (P < 0.05).
Conclusions: Based on the results of this study it seems that echocardiographic findings in the first 24 hours of post resuscitation period could not help to predict the prognosis of survivors of cardio-pulmonary arrest, and it's not reasonable to send the post resuscitative patients to the other wards to do echocardiography in the first 24 hours after resuscitation.
P180 Diagnostic and therapeutic value of coronary angiography and ct-scan after extracorporeal cardiopulmonary resuscitation (eCPR) – a single center registry study
VZ Zotzmann, DS Staudacher, TW Wengenmayer, DD Dürschmied, CB Bode
Heart Center, Freiburg, Germany
Introduction: Implantation of a venoarterial extracorporeal membrane oxygenation (ECMO) in patients with ongoing cardiopulmonary resuscitation without return of spontaneous circulation (eCPR) can stabilize hemodynamics. Further diagnostic work up is needed in order to diagnose and treat the cause of the collapse. Patients after eCPR compromise a heterogeneous population with more severe underlying pathologies when compared to patients with return of spontaneous circulation. Aim of this study is the evaluation of the diagnostic value of coronary angiography and CT-scan after eCPR.
Methods: All patients after eCPR treated at a single tertiary referral hospital between December 2010 and November 2015 were included in a retrospective registry study.
Results: A total of 123 patients were considered (age 59.5 ± 15.3 years, low-flow time 59.0 ± 28.2 min, survival 11.4%). 52 patients presented with non-shockable rhythm (age 63.8 ± 16.1 years, low-flow duration 51.0 ± 23.1 min, survival 15.4%) while 71 patients presented with either a shockable rhythm or ST-elevation (age 56.3 ± 14.0 years, low-flow duration 64.8 ± 30.2 min, survival 8.5% p < .01, <.01 and .03, respectively).
Coronary angiography was performed significantly less frequent in patients with non-shockable rhythm (59.6% vs. 93.0% p < .01), see Fig. 6. A lesion deemed responsible for collapse however was found at similar rates in both groups (71.0% with non-shockable rhythm vs. 83.3% with ST-elevation or shockable rhythm, p = .18).
CT-scan was performed at similar rates in both groups (65.4% vs 50.7%, p = .14). Pathologies deemed responsible for collapse however were found more often in patients with non-shockable rhythm (23.5% vs. 0%, p < .01). CT-Scan yielded findings relevant to the further treatment frequently in both groups (92.2% vs 91.6%, p = 1). Cause of collapse could be detected by CT-scan at significantly lower rates when compared to coronary angiography in both groups (23.5% vs.71.0% and 0% vs. 83.3%, both p < .01).
Conclusions: Coronary angiography yielded a significantly better diagnostic value than CT-scan after eCPR disregarding initial rhythm or presence of ST-elevation. Considering the potential therapeutic option, a coronary angiography first approach might be preferable. A routine CT-scan however might be reasonable in all patients since findings relevant to the further treatment are frequent.
P181 Comparison of FiO2 50% or 100% on brain oxygenation and cardiac mitochondrial function in experimental cardiac arrest
A Nelskylä1, J Nurmi2, M Jousi2, A Schramko1, E Mervaala2, G Ristagno3, M Skrifvars1
1Helsinki University Hospital, Helsinki, Finland; 2Helsinki University Hospital and University of Helsinki, Helsinki, Finland; 3Istituto di Ricerche Farmacologiche “Mario Negri”, Milan, Italy
Introduction: Guidelines advocate 100% oxygen during CPR. We hypothesized that 50% oxygen during CPR maintains cerebral oxygenation and compared to 100%, alleviates cardiac mitochondrial injury.
Methods: With Finnish National Animal Experiment Board (ESAVI/1077/04.10.07/2016) approval, ventricular fibrillation (VF) was induced electrically in anaesthetized adult pigs and left untreated for 7 minutes, followed by randomization to mechanical CPR (LUCAS) with 50% or 100% oxygen. Defibrillation was performed at 13 minutes and if unsuccessful, CPR continued for 20 minutes with defibrillation and 1 mg adrenaline every 2 minutes. Cerebral oxygenation was measured with near-infrared spectroscopy (rSO2, INVOS™ 5100C Cerebral Oximeter) and invasive brain tissue oxygen (pbO2) with an intraparenchymal probe (NEUROVENT-PTO, RAUMEDIC) in the frontal cortex. A heart biopsy was obtained 20 minutes after ROSC with analysis of mitochondrial respiration (OROBOROS Instruments Corp., Innsbruck, Austria) and compared to 4 control animals. Data are shown as mean with standard deviation (SD). Brain rSO2 and pbO2 were compared between groups over time with mixed linear model with mean arterial blood pressure (MAP) as covariate. Mitochondrial respiration was compared with analysis of variance.
Results: Of 20 pigs, one had a breach of protocol and were excluded leaving 9 in the 50% group and 10 in the 100% group. Groups were similar regarding rSO2 and pbO2 before CPR. With a median time of 15 minutes, 6 pigs achieved ROSC in the 50% group and 8 pigs in the 100% group. During resuscitation time was significantly associated with rSO2 (p < 0.001) and pbO2 (p < 0.001). The rSO2 (0.012) was lower with FiO2 50%, but pbO2 was not (p = 0.43). Mean arterial pressure was associated with pbO2 (p = 0.045). After ROSC the rSO2 (p < 0.001) and pbO2 (p < 0.001) increased significantly over time without difference between oxygen groups (p = 0.37, p = 0.18). Compared to controls mitochondrial respiration was decreased with adenosine diphosphate (ADP) levels of 57 (17) Pmol/sec/mg compared to 92 (23) Pmol/sec/mg (p = 0.008), no difference was seen between oxygen groups (p = 0.79).
Conclusions: Use of 50% oxygen during CPR results in lower oxygen content in blood, but brain tissue oxygenation can be maintained with efficient CPR. After ROSC brain oxygen increases rapidly. Cardiac arrest results in disturbed cardiac mitochondrial respiration but this is not alleviated with the use of 50% oxygen.
P182 Pediatric extracorporeal cardiopulmonary resuscitation experiences of a pediatric intensive care unit
G Ozsoy, T Kendirli, E Azapagasi, O Perk, U Gadirova, E Ozcinar, M Cakici, C Baran, S Durdu, A Uysalel, M Dogan, M Ramoglu, T Ucar, E Tutar, S Atalay, R Akar
Ankara Univercity, Ankara, Turkey
Introduction: Extracorporeal membrane oxygenation (ECMO) has been used during cardiopulmonary resuscitation (CPR) to improve the outcomes in selected patients. According to the international registry of the Extracorporeal Life Support Organization (ELSO), more than 1232 (41%) children have benefited from ECMO-assisted CPR (ECPR) since its introduction. We want to summarize our ECPR experiences in our unit.
Methods: This is a retrospective study performed in the 15-bed tertiary Pediatric Intensive Care Unit (PICU) at Ankara University Hospital. The children who underwent ECPR from September 2014 to August 2016 were assessed.
Results: Eight children underwent ECPR in our unit. Their median age and weight were 80.5 months and 35 kilograms respectively. They were all hospital-arrest. Their primary diseases were 62.5% cardiac and 37.5% non-cardiac. The causes of cardiac arrest were dysrhythmia (37.5%), heart failure (25%), sepsis (12.5%), bleeding (12.5%), low cardiac output syndrome (12.5%) and airway disease (12.5%). ECPR was performed in PICU (6) and in operation room (2). ECMO was started in the 78 minutes (median) of CPR. The time of ECPR was 85 minute (median). ECMO cannulas were placed in femoral vein-femoral artery (5), central (2), and internal jugular vein-carotid artery (1). The cannulas were not able to place in two patients. ECMO did not work in two patients which cannulated central and femoral vein-femoral artery. ECMO succeeded in 4 (50%) patients. The range of the ECMO time after ECPR was 12 hours and 9 days.
Conclusions: ECPR improves survival after cardiac arrest, especially in the patients who might benefit from this treatment.
P183 Midazolam is an independent risk factor for prolonged awakening after cardiac arrest
M Kamps1, G Leeuwerink2, J Hofmeijer2, O Hoiting3, J Van der Hoeven1, C Hoedemaekers1
1Radboudumc, Nijmegen, Netherlands; 2Rijnstate, Arnhem, Netherlands; 3Canisius Wilhelmina Ziekenhuis, Nijmegen, Netherlands
Introduction: Neurologic prognostication after cardiac arrest is a delicate process with lots of confounders that influence the outcome of these patients. Sedation is known as one of the major confounders. We assessed the hypothesis that prolonged awakening after cardiac arrest is mainly caused by the use of long-acting sedation.
Methods: This is a retrospective, multicentre, cohort study. We studied patients with ROSC after cardiac arrest in three different hospitals. We studied variables such as the cumulative dosage of sedatives, time of awakening after cessation of sedation, renal function, targeted temperature and GOS score after six months. Renal function was defined as the RIFLE score at admission. Early awakening was defined as awakening within 48 hours after cessation of sedation. The Glasgow coma scale was used to score awakening, with a motor score of 6 with an eye score of 3 or 4 defined as awakening. The patients with good neurologic outcome were divided in an early and late awakening group. Good neurologic outcome was defined as a GOS score of 4 or 5 after six months.
Results: We studied 122 patients with a good neurologic outcome after six months. Demographic variables such as age, weight, ROSC and targeted temperature were similar in the early and late awakening group. In the late awakening group 92% of the patients were treated with midazolam at day 0 compared to 57% in the early awakening group (p = 0.021). At day 1 83% of the patients with late awakening were treated with midazolam vs 56% in the early awakening group (p = 0.063). The cumulative dosage of midazolam did not differ between both groups (169 mg/24 hr in the early awakening group and 188 mg/24 hr in the late awakening group P = 0.613). Renal function was similar in both groups, RIFLE 0 in 81.8% in the early awakening group vs 67.7% in the late awakening group (P = 0.269) The patients in the early awakening group were significantly more often treated with propofol 74.5% vs 41.7% the late awakening group (P = 0.017) The dosage was significantly higher in the early awakening group. (2466 mg/24 hr in the early awakening group vs 643 mg/24 hr late awakening group p = 0.05)
Conclusions: In conclusion the use of midazolam, independent of the dosage or renal function, is a risk factor for prolonged awakening after cardiac arrest. Thereby midazolam could be a major confounder in the prognostication of neurologic outcome. The current protocol advises the use of opioids and hypnotics. We suggest that, if possible, patients after cardiac arrest are treated with short-acting sedation only to prevent inaccurate neurologic prognostication due to sedation effects.
P184 The influences of ketamine or morphine on hemodynamics, acid-base status and early survival in rats after asphyxia cardiac arrest: a pilot study
A Konkayev1, V Kuklin2, T Kondratyev3, M Konkayeva1, N Akhatov1, M Sovershaev4, T Tveita3, V Dahl2
1Astana Medical University, Astana, Kazakhstan; 2Akershus University Hospital, Oslo, Norway; 3The Arctic University of Norway, Tromsø, Norway; 4University Hospital of Northern Norway, Tromsø, Norway
Introduction: Acute hypoxia results in uncontrolled release of glutamate and the consequent stimulation of NMDA receptors, which affects the whole ionic homeostasis and finally activates apoptosis of neurons . A potential therapeutic approach to prevent this sequence of events is a blockade of NMDA receptors. Meanwhile, in different models of acute hypoxia, activation of delta-opioid receptors by morphine demonstrates cardioprotective effect with a consequent increase in animal survival . Thus, we aimed to test the effects of morphine or ketamine on hemodynamics, acid-base status and early survival in rats after asphyxia cardiac arrest (ACA)
Methods: After instrumentation under anaesthesia with Thiopental sodium (60 mg/kg, i.p.), Wistar rats (n = 21) weighing between 350–400 g were randomly assigned to three groups where: 1. Morhpine 5 mg/kg iv (n = 7) was given 10 min before ACA; 2. Ketamine 40 mg/kg iv (n = 7) was given 10 min before ACA; 3. Control (n = 7), the same amount of NaCl 0,9% iv was given 10 min before ACA. The rats were asphyxiated by clamping the tracheostomia tube at the end of expiration for 5 min. Resuscitation included epinephrine (0.02 mg/kg, iv), manual thoracic compressions (180 per min) and mechanical ventilation (21% O2, 80 breaths/min). Invasive MAP was recorded at the baseline (BL), every 1 min during ACA and every 5 min in post-resuscitation (PR) period. Blood gas samples were taken at the BL and 10 min at the PR period. Early survival was determined at the 20 min after ACA.
Results: No differences in MAP between the rats was found at the BL period. The rats pre-treated by ketamine got significantly higher MAP during PR period (133.9 ± 30.4 vs 52.7 ± 37.3 and 60.0 ± 26.2 mm Hg, respectively, p < 0.002) and had significantly lower production of lactate (11.8 ± 2.2 vs 13.5 ± 1.5 and 15.6 ± 1.2 mmol/l, respectively, p < 0.002) when compared to the rats treated by morhpine and only saline. Six of the seven rats survived at the 20 min after ACA in the ketamine group while four of the seven and two of the seven rats survived in the morhpine and Control groups respectively (P = 0.122).
Conclusions: Pre-treatment with ketamine attenuated significantly disturbances in hemodynamics and lactate after ACA, but it did not improve early survival when compared to the rats pre-treated by morphine or saline.
1. Choi DW. Neuron 1988;1:623–34
2. Endoh H, et al. Crit Care Med 2001;29:623–7
P186 Ubiquitin c-terminal hydrolase l1 as a predictor of neurological outcome after cardiac arrest and resuscitation
L Wihersaari1, MB Skrifvars2, S Bendel3, KM Kaukonen4, J Vaahersalo4, J Romppanen5, V Pettilä4, M Reinikainen1
1North Karelia Central Hospital, Joensuu, Finland; 2Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; 3Kuopio University Hospital, Kuopio, Finland; 4Helsinki University and Helsinki University Hospital, Helsinki, Finland; 5Eastern Finland Laboratory Centre, Kuopio, Finland
Introduction: Ubiquitin C-terminal hydrolase L1 (UCHL1) is an enzyme present in central nervous system neurons. We aimed to assess UCHL1 as a predictor of neurological outcome after cardiac arrest in comparison with neuron-specific enolase (NSE) in this FINNRESUSCI substudy .
Methods: We prospectively collected data on 249 patients who were admitted to 21 intensive care units after out-of-hospital cardiac arrest (OHCA) between March 1, 2010 and February 28, 2011. Of these patients, 177 (71%) had a shockable initial rhythm. We measured serum concentrations of UCHL1 and NSE at 24 h and 48 h after cardiac arrest. UCHL1 concentrations were analysed by a commercial ELISA kit and NSE concentrations were measured by electrochemiluminescence immunoassay. We evaluated the ability of these biomarkers to predict poor outcome (defined as Cerebral Performance Category 3-5, indicating death or severe neurologic deficits) at 12 months after cardiac arrest using the area under the receiver operating characteristic curve (AUROC).
Results: Overall, 121 patients (49%) had a poor outcome at 12 months. For both UCHL1 and NSE, the concentrations were higher for patients with poor outcome than for those with good outcome (Table 3). The NSE concentration at 48 h was the best predictor of poor outcome (AUROC 0.72).
The median time from cardiac arrest to return of spontaneous circulation (ROSC) was 20 min. The prognostic performance of NSE at 48 h was particularly good for patients with the time to ROSC longer than 20 min, with AUROC 0.80 (95% CI, 0.71-0.89). For patients with ROSC under 20 min, the AUROC for NSE at 48 h was only 0.53 (0.41-0.66), but the AUROC for UCHL1 at 24 h was 0.70 (0.59-0.81).
Conclusions: Post-cardiac arrest UCHL1 concentrations are higher in patients with poor outcome than in those with good outcome, but the ability of UCHL1 to predict long-term outcome is weaker than that of NSE in the overall population of ICU-treated OHCA patients. However, for patients with ROSC under 20 min, the prognostic performance of UCHL1 at 24 h was satisfactory.
1. Vaahersalo J et al. Therapeutic hypothermia after out-of-hospital cardiac arrest in Finnish intensive care units: the FINNRESUSCI study. Intensive Care Med 39: 826–37, 2013.
P187 Time to awakening after cardiac arrest and target temperature management
A Lybeck1, T Cronberg1, N Nielsen2, H Friberg1
1Skane University Hospital, Lund University, Lund, Sweden; 2Helsingborg Hospital, Lund University, Helsingborg, Sweden
Introduction: In this post hoc analysis of the target Target Temperature Management-trail (TTM-trail) , we investigate the time until awakening and its relationship to target temperature and neurological outcome. Sedation is also compared.
Methods: The TTM-trial randomized 950 patients to a target temperature of 33 °C (TTM33) or 36 °C (TTM36) in 36 hospitals in 12 countries, with no difference in survival or neurological outcome between groups. Awakening was defined as Glasgow Coma Scale motor score (GCS-M) 6 in the ICU. Neurological outcome was assessed using the cerebral performance category scale (CPC) at 180 days. Cumulative doses of sedative drugs (propofol, midazolam, fentanyl, morphine, remifentanil) were retrospectively collected at 12, 24 and 48 hours. There was a strict protocol for prognostication and withdrawal of care.
Results: 496 patients had registered awakening in the ICU. Day of awakening occurred later in TTM33 (median 4, IQR 3-6) vs TTM36 (median 4, IQR 3-5), p < 0.0021 (Mann-Whitney-U). The latest recorded awakening was at day 22. We found a correlation between day of awakening and neurological outcome (Spearmans correlation coefficient 0.20, p < 0.0001), but there was no difference in neurological outcome between treatment groups (p = 0.21, Chi-squared). Doses of sedative drugs were available for 352 patients from 20 trial sites. We found no difference in doses of sedative drugs at 12, 24 or 48 hours between TTM33 and TTM36.
Conclusions: Time to awakening was longer in TTM33 than in TTM36. Day of awakening correlated with neurological outcome. In patients who awoke, there was no difference in neurological outcome between treatment groups.
1. Nielsen, N et al. N Engl J Med 369(23): 2197–206, 2013.
P188 Target temperature management in comatose survivors of cardiac arrest - comparison of endovascular, esophageal and surface cooling
M Rauber, K Steblovnik, A Jazbec, M Noc
University Medical Centre Ljubljana, Ljubljana, Slovenia
Introduction: Target temperature management represents important part of post-resuscitation care in comatose survivors of out of hospital cardiac arrest (OHCA). Early induction of hypothermia, tight maintenance and prevention of hyperthermia during rewarming appear to be essential to maximize neuroprotection. The aim of our study was to compare endovascular, esophageal and surface cooling.
Methods: Endovascular cooling (ENC) using InnerCool Accutrol Catheter (Philips Healthcare, San Diego, CA, USA), esophageal cooling (ESC) using dedicated device (Advanced Cooling Therapy, Chicago, IL, USA) with concomitant 0.9% saline (0-4 °C, 30 ml/kg in 30 min) and surface cooling (SFC) with ice packs and concomitant cold saline were compared. Target temperature was 32-34 °C. After 24 hours of maintenance, gradual rewarming targeted at 0.1-0.2 °C/h was performed. Core body temperature was measured continuously by thermistor placed intravesically.
Results: A total of 22 OHCA patients were included. ENC was used in 7 patients, ESC in 5 patients and SFC in 10 patients (Fig. 7). By extrapolating temperature curves, mean time from initiation of cooling to 34 °C was 1.1 h in ENC group, 2.8 h in ESC group and 2.1 h in SC group (p = 0.08). Variation of temperature during the maintenance phase expressed as mean hourly standard deviation was 0.26 °C in ENC, 0.42 °C in ESC and 0.76 °C in SFC groups, respectively (p < 0.001). The percentage of patients with post-rewarming hyperthermia (>38 °C) at any measurement was 43% in ENC group, 20% in ESC group and 50% in SFC group (p = 0.3). The post-rewarming hyperthermia in ENC and ESC groups was linked with device removal prior to 72 hours post OHCA.
Conclusions: Our non-randomized comparison indicates that ENC provides the fastest induction of hypothermia and best temperature maintenance. Significant proportion of patients still experience temporary hyperthermia during rewarming regardless of the cooling method.
P189 Influence of an esophageal cooling and warming device on patient temperature in the operating room
P Kalasbail1, F Garrett2, E Kulstad3
1Cleveland Clinic, Cleveland, OH, United States; 2Garrett Technologies, Northbrook, IL, United States; 3Advocate Christ Medical Center, Oak Lawn, IL, United States
Introduction: Temperature management is important for a number of clinical conditions, and a variety of methods exist to effect changes in body temperature. In general, these methods are divided into external (surface) or internal/core (intravascular) approaches. A new device (the ECD, or Esophageal Cooling/Warming Device) utilizes a closed circulation of cooled or warmed water via the esophageal route to achieve patient heat transfer, offering core temperature control without the need to access the intravascular space. We sought to measure the influence of this device on the temperature of patients undergoing surgical procedures in the operating room.
Methods: This was a secondary analysis of data from a prospective interventional study of patients undergoing elective non-cardiac surgery at the Cleveland Clinic, USA. The primary outcome was quantification of heat transferred to or from patients. Under this IRB approved study, after written informed consent, patients were subjected to two distinct 30-minute periods of either warming or cooling (with the order randomized), during which inlet temperature, outlet temperature, and flow rate through the ECD was measured, providing the data necessary for heat balance calculations. In this secondary analysis we examined patient temperatures recorded during the study, and determined mean temperature change over each 30 minute interval. Temperatures were recorded using zero-flux cutaneous thermometry (3 M SpotOn).
Results: Nineteen patients were enrolled in this study from April to November, 2016. During the warming cycle, mean patient starting temperature was 35.5 C +/- 0.52 C, increasing to 35.8 +/- 0.62 C over 30 minutes. The mean warming rate was 0.56 +/- 0.64 C/hr. During the cooling cycle, mean patient starting temperature was 35.7 C +/- 0.61 C, decreasing to 35.3 +/- 0.61 C over 30 minutes. The mean cooling rate was 0.88 +/- 0.87 C/hr. The finding that cooling was faster than warming may be attributed to the greater difference in core-to-perfusion temperature (water temperature of 7 C cooling, 42 C warming); however, extraneous factors such as patient exposure, body habitus, external warming, and room temperature, may also have influenced performance.
Conclusions: Although patients differed slightly in their rates of temperature change, these data suggest that patient temperature modulation utilizing the esophageal route is effective, and that clinically meaningful core patient temperature change can be attained in both cooling and warming, without the need to access the intravascular space.
Markota A, Fluher J, Balazic P, Kit B, Sinkovic A: Therapeutic hypothermia with esophageal heat transfer device. Resuscitation 2015, 96:138.
P190 Outcomes and interventions among out-of-hospital cardiac arrest patients transported to hospital with ongoing cardiopulmonary resuscitation
DJ Bergström, HR Olsson, S Schmidbauer, H Friberg
Skåne University Hospital, Lund, Lund, Sweden
Introduction: The introduction of automatic chest compression (ACC) devices has made it possible to transport patients with ongoing cardiopulmonary resuscitation (CPR) following out-of-hospital cardiac arrest (OHCA). In the region of Skåne in Sweden, all ambulances are equipped with an ACC device and local guidelines encourage prompt transportation of a majority of patients to hospital, regardless of whether field return of spontaneous circulation (ROSC) is achieved. In this retrospective registry study, we investigated the outcomes for patients transported with ongoing CPR between 2010-2015. We also studied the frequency of hospital-bound interventions against suspected reversible causes of cardiac arrest.
Methods: A local register containing Utstein-style data from all OHCA patients transported to SUS Lund was used and additional data were retrieved from medical records. If and where patients achieved ROSC was recorded. Interventions against suspected reversible causes of cardiac arrest were also noted and categorised per the “4Hs & 4Ts”, outlined in resuscitation guidelines. Patients with in-ambulance arrest were excluded.
Results: During the study period, 639 patients were transported to hospital following OHCA. A total of 160 patients achieved sustained ROSC before admission to hospital, 72 of whom (45%) survived to hospital discharge. Seventy-eight patients were excluded due to in-ambulance arrest (n = 49), arrest at hospital grounds (n = 11) and missing data (n = 18). The remaining 401 patients were transported with ongoing CPR of whom 52 (13%) eventually had sustained ROSC and admitted to the ICU. Eight patients (2%) survived to hospital discharge, 4 did not receive any further in-hospital intervention while 4 received an intervention that could not have been performed in the prehospital setting. These interventions were: angiography with epinephrine injected in the aortic root (n = 1), percutaneous coronary intervention (n = 1), insertion of a trans-venous pacemaker (n = 1), intubation and suction of aspirated fluids (n = 1). Three of these four survivors had intermittent ROSC in the field. The initial rhythm was shockable in 5 of 8 survivors and 3 had pulseless electrical activity.
Conclusions: The prognosis for patients transported to hospital with ongoing CPR is poor and the extra treatment potential in-hospital are rarely utilised. No patient with asystole without ROSC in the field survived.
P191 Hypoxic and hyperoxic preconditioning in organ protection against ischemia-reperfusion injury: the experimental study
I Mandel1, S Mikheev2, Y Podoxenov2, I Suhodolo3, A Podoxenov2, J Svirko2, A Sementsov2, L Maslov2, V Shipulin2
1City Clinical Hospital No 83 of FMBA of Russia, Moscow, Russia; 2Cardiology Research Institute, Tomsk, Russia; 3Siberian State Medical University, Tomsk, Russia
Introduction: Preconditioning with a moderate hypoxia and hyperoxia is an effective drug-free way to mitigate organ dysfunction to ischemia-reperfusion injury [1, 2].
Methods: The prospective study included 20 rabbits divided into four groups: hypoxic preconditioning (HypP), n = 5; hyperoxic preconditioning (HyperP), n = 5; hypoxic-hyperoxic preconditioning (HHP), n = 5; and control group, n = 5. Study was approved by local ethics committee. All animals were anesthetized by sevoflurane and mechanically ventilated via nasotracheal tube. In HypP group we exposed rabbits to two series of 10% oxygen for 10 min with 5 min reoxygenation. In HyperP group rabbits were exposed to 80% oxygen for 30 min. In HHP group rabbits were exposed to two series of 10% oxygen for 10 min with 5 min reoxygenation followed by 80% oxygen for 30 min. Then we started CPB and induced acute myocardial infarction by ligation of left coronary artery. After 45 min of ischemia reperfusion was performed for 60 min. We investigated myocardial slices and measured ischemic area (IA) and risk area (RA)  and calculated IA/RA ratio; also we conducted light microscopy of gut mucosa, kidneys, liver, spleen and lungs.
Results: IA/RA decreased in HypP group by 23%, in HyperP group 26%, in HHP group by 32% in comparison with control group (p = 0.009, Kruskal-Wallis test) . Acid-based status, blood lactate and glucose levels were stable during all types of preconditioning. Single ventricular arrhythmia was observed more often than multiple ventricular arrhythmia in preconditioning animals and the opposite in control group. Incidence of ventricular fibrillation were lower in HHP group (differences did not reach statistical significance, X2 test). Light microscopy of myocardium revealed less damage in HHP group as compared to other groups. Light microscopy of kidneys revealed marked edema of cortical and medullar substances in the control group. Gut mucosa and liver parenchyma had enlarged capillaries, sometimes filled with erythrocytes. Microscopic structure of kidneys, small intestine and liver was less affected in HHP group.
Conclusions: Hypoxic-hyperoxic preconditioning provided the highest tolerance of the myocardium and splanchnic organs to the effects of ischemia-reperfusion injury.
1. Petrosillo G. et al. Free Radic Biol Med. - 2011. - Vol 50(3). – p.. 477–483.
2. Xu K. et al. Adv Exp Med Biol. - 2014. - Vol. 812. – p. 309–315.
3. Mandel I. et al. Journal of Cardiothoracic and Vascular Anesthesia. - 2016. - Vol. 30 (Supplement 1), p. S6–S7.
P192 Diabetes in an animal model worsens neurological outcome following cardiac arrest
LV Vammen1, SR Rahbek2, NS Secher1, JP Povlsen3, NJ Jessen4, BL Løfgren1, AG Granfeldt1
1Aarhus University Hospital, Aarhus C, Denmark; 2Regional Hospital of Randers, Randers, Denmark; 3Regional Hospital of Horsens, Horsens, Denmark; 4Aarhus University, Aarhus, Denmark
Introduction: Cardiac arrest carries a poor prognosis. The average cardiac arrest patient is comorbid and retrospective studies suggest that diabetes mellitus is an independent risk factor for increased mortality after cardiac arrest. Despite this, cardiac arrest animal studies are conducted on healthy young animals, limiting our knowledge regarding the post-cardiac arrest organ dysfunction and the impact of type 2 diabetes mellitus (T2DM).
We hypothesize that T2DM, in a rat model of cardiac arrest, is associated with increased brain injury and reduced left ventricular function following resuscitation.
Methods: We used the Zucker Diabetic Fatty (ZDF) rat as an animal model of T2DM. The ZDF rats (n = 13), non-diabetic Zucker Lean Control (ZLC) rats (n = 15), and healthy Sprague Dawley (SprD) rats (n = 8) underwent asphyxia-induced cardiac arrest and were resuscitated and monitored for 180 min. after return of spontaneous circulation (ROSC). Brain injury was evaluated by neuron specific enolase (NSE) and left ventricular function was measured as fractional shortening (FS) by echocardiography both measured at baseline and 180 min. after ROSC.
Results: Total asphyxia time was 639 s (SD 24) in the ZDF group which was significantly longer than 592 s (SD 18, p < 0.0001) in the ZLC group, but no different from the SprD group at 634 s (SD 20, p = 0.6). There were no differences among groups in baseline NSE or FS. 180 min. after ROSC median levels of NSE were significantly increased in the ZDF group, 10.8 ng/mL [25%Q;75%Q: 7.6;11.3], compared with the two control groups: ZLC group 2.0 ng/mL [25%Q;75%Q 1.7;2.3, p = 0.0004] and SprD group 2.8 ng/mL [25%Q;75%Q 2.3;3.4, p = 0.0004]. At the end of experiment mean FS was significantly higher in the ZDF group at 36% (SD 6), compared with the ZLC group, 22% (SD 3, p = 0.0031), and the SprD group, 24% (SD 6, p < 0.0001). At baseline lactate was 1.9 (SD 0.9) in the ZDF group, which was comparable with 1.4 (SD 0.4, p = 0.512) in the ZLC group and 1.2 (SD 0.5, p = 0.052) in the SprD group. At the end of experiment lactate concentration in the ZDF group was at 8.2 mmol/L (SD 3.1) significantly higher than the control groups: ZLC group 2.6 mmol/L (SD 1.7, p = 0.001) SprD group 1.8 mmol/L (SD 0.9, p < 0.0001).
Conclusions: Cardiac arrest in an animal model of T2DM results in increased brain injury, while in contrast left ventricular function was increased when compared to non-diabetic animals.
P193 Increased energy required to reach target temperature in post-cardiac arrest patients is associated with better outcomes
A Grossestreuer1, S Perman2, P Patel1, S Ganley1, J Portmann1, M Cocchi1, M Donnino1
1Beth Israel Deaconess Medical Center, Boston, MA, United States; 2University of Colorado, Denver, CO, United States
Introduction: We hypothesized the amount of energy required by the surface device to reach target temperature (Ttarget) in post-cardiac arrest patients treated with therapeutic hypothermia (TH) may be associated with outcomes by serving as a proxy for patient thermoregulatory ability and may modify the relationship between the time to Ttarget and outcomes. Some studies have shown that TH-treated post-arrest patients who reach Ttarget quickly have worse outcomes than those who cool more slowly. However, the ischemia-reperfusion insult of cardiac arrest may cause temperature derangements that affect the time trajectory of TH independent of external cooling factors.
Methods: Adult patients with sustained return of spontaneous circulation treated with TH between 2008-2015 with serial temperature data were included. Time to Ttarget was defined as time from TH initiation to the first time the patient temperature was < =34C. Patients with Ttarget >34C were excluded. The energy required to bring a patient to Ttarget (“energy units”) was calculated as average inverse water temperature x 100 x hours between initiation and Ttarget. Primary outcome was neurologic status (measured by Cerebral Performance Category [CPC] score); secondary outcome was survival, both at hospital discharge. Univariate analyses were performed using Wilcoxon rank-sum tests; multivariate analyses used logistic regression. P < 0.05 was considered statistically significant.
Results: Of 205 patients included, those with CPC 3-5 required less energy to reach Ttarget (median 8.1 (IQR: 3.6-21.6) vs median 20.0 (IQR: 9.0, 33.5) energy units, p = 0.001) and reached Ttarget quicker (median 2.3 (IQR: 1.5, 4.0) vs median 3.6 (IQR: 2.0, 5.0) hours, p = 0.01) than patients with CPC 1-2. Patients who did not survive required less energy than survivors (median 8.1 (IQR: 3.6-20.8) vs median 19.0 (IQR: 6.5, 33.5) energy units, p = 0.001) and reached Ttarget quicker (median 2.2 (IQR: 1.5, 3.8) vs median 3.6 (IQR: 2.0, 5.0) hours; p = 0.01). Controlling for average water temperature between initiation and Ttarget, the relationship between outcomes and time to Ttarget was no longer significant. Controlling for location, witnessed arrest, age, initial rhythm, and neuromuscular blockade use, increased energy was associated with better neurologic (aOR: 1.01 (95%CI 1.00-1.03), p = 0.039) and survival (aOR: 1.01 (95%CI 1.00-1.03), p = 0.045) outcomes.
Conclusions: Increased energy requirement during TH initiation is associated with better outcomes at hospital discharge and may affect the relationship between time to Ttarget and outcomes.
P195 Clinical outcomes of patients with different co-morbideties witnessed in cardiac arrests inside the intensive care unit
Y Nassar, S Fathy, A Gaber, S Mokhtar
Cairo University, Giza, Egypt
Introduction: We aimed for clinical assessment of cardiopulmonary resuscitation (CPR) procedures of witnessed cardiac arrests inside the intensive care units (ICU) and follow up of patients surviving to discharge.
Methods: Data were collected prospectively from patients who were witnessed in cardiac arrest and underwent CPR inside an adult medical ICU of Cairo University in the period from Jan. 2013 to Feb 2015. Resuscitation protocol was done according to the latest recommendation of the European society of cardiology. Clinical data were recorded and surviving patients were clinically followed daily until hospital discharge.
Results: The study included 110 patients: 41 females (37%) and 69 males (63%). There were 26(24%) patients under 50 years and 84(76%) patients above 50 years. ROSC occurred in 60(55%) and 22(20%) survived to discharge.
According to underlying illness:
ROSC increased with CNS comorbidities (p0.05), Shock (p0.008), Low MPM0-III (p 0.015) While ROSC decreased with and Respiratory failure (p 0.01)
Long term survival increased with Low MPM0-III score (p0.018), Low Sofa score (p 0.01), and Rapidly correctable causes (Hypoxia, Hypovolemia, Hydrogen ion acidosis, Hypokalemia, Hyperkalemia, Hypoglycemia, Hypothermia, Toxins, Cardiac Temponade, Tension pneumothorax, Thrombosis and Trauma) (p0.004), while Long term survival decreased with CNS comorbidities (p0.02), Shock (p,0.01), Respiratory Failure post-arrest (p0.02) and Mechanical ventilation post-arrest (p < 0.001)
According to CPR procedures:
ROSC increased with AF Rhythm (p0.03),less duration of CPR (p0.03), number of cycles of CPR < 2 (p < 0.001), number of DC shocks <2 (p0.02), EF >50% (p0.01), Low HCO3 pre-arrest (p0.009), low HCO3 during arrest (p0.03) and Noradrenaline post-arrest (p0.003).ROSC decreased with high PaCO2 pre-arrest (p 0.002) and high PaCO2 during arrest (p 0.001).
Long term survival increased with RBBB (p < 0.001) and frequent PVCs (p < 0.001). Long term survival decreased with Asystole (p 0.01).
Conclusions: CPR in the ICU may achieve variable rates of short and long term survival depending on the associated comorbidities
P196 Outcomes of non-traumatic out-of-hospital cardiac arrests witnessed by layperson
Tan Tock Seng Hospital, Singapore, Singapore
Introduction: To look at the outcomes of patients who suffered a non-traumatic OHCA, witnessed by layperson.
Methods: This is a retrospective case record review. Inclusion criteria included all patients who suffered a non-traumatic OHCA conveyed by emergency medical services (EMS) to our Emergency Department (ED) from 1st Aug 2012 to 31st Aug 2014. Exclusion criteria included traumatic OHCA and all patients declared dead at scene. EMS data were extracted from National Cardiac Arrest registry. Data of patients admitted were extracted from inpatient electronic case records. Patient discharged from hospital were followed up for 30 days.
Results: There were 888 OHCA. 529 were witnessed. Among witnessed, 279 by family, 134 by layperson, 76 by EMS, and 40 by healthcare providers.
134 OHCA witnessed by layperson, 47 occurred in night-time between 2000-0800 hrs. 87 occurred in daytime between 0800-2000 hrs. 4 happened in healthcare facility, 40 in a residential area, 8 in industrial area, 13 in places of recreation, 43 in commercial / public area, 20 in the streets or highway and 6 in brothels.
57 received bystander CPR while 77 did not. Among 57 who received bystander CPR, 9 also had community AED applied. The rhythms on the AED were 4 unknown, 4 asystole and 1 PEA. None was shockable. The initial rhythms by EMS on those 57 patients who received bystander CPR were 24 asystole, 8 PEA, 10 unknown and 15 VF. 3 of the patients with VF were subsequently discharged from hospital alive with CPC 1.
None of the 77 patients who had a witnessed OHCA by a layperson and did not received bystander CPR survived.
134 OHCA witnessed by layperson, 21 were admitted to hospital. 4 were discharged alive with cerebral performance category (CPC) 1. Among these 4 patients with good outcome, 3 had VF as initial presenting rhythm, while 1 had PEA. All happened in public area in daytime, all had bystander CPR, all did not have community AED applied but all had field ROSC
Conclusions: Our results showed patients with OHCA witnessed by layperson tend to occur in public areas during daytime and most did not received bystander CPR or application of community AED. Some of these arrests were witnessed by laypersons, however, none survived when CPR was not started. This warrants further study to find out the reasons for not initiating CPR. There should be more efforts directed at community CPR programs. Technology can help to direct rescuers to OHCA victim so that early CPR can be initiated.
P197 Reducing the risk of a poor outcome: considering the ‘other’ victim of out-of-hospital cardiac arrest (OOHCA) following unsuccessful resuscitation
R Lewis-Cuthbertson1, K Mustafa2, A Sabra2, A Evans2, P Bennett1
1Swansea University, Swansea, United Kingdom; 2Abertawe Bro Morgannwg Health Board, Swansea, United Kingdom
Introduction: Early intervention and prevention of psychological disorders could help to significantly reduce costs to the NHS. Relatives who experience the sudden and unexpected death of a relative following OOHCA may be at high risk of developing both psychological and physical health problems. As many of these deaths occur within the Emergency Department(ED), it is important to understand the support needs of relatives to help minimise risk of a poor outcome.
Methods: Next of kin of deceased non-traumatic, non-paediatric OOHCA patients were invited to take part in face-to-face interviews 3 months’ after death. Twelve male and female participants who experienced the death of a relative following an OOHCA and who had either i)witnessed the event and provided CPR, ii)witnessed the event and did not provide CPR, and iii)those who did not witness the event completed audio-recorded interviews lasting up to 90 minutes. Audio-recordings were transcribed verbatim and subjected to inductive thematic analysis.
Results: Three major themes were identified. 1)Negative psychological and physical health outcomes: Post-traumatic stress symptoms were reported including vivid and intrusive re-experiencing of the event. Flashbacks, recurring traumatic images, and experiencing physical symptoms associated with the heart were common. Intimations of mortality were associated with hyperarousal symptoms and health anxieties. Coping techniques included avoidance behaviours and emotional numbing, often masking their distress and support needs. 2)Am I to Blame: Self-critical thinking regarding one’s own actions in relation to this event were evident. Relatives blamed themselves for not noticing sooner that something was wrong, particularly when an underlying heart condition was identified as cause of death. Many were pre-occupied with the thought: ‘Could I have done more?’. 3)Information and Support Needs: Many felt uncertain and uninformed about what was happening creating feelings of anger, frustration and confusion. Seeking information was important for relatives to help both try to make sense of what happened and exonerate feelings of guilt and self-blame.
Conclusions: Findings suggest that the psychological impact of experiencing the sudden death of a relative following an OOHCA may be profound. Information provision is crucial to help relatives make sense of their experience and exonerate feelings of guilt and self-blame. Support of relatives needs to be a more serious consideration to help minimise risk of poor psychological outcome and reduce the health economic burden this may pose.
P199 he use of the bispectral index and suppression ratio to predict poor neurological outcome in post-cardiac arrest patients treated with targeted temperature management at 33°c
W Eertmans, C Genbrugge, W Boer, J Dens, C De Deyne, F Jans
Ziekenhuis Oost-Limburg, Genk, Belgium
Introduction: Bispectral index (BIS) monitoring has been considered as a promising electrophysiological tool for early prognostication after out-of-hospital cardiac arrest (OHCA). In recent years, a broad range of BIS thresholds has been put forward at diverse time points to predict neurological outcome in OHCA patients. This study aimed to reach consensus about the optimal time point and threshold for predicting poor neurological outcome after OHCA using the BIS monitor.
Methods: A prospective, observational study was performed during TTM at 33 °C in 77 successfully resuscitated OHCA patients. After admission to the ICU, BIS and Suppression Ratio (SR) monitoring was started using the BIS VISTA™ (Aspect Medical Systems, Inc. Norwood, USA). BIS and SR values were continuously recorded during the hypothermic and rewarming phase. During this time period, mean BIS and SR values per hour were calculated and used for analysis. The Cerebral Performance Category (CPC) scale was used to define patient’s outcome at 180 days after OHCA (CPC 1-2: good - CPC 3-5: poor neurologic outcome). Receiver operator characteristics curves were constructed to determine the best cut-off value and time point to predict poor neurological outcome.
Results: At 180 days post-cardiac arrest, 38 patients (49%) had a good neurological outcome (CPC 1-2), while 39 patients (51%) had a poor outcome (CPC 5). There were no patients with a CPC 3 or 4. Patients with a good neurological outcome had higher BIS and lower SR values than non-survivors. Using a mean BIS value below 25.5 at hour 12 as threshold criteria, poor neurological outcome was predicted with a sensitivity of 49% (95% CI 30-65%) and specificity of 97% (95% CI 85-100%) (AUC: 0.722 (0.570-0.875); p = 0.006). With a cut-off value of SR above 2.5, the optimal sensitivity (74%, 95% CI 56-87%) and specificity (92%, 95% CI 78-98%) for poor neurological outcome was obtained at hour 23 (AUC: 0.836 (0.717-0.955); p < 0.001).
Conclusions: This prospective, observational study confirmed that mean BIS values at hour 12 can be used to predict poor neurological outcome. In addition, we showed that the predictive ability of the SR might be even higher as compared to the one of BIS. Overall, our results suggest that BIS and SR monitoring can be used to assist with early neuroprognostication after OHCA.
P200 Retrospective analysis of trends in outcome following Out of Hospital Cardiac Arrest from a UK regional cardiac arrest centre, with a focus on haematological parameters
A Skorko, M Thomas
Bristol Royal Infirmary, Bristol, United Kingdom
Introduction: The Bristol Royal Infirmary is a tertiary out of hospital cardiac arrest (OHCA) centre, serving a population of 1,000,000 in the South West of England.
Debate is ongoing regarding the optimal antiplatelet strategy for survivors of OHCA, given the concerns of both bleeding and clotting complications in this population. Studies vary in the rates of bleeding seen in this population, from 0 to 56% .
To understand why OHCA survivors are at risk of bleeding and whether this impacts survival to hospital discharge, we retrospectively analysed laboratory parameters of coagulation(PT and APTT), platelet count, and haemoglobin then stratified these by survival to hospital discharge, over the period January 2009 to August 2016.
Methods: Routinely collected electronic data was used to identify patients for this study. Data was extracted for those coded as ‘Anoxic or ischaemic coma or encephalopathy’ with ‘Acute myocardial infarction’ or ‘Ventricular tachycardia or fibrillation´.
Parameters of; status at hospital discharge, platelet count, APTT and haemoglobin within 24 hours of admission were extracted from the database.
Results: Comparing the relative risks; An INR of >2 gave a risk ratio of death of 1.29 (95% CI 0.828- 2.01, p =0.257). A platelet count of <50 gave a risk ratio of death of 1.30 (95% CI 0.866- 1.97, p =0.301).
Conclusions: Our data demonstrates that platelet count, hemoglobin, PT and APTT do not differ between survivors and non-survivors of OHCA.
However, absolute values do not give an indication as to the function of platelets or of the coagulation cascade. An analysis of platelet function and the coagulation cascade as a whole may provide better insights into the risks of bleeding in this population. We therefore propose to carry out a prospective analysis of thromoelastometric coagulation assessment and platelet inhibition, and correlate this with bleeding events and administration of antiplatelet therapy
1. Nolan JP et al. Increasing survival after admission to UK critical care units following cardiopulmonary resuscitation. Critical Care. 2016;20.
P201 Organ donation after brain death in refractory cardiac arrest treated with extracorporeal CPR
M Casadio1, A Coppo2, A Vargiolu2, J Villa1, M Rota1, L Avalli2, G Citerio1
1University of Milano-Bicocca, Monza, Italy; 2San Gerardo Hospital, Monza, Italy
Introduction: Cardiac arrest (CA) is a catastrophic event with a high rate of mortality, often resulting in devastating brain injury that might evolve to brain death (BD). Organ donation from BD after CA patients with ECMO support is still a poorly explored field.
Methods: We retrospectively enrolled all patients admitted to our hospital between January 2011 and September 2016 after refractory CA treated with eCPR.
Results: In the study period 112/215 CA patients received eCPR (52.09%). 30 eCPR-subjects (26.78%) survived at 6 months (85.71% with good cerebral performance, CPC 1-2). 82 died in ICU (25 BD, 22.32% and 57 for other causes, 50.89%) [Fig. 9]. Deads vs. alives differed in age (p = 0.02), comorbidities (p = 0.001), CA (intra or extra-hospital p = 0.03), low flow time (p < 0.0001), mean arterial pressure (p = 0.004), glycemia (p = 0.04) anemia (p = 0.02), renal function (creatinine p < 0.0001, urea p = 0.0005), and early neurological evaluation (CT scan p < 0.001, EEG recording p < 0.001, brainstem reflexes p < 0.001, presence of somatosensory potentials p = 0.03 and GCS p < 0.0001). BD and dead from other causes patients differed in early neurological evaluation (CT scan p < 0.0001, EEG p = 0.004, brainstem reflexes p = 0.02), thrombocytopenia (p = 0.008), coagulation derangement (p = 0.01), inotropic support (p = 0.03). Tab1 shows characteristics of eligible patients at the time of donation. Rate of donation in BD patients was 56% (refusal based on organ biopsy or evaluation in the operation room) with 39 donated organs (23 kidneys, 12 livers, 4 lungs, 89.74% with good functional recovery).
Conclusions: eCPR patients might become BD and be considered potential resource for organ donation with a similar success rate as organs retrieved from patients deceased from other causes.
1. Sandroni C et al Int Care Med 42(11):1661–1671,2016
2. Citerio G et al Int Care Med 42(3):305–15,2016
P204 Effects of long-term post-ischemic treadmill exercise on gliosis in the aged gerbil hippocampus induced by transient cerebral ischemia
JB Moon, JH Cho, CW Park, TG Ohk, MC Shin, MH Won
Kangwon National University, Chuncheonsi, South Korea
Introduction: Therapeutic exercise is an integral component of the rehabilitation of patients with stroke. The objective of the present study was to investigate effects of post-ischemic exercise on neuronal damage or death and gliosis in the aged gerbil hippocampus after transient cerebral ischemia using immunohistochemistry.
Methods: Aged gerbils (male, 22 to 24 months) induced by ischemia were subjected to treadmill exercise for 1 or 4 weeks. Neuronal death was apparently found in the stratum pyramidale of the hippocampal CA1 region and in the polymorphic layer (PoL) of the dentate gyrus (DG) using cresyl violet and Fluoro-Jade B histofluorescence staining.
Results: In addition, no significant difference in neuronal death was found after 1 or 4 weeks of post-ischemic treadmill exercise. However, post-ischemic treadmill exercise apparently affected gliosis (activation of astrocytes and microglia). GFAP immunoreactive astrocyte and Iba-1 immunoreactive microglia were activated in the CA1 and PoL of the DG of the group without treadmill exercise. However, 4 weeks after treadmill exercise significantly alleviated ischemia-induced astrocyte and microglia activation, although the gliosis was not alleviated in the animals with 1-week exercise.
Conclusions: These findings suggest that long-term post-ischemic treadmill exercise after transient cerebral ischemia could not influence neuronal protection, however, it could effectively alleviate astrocyte and microglial activation in the aged hippocampus induced by 5 min of transient cerebral ischemia.
P205 Predictors of need for critical care support after stroke thrombolysis in an intensive care unit
P Papamichalis1, V Zisopoulou1, E Dardiotis2, S Karagiannis1, D Papadopoulos1, T Zafeiridis1, D Babalis1, A Skoura1, I Staikos1, A Komnos1
1General Hospital of Larissa, Larissa, Greece; 2University Hospital of Larissa, Larissa, Greece
Introduction: One of the most promising interventions for acute ischemic strokes is intravenous thrombolysis (IVT). In our hospital it is performed in the Intensive Care Unit (ICU), with a 10 year experience for the intervention and participation at international studies [Safe Implementation of Thrombolysis in Stroke – MOnitoring STudy (SITS-MOST)]  and registries [Safe Implementation of Treatments in Stroke - International Stroke Thrombolysis Register (SITS-ISTR)]. The aim of the study was to evaluate which factors can predict the need for critical care support after thrombolysis.
Methods: Retrospective study including 124 patients with acute ischemic stroke, with mean age 65 years and National Institutes of Health Stroke Scale (NIHSS) at admission 11/range 2 – 28. They all fulfilled the international inclusion criteria  and received IVT with alteplase. Demographic data and severity scores [Simplified Acute Physiology Score (SAPS) II and NIHSS] were recorded. Patients were divided to those who demanded advanced life support and neurocritical care interventions after IVT (n = 14) and those who did not (n = 110). Comparison amongst the two groups was performed with application of proper statistical tests.
Results: The need for critical care support was significantly greater for patients with higher SAPSII, higher NIHSS after 2 hours, at 24 hours and at 7 days (Mann-Whitney U test for the above mentioned comparisons) and patients with history of vascular disease (Fisher’s exact test) (p < 0.05 for all comparisons). Off-Label Thrombolysis, NIHSS <5, age >80 years, sex, age, NIHSS at admission, aggregate thrombolysis time, history of: diabetes mellitus, arrhythmia, hypertension, smoking, hyperlipidemia, former ischemic stroke did not significantly correlate with critical care need.
Conclusions: In accordance with previous studies [3,4] higher severity scores (SAPSII, NIHSS) and presence of vascular disease can serve as markers for prediction of need for critical care support after IVT. Our report is the first one in the international literature of SAPSII correlating with thrombolysis results.
1) Wahlgren N et al, Lancet 369:275–282, 2007
2) The European Stroke Organisation (ESO) Executive Committee and the ESO Writing Committee, Cerebrovasc Dis 25:457–507, 2008
3) Faigle R et al, PLoS One 9:e88652, 2014
4) Mazya M et al, Stroke 43:1524–1531, 2012
P206 A life threatening emergency: PRES - cases series and literature review
S Silva Passos, F Maeda, L Silva Souza, A Amato Filho, T Araújo Guerra Granjeia, M Schweller, D Franci, M De Carvalho Filho, T Martins Santos, P De Azevedo
University of Campinas, Campinas, Brazil
Introduction: To describe comorbidities, clinical presentation, diagnostic method, treatment and outcome of 6 patients with Posterior Reversible Encephalopathy Syndrome (PRES). PRES is consequence of a reversible subcortical brain edema in patients with acute neurological symptoms, such as headache, impaired sensorium, visual abnormalities, nausea/vomiting, cerebellar syndrome, focal neurological deficits and seizures. Causes include hypertension, eclampsia/pre-eclampsia, sepsis, autoimmune disease, immunosuppressive agents, chemotherapy and renal failure. Radiological findings on computed tomography (CT) and magnetic resonance imaging (MRI) include abnormalities of white and grey matter, predominantly affecting parietal and occipital lobes. The treatment is based on the removal of the underlying cause.
Methods: Retrospective and descriptive study of 6 medical records of patients hospitalized with diagnosis of PRES at the tertiary hospital of the University of Campinas, São Paulo, between 2015 and 2016.
Results: Four patients had lupus, 2 were solid-organ transplant patients (1 kidney and 1 liver). Immunosuppression and headache were found in all patients, 5 presented hypertensive emergencies, 4 had seizures, 3 showed decreased level of consciousness and nausea and vomiting, 1 had status epilepticus. The diagnosis was made clinically and with CT in 4 cases and MRI in 2 cases (Fig. 10). Treatment was performed with intravenous blood pressure lowering agents and antiepileptic drugs. The length of stay ranged from 22 days to 66 days. Five patients showed full recovery, and 1 died of intracranial hemorrhage.
Conclusions: Autoimmune disease, use of immunosuppressant and hypertension are important risk factors for PRES. Patients usually have a good recovery after prolonged stay in hospital, but death and neurological disability may occur. Therefore, early recognition and appropriate treatment may change patient´s outcome.
P207 A case report: chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS)
R Wall, I Welters
Royal Liverpool University Hospital, Liverpool, United Kingdom
Introduction: Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) was first described in 2010 . Symptoms include diplopia and gait ataxia. Pontine lesions are a commonly seen on magnetic resonance imaging. Patients display a favourable response to glucocorticosteroid therapy.
Methods: A 54 year-old man with no significant past medical history presented to the emergency department with a 10-day history of vomiting and feeling generally unwell. He suffered from dizziness, ataxia, diplopia, bilateral nystagmus, taste and hearing disturbances. Within 24 hours of admission he developed right sided weakness. GCS dropped to 8 and he required intubation. He had downgoing plantar reflexes, myoclonic jerks, tonic-clonic movements of lower limbs and spasticity of both upper and lower limbs. Seizures occurred daily and were terminated with lorazepam. Two weeks after admission, the patient developed pyrexia of 420 C and required cooling for 7 days.
Results: The patient was treated for infective encephalitis with amoxicillin, ceftriaxone and acyclovir. Cerebrospinal fluid showed a white cell count of 96 cells/mcl (40% polymorphs and 60% lymphocytes). A second lumbar puncture a week later had a white cell count of 72 (5% polymorphs and 95% lymphocytes). All cultures, viral PCR and cryptococcal antigens were negative. The first MR head showed high T2 signal and swelling in the pons, which extended into the cerebral peduncle on the left. This area and the middle cerebral peduncles had high signal on the FLAIR sequence. There was restricted diffusion within the pons and middle cerebellar peduncle. A second MR scan identified several irregular regions of enhancement within the midbrain and pons, leading to a diagnosis of CLIPPERS. High-dose methylprednisolone was commenced intravenously. The patient’s clinical condition improved rapidly. He was alert and followed commands within days. Nystagmus persisted, but he had no further spasticity. A third MR after five days of steroid treatment described significant improvement in the pontine lesions, but a small focus of high signal remained. Midbrain oedema present on previous scans had resolved.
Conclusions: CLIPPERS is a diagnosis of exclusion, with patients often initially treated for stroke or encephalitis. Pyrexia has not been reported in cases of CLIPPERS. Central pyrexia is common in neurological conditions. An infective cause was not identified, however, with no response to antimicrobials in the absence of positive cultures, central pyrexia is likely. The rapid response to steroids supports a diagnosis of CLIPPERS.
1. Pittock S et al. Brain 2010;13:2626
P208 Comparison of successful rate between ultrasound guided lumbar puncture and surface landmark method for difficult LP patients in ED; a randomized controlled trial
P Tansuwannarat, P Sanguanwit
Ramathibodi hospital, Bangkok, Thailand
Introduction: Lumbar puncture (LP) is the main procedure to obtain the diagnosis of meningitis and subarachnoid hemorrhage. However the success rate could be compromised in difficult LP patients such as patients with obesity or scoliosis. Ultrasound-guided LP (UGLP) was proposed as a potential method to improve the success rate of this procedure.We aimed to investigate the success rate of UGLP compared to surface-landmarked LP (SMLP) in patients who visited an Emergency Department at Ramathibodi Hospital, Bangkok, Thailand.
Methods: This is a prospective randomized controlled trail from August 2015 to July 2016. All adult (>18 years old) patients with a diagnosis of suspected meningitis were included. Difficult LP patient was defined as patient with bone mineral density of 25 kg/m2 or more and scoliosis. Primary outcome was the success rate of first LP attempt. Secondary outcome included number of attempts, time to complete the procedure, and post-procedure complication.
Results: There were 40 patients included with a mean age of 60 + 19.34 years and 53% were male. The majority of patients were suspected for meningitis (82%).There were 20 patients in each group. Success rate at the first LP attempt was greater in UGLP group compared to SMLP group [16(80%) vs 7(35%), p 0.009]. Median time (minutes) to complete the procedure was shorter in UGLP compared to SMLP group [(5 vs. 13.5), p 0.002]. Post-procedure complication (blood-contaminated CSF) occurred less in UGLP compared to SMLP group [(2(10%) vs. 6(30%), p 0.235
Conclusions: UGLP significantly improve the success rate of first LP attempt and decrease time to complete the procedure in difficult LP patients.
UGLP significantly improve the success rate of first LP attempt and decrease time to complete the procedure in difficult LP patients.
P209 Acid-base characteristics of the cerebrospinal fluid of patients with subarachnoid hemorrhage and in control subjects according to Stewart’s approach
T Langer 1, M Carbonara2, A Caccioppola1, C Ferraris Fusarini2, E Carlesso1, E Paradiso1, M Battistini1, E Cattaneo1, F Zadek1, R Maiavacca2, N Stocchetti1, A Pesenti1
1University of Milan, Milan, Italy; 2Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
Introduction: The pathophysiology of the acid-base equilibrium of the cerebrospinal fluid (CSF) is important, as it influences respiration . Aim of the present study was to describe CSF acid-base of patients with subarachnoid hemorrhage (SAH) and compare them with control subjects.
Methods: In patients with SAH, a CSF sample was taken from the external ventricular drain simultaneously with an arterial blood sample to measure electrolytes, albumin, phosphates, PCO[sub]2[/sub] and pH. A similar procedure was performed in patients without significant comorbidities undergoing spinal anesthesia for elective surgery. For each sample the Strong Ion Difference (SID[sub]CSF[/sub]) and the total concentration of weak, non-volatile acids (A[sub]TOT[/sub]) were calculated using standard formulae. Furthermore plasma SID and its difference with SID[sub]CSF[/sub] was computed (Δ SID). Comparison between groups was performed via t-test or Rank Sum Test, as appropriate.
Results: Ten patients with SAH (55 ± 16 years) and 7 controls (56 ± 11 years) were enrolled. Acid-base results are summarized in Table. In SAH patients, SID[sub]CSF[/sub] was lower, mainly due to a higher lactate (3.2 ± 1.5 vs. 1.5 ± 0.3 mEq/L, p < 0.001) and chloride concentration (125 ± 2 vs. 120 ± 2 mEq/L, p < 0.001). Despite the acidifying effect of lower SID[sub]CSF[/sub], a lower CSF PCO[sub]2[/sub], with unchanged CSF A[sub]TOT[/sub] led to CSF pH values similar to controls. Finally, despite a lower plasma SID in the SAH group, Δ SID was significantly higher in these patients.
Conclusions: The CSF of patients with SAH, as compared to control subjects, has lower SID and PCO[sub]2[/sub], but similar pH. In these patients, the reduction in SID[sub]CSF[/sub] is not coupled with a similar reduction in plasma SID, leading to a higher Δ SID, i.e. a more pronounced acidification of CSF as compared to plasma.
1. Langer T et al. Intensive Care Med 42(3):436–9, 2016
P210 Polyuria and natriuresis after aneurysmal subarachnoid haemorrhage
A Ramos1, F Acharta1, J Toledo1, M Perezlindo1, L Lovesio1, A Dogliotti2, C Lovesio1
1Sanatorio Parque, Rosario, Argentina; 2Grupo Oroño, Rosario, Argentina
Introduction: Natriuresis and polyuria are common events after aneurysmal subarachnoid haemorrhage (aSAH). A relationship has been found between polyuria, cerebral salt wasting syndrome (CSWS) and vasospasm . The aim of this study is to determine the relationship between creatinine clearance and natriuresis, and to identify variables related to natriuresis.
Methods: During 2 years (2014-2016) 29 patients with aSAH and polyuria were identified. The tomographic characteristics and neurological clinical scores were considered. 24-hour urine was obtained in individuals with polyuria (>3 liters / day). CSWS was defined as the 75th percentile (>923 mEq / l urinary sodium). Symptomatic vasospasm was defined as clinical deterioration confirmed with cerebral angiography.
Results: 29 patients were included, eight of them (27.6%) developed CSWS. No patient presented hyponatremia. No predictors of CSWS were found (Fig. 11). Neither sodium in 24 hours (AUC: 0.57, 95% CI: 0.37-0.75 p = 0.5), nor the volume of diuresis predicted symptomatic vasospasm (AUC: 0.57, 95% CI: 0.37-0.75 p = 0.5). There was no correlation between creatinine clearance and natriuresis (p = 0.17) (Fig. 12).
Conclusions: We found no relationship between polyuria, natriuresis and symptomatic vasospasm.
1. Brown RJ et al. Polyuria and cerebral vasospasm after aneurysmal subarachnoid hemorrhage. BMC Neurology. 15:1–7, 2015.
P211 Coma in late night amsterdam; do not forget the travel history
N Schroten1, B Van der Veen2, MC De Vries2, J Veenstra2
1VUMC, Amsterdam, Netherlands; 2OLVG, Amsterdam, Netherlands
Introduction: Unconscious young patients are admitted to hospitals in Amsterdam nearly on a daily basis, mostly due to intoxications. However, the following case underscores that routine laboratory and imaging investigations do not replace a detailed interrogation.
Methods: A 17-year old woman was found unconscious in the early morning. Her family mentions she had complained about headaches, but no other complaints or fever. At the emergency department her temperature was 37 °C, respiratory frequency 31/min and pulse 120/min. She was unresponsive and had uncontrolled jerking movements, without signs of lateralisation and with normal stem reflexes. Laboratory analyses showed C-reactive protein 36 mg/l; Leukocytes 6,4x10^9/l; Haemoglobin 5,4 mmol/l; Mean corpuscular volume 86 fl; Thrombocytes 156x10^9/l; LD 318 U/l, bilirubin 28 μ mol/l. Cerebral computer tomography and analysis of cerebrospinal fluid were unremarkable. Empiric therapy with broad-spectrum antibiotics, acyclovir and dexamethasone were started.
Results: At the intensive care unit she developed a fever up to 40 °C and haemoglobin levels decreased to 3,8 mmol/l. Further interrogation of the parents reported a visit to Ghana for 2 weeks 3 months before. She had taken mefloquine prophylactically. A thick smear was positive: plasmodium falciparum with a parasitaemia of 0,3%. After artesunate 2,4 mg/kg twice daily intravenously the patient recovered rapidly. On follow up she had minor concentration problems.
Conclusions: Cerebral malaria is a diffuse symmetric encephalopathy. Children are at a higher risk than adults. Focal signs are unusual. CT scans and cerebrospinal fluid analysis are usually unremarkable. It is important to note that cerebral malaria may have a prolonged incubation time, especially in patients using malaria prophylaxis, like in the current case, and may be lethal even at a low parasitemia. Early treatment is vital. The authors confirm they have received informed consent to publish from the patient.
1. Jakka SR, Veena S, Atmakuri RM, Eisenhut M. Characteristic abnormalities in cerebrospinal fluid biochemistry in children with cerebral malaria compared to viral encephalitis. Cerebrospinal Fluid Res. 2006;3:8.
2. Giha HA1, A-Elbasit IE, A-Elgadir TM, Adam I, Berzins K, Elghazali G, Elbashir MI. Cerebral malaria is frequently associated with latent parasitemia among the semi-immune population of eastern Sudan. Microbes Infect. 2005 Aug-Sep;7(11-12):1196–203.
P212 Healthcare-associated infections in the neurological intensive care unit: 6-year surveillance study at a major tertiary care center
YB Abulhasan1, S Rachel1, M Châtillon-Angle1, N Alabdulraheem1, I Schiller2, N Dendukuri2, M Angle1, C Frenette1
1Montreal Neurological Institute and Hospital, Montreal, Canada; 2McGill University, Montreal, Canada
Introduction: To report incidence rates, pathogens distribution, and patient related outcomes of healthcare-associated infections (HAIs) in a neurological intensive care unit (Neuro-ICU) patient population over a 6-year period.
Methods: We are presenting a prospective cohort study of all patients admitted in a 14 bed Neuro-ICU part of a highly-specialized referral center from April 1, 2010 to March 31, 2016. Surveillance for HAIs was carried by infection control professionals who reviewed laboratory results and targeted specific clinical indicators to match National Healthcare Safety Network infection criteria. Rates were calculated per 1,000 patient days and per 1,000 device days. Differences in infection rates were analyzed by emergency neurocritical care diagnostic categories. We studied the association between: i) primary diagnosis and infection using Cox proportional hazards model, ii) infection and length of stay using linear regression, and iii) infection and mortality using Cox proportional hazards model. Yearly objectives were set to reduce HAIs with implementation of targeted infection control measures.
Results: There were 6,034 Neuro-ICU admissions resulting in 20,845 Neuro-ICU days. A total of 228 HAIs were identified. Pooled mean HAI incidence rates were pneumonia 17.1, UTI 3.7, ventriculostomy-associated infection (VAI) 0.8, central line-associated blood stream infection (CLABSI) and primary bacteremia 0.2, Clostridium difficile-associated diarrhea (CDAD) 0.6, and other HAIs 0.7 per 1,000 Neuro-ICU days. For device-associated infections, which accounted for 80.7% of HAIs, pooled mean rates were 18.5 ventilator-associated pneumonia (VAP), 5.0 catheter-associated urinary tract infection (CAUTI), 4.0 VAI, and 0.6 CLABSI episodes per 1,000 device days. Among the various diagnostic categories, intracerebral/intraventricular hemorrhage (ICH/IVH), subdural hematoma, seizure/status epilepticus, and subarachnoid hemorrhage were associated with the highest pooled HAIs with incidence rates of 22.2, 21.3, 16.5, and 15.2 per 1,000 Neuro-ICU days respectively. Pathogen frequencies were S. aureus (27%) and Klebsiella species (12.2%) for pneumonias, E. coli (44.8%) for UTIs, S. epidermidis (57.9%) for VAIs. Among patients with HAIs, all-cause 30-day case mortality proportion was 9.7% and occurred a median of 14 days after the HAI. Prolonged Neuro-ICU length of stay was strongly associated with all HAIs (P < 0.05).
Conclusions: Pneumonia, UTI and VAI are the commonest HAIs among our cohort of neurocritical care patients with pooled rates of HAIs most pronounced among ICH/IVH patients.
P213 Paradoxical cerebrovascular hemodynamic changes with nicardipine
S Lahiri1, K Schlick1, SA Mayer2, P Lyden1
1Cedars-Sinai Medical Center, Los Angeles, CA, United States; 2Mount Sinai Medical Center, New York, United States
Introduction: IV nicardipine is commonly used for blood pressure reduction. Few studies have described its effects on cerebrovascular hemodynamics as measured by transcranial Doppler (TCD) waveform analysis and pulsatility index (PI).
Methods: The data presented are from patients who underwent TCD monitoring before, after, or during nicardipine administration.
Results: TCD waveforms during nicardipine infusion are characterized by a prominent systolic peak and dicrotic notch. Systolic deceleration is more pronounced and PIs are significantly elevated in patients on nicardipine (p < 0.05).
Conclusions: This study provides first evidence of paradoxical intracranial vasoconstriction associated with nicardipine. This is a consistent finding in patients treated with IV nicardipine and is contradictory to what is expected from a vasodilator and anti-hypertensive.
P214 Clinical manifestations and diagnosis of patients with cerebral venous thrombosis: retrospective study and literature review
M Akatsuka1, J Arakawa1, M Yamakage2
1Japanese Red Cross Kitami Hospital, Kitami, Japan; 2Sapporo Medical University School of Medicine, Sapporo, Japan
Introduction: Cerebral venous thrombosis (CVT) is a rare neurovascular disorder with a highly variable presentation that accounts for only 0.5% of all cases of stroke . It can lead to neurologic impairment. There have been some studies and case reports about CVT; however, there is a lack of information on the incidence and clinical features of CVT due to its rarity. We, therefore, conducted this study to clarify important aspects of the epidemiology, diagnosis, and prognosis of CVT.
Methods: We carried out a retrospective observational study of all patients with a diagnosis of CVT in our hospital between January 2003 and October 2016. From the electronic patient data management system, we obtained information on the patient• fs age, gender, symptoms, risk factors, location of thrombosis, and outcome as well as images. We also performed a systemic review of the literature for CVT using a multiple web research platform (PubMed) from 2000 to 2016.
Results: Four patients were diagnosed with CVT in our hospital during the study period. A total of 17 articles were found, from which 1220 cases were determined eligible for review and the author• fs cases were added. The mean age of the patients was 39.3 years (standard deviation [SD]: 17.4 years), and 70.8% of the patients were female. The most frequent symptom was headache (884 cases, 72.2%). The use of an oral contraceptive was one of the most frequent predisposing risk factors (290 patients, 33.5%). For diagnosis of CVT, the majority of patients underwent computed tomography (CT) (80.5%), magnetic resonance imaging (MRI) (83%), and magnetic resonance venography (MRV) (66.8%). The most frequent site of involvement was the superior sagittal sinus (543 cases, 44.4%). The hospital mortality rate was 5.4%. There was no association between hospital mortality and location of thrombosis. The results of CT or MRI were normal in some cases, but the results of MRV were abnormal in all cases and lead to the diagnosis of CVT.
Conclusions: Patients presenting with headache, especially patients taking an oral contraceptive, should be examined carefully. Not only CT but also MRI in combination with MRV has high sensitivity and specificity for establishing a diagnosis of CVT. Although there is no typical red flag symptomatology, recognition of CVT is important.
 Bousser MG et al.: Lancet Neurol 6: 162–70, 2007
P215 Diaphragmatic electric activity during apnea testing for brain death determination
J Rubio1, JA Rubio Mateo-Sidron2, R Sierra1, M Celaya1, L Benitez1, S Alvarez-Ossorio1
1Hospital Universitario Puerta del Mar, Cadiz, Spain; 2Hospital Xanit, Benalmadena, Malaga, Spain
Introduction: Absence of respiratory control reflexes in the brainstem in response to hypercapnic stimulation through the observation of the thoracic and abdominal movements, positive apnea testing (AT), is a key component in the clinical assessment of brain death (BD). False negative results of AT may occur due to ventilatory auto-triggering which could hamper and delay BD determination. Electrical activity of the diaphragm (EAdi) reflects the neural respiratory drive. We hypothesized that EAdi monitoring would add accuracy and safety to AT procedure.
Methods: We performed a single centre prospective observational study of adult patients admitted to the ICU with devastating acute brain injury and clinical examination consistent with BD. All patients were mechanically ventilated using the Servo-i® and the conventional nasogastric tube was replaced with an EADi catheter (16Fr/125 cm; Maquet Critical Care, Solna, Sweden) designed to be used with neurally adjusted ventilation. Stable patients on ventilator control mode were switched to Pressure Support during the period of apnea. Respiratory movements, arterial pressure, hearth rhythm and SpO2 were continuously monitored and airway pressure, airflow and EADi were also saved using a Ventilation Record Card for later analysis. Study variables were recorded at 3 time points: basal (T1), start of AT (T2) end of AT (T3). AT duration and complications during the procedure were recorded.
Results: We included 8 patients in the study. EADi signals recorded during AT were tonic and with very low voltage. EADi amplitude values at T2 and T3 ranged between 0,2 ± 0,15 μV to 0,5 ± 0,52 μV and 0,2 ± 0,07 μV to 0,55 ± 0,52 μV respectively. The median procedure duration was 12 ± 2,5 min. Sensitive auto-triggering was observed in a case. The AT was positive and completed in all patients and no severe complications were noted.
Conclusions: We found that EADi monitoring and analysis is a safe and effective tool for diagnosing apnea during BD confirmation, avoiding false negative diagnosis based on direct observation. This strategy of rapid implementation, operator-independent, minimally invasive and low cost, may be introduced in the AT protocols.
P216 Usefulness of a method for doing apnea testing during brain death determination
J Rubio1, JA Rubio Mateo-Sidron2, R Sierra1, A Fernandez1, O Gonzalez1
1Hospital Universitario Puerta del Mar, Cadiz, Spain; 2Hospital Xanit, Benalmadena, Malaga, Spain
Introduction: Apnea Testing (AT) is a key element for Brian Death (BD) determination but accepted guidelines including the procedure itself do not exist. All current methods of AT have as main purpose to elevate CO2 and observe the patient for any spontaneous effort by close observation of respiratory movements that may sometimes be subtle and doubtful. Moreover, commonly AT practice involve disconnection of ventilator circuit, adding an adjustable CPAP valve to the distal extremity of the T-piece extension in order to try to preserve oxygenation. This study was aimed to evaluate an alternative AT method that allows the patient to stay connected to the mechanical ventilator circuit during AT procedure and avoid the disadvantages of the current methods.
Methods: We performed a single centre prospective observational study of adult patients admitted to the ICU with devastating acute brain injury and clinical examination consistent with BD. All patients were mechanically ventilated using the Servo-i® ventilator (Maquet Critical Care, Solna, Sweden). After 10 minutes of preoxygenation, controlled mode ventilation was switched to Pressure Support (PS) during the whole test, setting level of PS to 8 cmH2O above PEEP 5 cmH2O, Trigger Pressure -2 cmH2O and FiO2 100% with backup ventilation off. Patients were closely monitored throughout the procedure by clinical observation. Airway pressure, airflow and volume waveforms were displayed on the ventilator screen. Patient and screen data were saved to a Ventilation Record Card for later analysis. Duration of AT, invasive arterial pressure, heart rate and SpO2 were recorded. Physiologic, ventilatory mode and settings, respiratory mechanics and arterial blood gases were collec