Outcome after rewarming from accidental hypothermia by use of extracorporeal circulation

Background: Accidental hypothermia with arrested circulation remains a condition associated with high mortality. In our institution, extracorporeal circulation (ECC) rewarming has been the cornerstone in treating such patients since 1987. We here explore characteristics and outcomes of this treatment, to identify significant merits and challenges from 3 decades of experience in ECC rewarming. Methods: Sixty-nine patients rewarmed by ECC during the period from December 1987 to December 2015 were analyzed. One patient was excluded from the analyses because of combined traumatic cerebral injury. The analysis was focused on patient characteristics, treatment procedures, and outcomes were focused. Survivors were evaluated according to the cerebral performance categories scale. Simple statistics with nonparametric tests and χ2 tests were used. Median value and range are reported. Results: Median age was 30 years (minimum 1.5, maximum 76), and the cause of accidental hypothermia was cold exposure (27.9%), avalanche (5.9%), and immersion/submersion accidents (66.2%). Eighteen patients survived (26.5%). The survival rate did not improve during the years. Survivors had lower serum potassium (p = 0.002), higher pH (p = 0.03), lower core temperature (p = 0.02), and shorter cardiopulmonary resuscitation time (p = 0.001), but ranges were wide. Although suspected primary hypoxia and hypothermia were associated with lower survival, we observed a 10.5% survival of these victims. Sixteen survivors had good outcome (cerebral performance category 1 or 2), whereas 2 patients with suspected primary hypoxia survived with severe cerebral disability (cerebral performance category 3). Conclusions: Despite extended experience with ECC rewarming, improved handling strategies, and intensive care, no overall improvement in survival was observed. Good outcome was observed even among patients with a dismal prognosis.publishedVersio

Accelerometry May be Superior to EMG for Early Evaluation of Vocal Cord Function After Nerve Injury in a Pig Model

Objective Vocal cord (VC) movement has been demonstrated by the use of accelerometry (ACC) to decrease in parallel with the electromyographic amplitude (EMG) during ongoing traction injury to the recurrent laryngeal nerve (RLN). When RLN function recovers, discrepancies between EMG and VC movement have been reported in clinical and experimental studies. The present study was conducted to clarify the actual relationship between EMG and VC movement measured by ACC during nerve recovery. Methods EMG obtained by continuous nerve monitoring (C-IONM) was compared with ACC during traction injury to the RLN, and throughout 40-min nerve recovery. A three-axis linear accelerometer probe was attached to the VC, and ACC data were registered as described. Traction damage was applied to the RLN until there was a 70% amplitude decrease from baseline EMG, or until loss of signal (LOS), that is, EMG values ≤100 μV. Results Thirty-two RLN from 16 immature pigs were studied. Correlation between EMG and ACC were calculated during nerve injury and nerve recovery. The mean correlations were for the 70% and LOS group from start to end of traction: 0.82 (±0.17) and 0.87 (±0.17), respectively. Corresponding correlation coefficients during 40-min recovery was 0.50 (±0.48) in the 70% group and 0.53 (±0.33) in the LOS group. Conclusion There is a high correlation between EMG and VC movement during nerve injury, and a moderate correlation during early nerve recovery. EMG recovery after RLN injury ensures sufficient VC function as assessed by ACC.publishedVersio

The Psychological and HRQoL related Aftermaths of Extra Corporeal Membrane Oxygenation Treatment: A Cross‐Sectional Study

Objectives: To assess symptoms of post-traumatic stress disorder, anxiety, depression and health related quality of life in a sample of adult patients treated with veno-arterial extracorporeal membrane oxygenation. Design and setting: This is a cross-sectional study. The population were all patients discharged (2008–2018) from a thoracic surgical intensive ward at a tertiary university hospital in Norway. A sample of 20 patients was recruited. Main outcome measures: Symptoms of post-traumatic stress disorder were assessed using Impact of Events Scale-Revised, while symptoms of depression and anxiety were assessed using Hospital Anxiety and Depression Scale. RAND 36-Item Short Form Health Survey was applied to measure health-related quality of life. Results: Symptoms of post-traumatic stress disorder were reported by 40% of the participants. Twenty percent reported symptoms of depression and anxiety. Compared to the general population, participants reported poorer health-related quality of life on all domains, and significantly worse on the domains physical function, general health and social function. Conclusion: Patients in our study reported symptoms of post-traumatic stress disorder, anxiety, depression and impaired health-related quality of life following treatment with veno-arterial extra corporeal membrane oxygenation. Addressing possible emotional and psychological distress could represent a potential major improvement in health care provided to this group. Further research is needed to incorporate prophylactic methods, such as identifying vulnerable patients and implement corresponding interventions, into clinical practice.publishedVersio

The influence of socio-demographic and clinical factors on sick leave and return to work after open-heart surgery: a nationwide registry-based cohort study

Aims - To estimate sick leave (SL) duration after first-time elective open-heart surgery and identify factors contributing to increased SL. Methods and results - A retrospective nationwide cohort study combined data from the Norwegian Register for Cardiac Surgery and SL data from the Norwegian Labour and Welfare Administrations. All able-bodied adults who underwent first-time elective open-heart surgery in Norway between 2012 and 2021 were followed until 1 year after surgery. The impact of socio-demographic and clinical factors on SL after surgery was analysed using logistic regression and odds ratios. Of 5456 patients, 1643 (30.1%), 1798 (33.0%), 971 (17.8%), 1035 (18.9%), and 9 (0.2%) had SL of 6 months was associated with female gender, primary education only, and average annual income. Post-operative stroke, post-operative renal failure, New York Heart Association Functional Classification system (NYHA) score >3, earlier myocardial infarction, and diabetes mellitus increased the odds of SL >6 months. Conclusion - This study demonstrates that socio-demographic and clinical factors impact SL after first-time elective open-heart surgery. Patients who experience a stroke or develop renal failure after surgery have the highest odds of SL >6 months. Females and patients with low education levels, earlier myocardial infarction, or NYHA scores III–IV have a two-fold chance of SL >6 months. The findings allow for future investigations of pre- and post-surgery interventions that can most effectively reduce SL and aid return to work

Alpha-2-adrenergic receptor agonists for the prevention of delirium and cognitive decline after open heart surgery (ALPHA2PREVENT): protocol for a multicentre randomised controlled trial

INTRODUCTION: Postoperative delirium is common in older cardiac surgery patients and associated with negative short-term and long-term outcomes. The alpha-2-adrenergic receptor agonist dexmedetomidine shows promise as prophylaxis and treatment for delirium in intensive care units (ICU) and postoperative settings. Clonidine has similar pharmacological properties and can be administered both parenterally and orally. We aim to study whether repurposing of clonidine can represent a novel treatment option for delirium, and the possible effects of dexmedetomidine and clonidine on long-term cognitive trajectories, motor activity patterns and biomarkers of neuronal injury, and whether these effects are associated with frailty status. METHODS AND ANALYSIS: This five-centre, double-blind randomised controlled trial will include 900 cardiac surgery patients aged 70+ years. Participants will be randomised 1:1:1 to dexmedetomidine or clonidine or placebo. The study drug will be given as a continuous intravenous infusion from the start of cardiopulmonary bypass, at a rate of 0.4 µg/kg/hour. The infusion rate will be decreased to 0.2 µg/kg/hour postoperatively and be continued until discharge from the ICU or 24 hours postoperatively, whichever happens first.Primary end point is the 7-day cumulative incidence of postoperative delirium (Diagnostic and Statistical Manual of Mental Disorders, fifth edition). Secondary end points include the composite end point of coma, delirium or death, in addition to delirium severity and motor activity patterns, levels of circulating biomarkers of neuronal injury, cognitive function and frailty status 1 and 6 months after surgery. ETHICS AND DISSEMINATION: This trial is approved by the Regional Committee for Ethics in Medical Research in Norway (South-East Norway) and by the Norwegian Medicines Agency. Dissemination plans include publication in peer-reviewed medical journals and presentation at scientific meetings. TRIAL REGISTRATION NUMBER: NCT05029050

Outcome after rewarming from accidental hypothermia by use of extracorporeal circulation

Background: Accidental hypothermia with arrested circulation remains a condition associated with high mortality. In our institution, extracorporeal circulation (ECC) rewarming has been the cornerstone in treating such patients since 1987. We here explore characteristics and outcomes of this treatment, to identify significant merits and challenges from 3 decades of experience in ECC rewarming. Methods: Sixty-nine patients rewarmed by ECC during the period from December 1987 to December 2015 were analyzed. One patient was excluded from the analyses because of combined traumatic cerebral injury. The analysis was focused on patient characteristics, treatment procedures, and outcomes were focused. Survivors were evaluated according to the cerebral performance categories scale. Simple statistics with nonparametric tests and χ2 tests were used. Median value and range are reported. Results: Median age was 30 years (minimum 1.5, maximum 76), and the cause of accidental hypothermia was cold exposure (27.9%), avalanche (5.9%), and immersion/submersion accidents (66.2%). Eighteen patients survived (26.5%). The survival rate did not improve during the years. Survivors had lower serum potassium (p = 0.002), higher pH (p = 0.03), lower core temperature (p = 0.02), and shorter cardiopulmonary resuscitation time (p = 0.001), but ranges were wide. Although suspected primary hypoxia and hypothermia were associated with lower survival, we observed a 10.5% survival of these victims. Sixteen survivors had good outcome (cerebral performance category 1 or 2), whereas 2 patients with suspected primary hypoxia survived with severe cerebral disability (cerebral performance category 3). Conclusions: Despite extended experience with ECC rewarming, improved handling strategies, and intensive care, no overall improvement in survival was observed. Good outcome was observed even among patients with a dismal prognosis

0729. Interstitial changes in spleen during sepsis

publishedVersio

Integrin αvβ3 acts downstream of insulin in normalization of interstitial fluid pressure in sepsis and in cell-mediated collagen gel contraction

The administration of insulin is recommended to patients with severe sepsis and hyperglycemia. Previously, we demonstrated that insulin may have direct anti-inflammatory properties and counteracted fluid losses from the circulation by normalizing the interstitial fluid pressure (PIF). PIF is one of the Starling forces determining fluid flux over the capillary wall, and a lowered PIF is one of the driving forces in early edema formation in inflammatory reactions. Here we demonstrate that insulin restores a lipopolysaccharide (LPS)-lowered PIF via a mechanism involving integrin αvβ3. In C57 black mice (n = 6), LPS lowered PIF from −0.2 ± 0.2 to −1.6 ± 0.3 (P < 0.05) and after insulin averaged −0.8 ± 0.2 mmHg (P = 0.098 compared with after LPS). Corresponding values in wild-type BALB/c mice (n = 5) were −0.8 ± 0.1, −2.1 ± 0.3 (P < 0.05), and −0.8 ± 0.3 mmHg (P < 0.05 compared with LPS) after insulin administration. In BALB/c integrin β3-deficient (β3−/−) mice (n = 6), LPS lowered PIF from −0.1 ± 0.2 to −1.5 ± 0.3 mmHg (P < 0.05). Insulin did not, however, restore PIF in these mice (averaged −1.7 ± 0.3 mmHg after insulin administration). Cell-mediated collagen gel contraction can serve as an in vitro model for in vivo measurements of PIF. Insulin induced αvβ3-integrin-dependent collagen gel contraction mediated by C2C12 cells. Our findings suggest a beneficiary effect of insulin for patients with sepsis with regard to the fluid balance, and this effect may in part be due to a normalization of PIF by a mechanism involving the integrin αvβ3

The Psychological and HRQoL related Aftermaths of Extra Corporeal Membrane Oxygenation Treatment: A Cross‐Sectional Study

Objectives: To assess symptoms of post-traumatic stress disorder, anxiety, depression and health related quality of life in a sample of adult patients treated with veno-arterial extracorporeal membrane oxygenation. Design and setting: This is a cross-sectional study. The population were all patients discharged (2008–2018) from a thoracic surgical intensive ward at a tertiary university hospital in Norway. A sample of 20 patients was recruited. Main outcome measures: Symptoms of post-traumatic stress disorder were assessed using Impact of Events Scale-Revised, while symptoms of depression and anxiety were assessed using Hospital Anxiety and Depression Scale. RAND 36-Item Short Form Health Survey was applied to measure health-related quality of life. Results: Symptoms of post-traumatic stress disorder were reported by 40% of the participants. Twenty percent reported symptoms of depression and anxiety. Compared to the general population, participants reported poorer health-related quality of life on all domains, and significantly worse on the domains physical function, general health and social function. Conclusion: Patients in our study reported symptoms of post-traumatic stress disorder, anxiety, depression and impaired health-related quality of life following treatment with veno-arterial extra corporeal membrane oxygenation. Addressing possible emotional and psychological distress could represent a potential major improvement in health care provided to this group. Further research is needed to incorporate prophylactic methods, such as identifying vulnerable patients and implement corresponding interventions, into clinical practice

The Psychological and HRQoL related Aftermaths of Extra Corporeal Membrane Oxygenation Treatment: A Cross‐Sectional Study

Objectives To assess symptoms of post-traumatic stress disorder, anxiety, depression and health related quality of life in a sample of adult patients treated with veno-arterial extracorporeal membrane oxygenation. Design and setting This is a cross-sectional study. The population were all patients discharged (2008–2018) from a thoracic surgical intensive ward at a tertiary university hospital in Norway. A sample of 20 patients was recruited. Main outcome measures Symptoms of post-traumatic stress disorder were assessed using Impact of Events Scale-Revised, while symptoms of depression and anxiety were assessed using Hospital Anxiety and Depression Scale. RAND 36-Item Short Form Health Survey was applied to measure health-related quality of life. Results Symptoms of post-traumatic stress disorder were reported by 40% of the participants. Twenty percent reported symptoms of depression and anxiety. Compared to the general population, participants reported poorer health-related quality of life on all domains, and significantly worse on the domains physical function, general health and social function. Conclusion Patients in our study reported symptoms of post-traumatic stress disorder, anxiety, depression and impaired health-related quality of life following treatment with veno-arterial extra corporeal membrane oxygenation. Addressing possible emotional and psychological distress could represent a potential major improvement in health care provided to this group. Further research is needed to incorporate prophylactic methods, such as identifying vulnerable patients and implement corresponding interventions, into clinical practice