Biochemical and electrophysiological markers predictive of return of spontaneous circulation and post-resuscitation outcome

The majority of patients resuscitated from cardiac arrest (CA) subsequently die due to post-cardiac arrest syndrome (PCAS), whose mechanisms are only partially understood. We adopted an approach of untargeted/targeted plasma metabolomics in rats to identify metabolites involved in the mechanisms of PCAS to be tested as predictors of outcome. Activation of the kynurenine pathway (KP) for tryptophan (TRP) degradation was demonstrated in rats, pigs and in a small cohort of patients. Decreases in TRP occurred during the post-CA period and were accompanied by significant increases in KP metabolites, 3-hydroxyanthranilic acid (3 -HAA) and kynurenic acid in each species, that persisted up to 3-5 days post-CA (p<0.01). KP metabolites changes were significantly related to the severity of myocardial and cerebral injuries and survival. Finally, when tested in 155 patients resuscitated from CA, KP metabolites were significantly higher in patients with poor outcomes. The quality of chest compression (CC) is another major issue for cardiopulmonary resuscitation (CPR) success and survival. The decision whether to interrupt CC to deliver a defibrillation (DF) is difficult. The potential benefit of a DF guided by a real time ventricular fibrillation (YF) waveform analysis would maximize DF success, minimize CC interruptions and myocardial damage by repetitive and unnecessary DFs. We evaluated amplitude spectrum area (AMSA) as predictor of DF outcome in two large databases of out-of-hospital VFs, from US (609 patients) and Italy (1.617 patients). AMSA was significantly higher prior to a successful DF than prior to an unsuccessful one (p<0.0001). Thresholds for prediction of successful and unsuccessful DFs were 16-17 mV-Hz for success and <7 mV-Hz for failure, with a positive predictive value of 80% and a negative predictive value of 97%. AMSA was a better predictor of DF outcome (AUC 0.86, p<0.0001) compared to other VF parameters, i.e. amplitude and frequencies. In conclusion, AMSA would be a useful tool for guiding CPR

Evaluation of microbial adjuncts and their effect on the ripening of cheddar cheese

A bacteriocin-producing strain of Lactobacillus paracasei DPC 4715 was used as an adjunct culture in Cheddar cheese in order to control the growth of “wild” nonstarter lactic acid bacteria. No suppression of growth of the indicator strain was observed in the experimental cheese. The bacteriocin produced by Lactobacillus paracasei DPC 4715 was sensitive to chymosin and cathepsin D and it may have been cleaved by the rennet used for the cheese manufactured or by indigenous milk proteases. A series of studies were performed using various microbial adjuncts to influence cheese ripening. Microbacterium casei DPC 5281, Corynebacterium casei DPC 5293 and Corynebacterium variabile DPC 5305 were added to the cheesemilk at level of 109 cfu/ml resulting in a final concentration of 108 cfu/g in Cheddar cheese. The strains significantly increased the level of pH 4.6-soluble nitrogen, total free amino acids after 60 and 180 d of ripening and some individual free amino acids after 180 d. Yarrowia lipolytica DPC 6266, Yarrowia lipolytica DPC 6268 and Candida intermedia DPC 6271 were used to accelerate the ripening of Cheddar cheese. Strains were grown in YG broth to a final concentration of 107 cfu/ml, microfluidized, freeze-dried and added to the curd during salting at level of 2% w/w. The yeasts positively affected the primary, secondary proteolysis and lipolysis of cheeses and had aminopeptidase, dipeptidase, esterase and 5’ phosphodiestere activities that contributed to accelerate the ripening and improve the flavor of cheese. Hafia alvei was added to Cheddar cheesemilk at levels of 107 cfu/ml and 108 cfu/ml and its contribution during ripening was evaluated. The strain significantly increased the level of pH 4.6-soluble nitrogen, total free amino-acids, and some individual free amino-acids of Cheddar cheese, whereas no differences in the urea-polyacrylamide gel electrophoresis (urea-PAGE) electrophoretograms of the cheeses were detected. Hafia alvei also significantly increased the level of some biogenic amines. A low-fat Cheddar cheese was made with Bifidobacterium animalis subsp. lactis, strain BB-12® at level of 108 cfu/ml, as a probiotic adjunct culture and Hi-Maize® 260 (resistant high amylose maize starch) at level of 2% and 4% w/v, as a prebiotic fiber which also played the role of fat replacer. Bifidobacterium BB-12 decreased by 1 log cycle after 60 d of ripening and remained steady at level of ~107 cfu/g during ripening. The Young’s modulus also increased proportionally with increasing levels of Hi-maize. Hencky strain at fracture decreased over ripening and increased with increasing in fat replacer. A cheese based medium (CBM) was developed with the purpose of mimicking the cheese environment at an early ripening stage. The strains grown in CBM showed aminopeptidase activity against Gly-, Arg-, Pro- and Phe-p-nitroanalide, whereas, when grown in MRS they were active against all the substrates tested. Both Lb. danicus strains grown in MRS and in CBM had aminotransferase activity towards aromatic amino acids (Phe and Trp) and also branched-chain amino acids (Leu and Val). Esterase activity was expressed against p-nitrophenyl-acetate (C2), pnitrophenyl- butyrate (C4) and p-nitrophenyl-palmitate (C16) and was significantly higher in CBM than in MRS

Oxygen and carbon dioxide targets during and after resuscitation of cardiac arrest patients

Non peer reviewe

Cardiac rhythm analysis during ongoing cardiopulmonary resuscitation using the Analysis During Compressions with Fast reconfirmation technology

BACKGROUND Pauses in chest compressions (CCs) have a negative association with survival from cardiac arrest. Electrocardiographic (ECG) rhythm analysis and defibrillator charging are significant contributors to CC pauses. OBJECTIVE Accuracy of the Analysis During Compressions with Fast Reconfirmation (ADC-FR) algorithm, which features automated rhythm analysis and charging during CCs to reduce CC pauses, was retrospectively determined in a large database of ECGs from 2701 patients with out-of-hospital cardiac arrest. METHODS The ADC-FR algorithm generated a total of 7264 advisories, of which 3575 were randomly assigned to a development data set and 3689 to a test data set. With ADC-FR, a high-pass digital filter is used to remove CC artifacts, while the underlying ECG rhythm is automatically interpreted. When CCs are paused at the end of the 2-minute cardiopulmonary resuscitation interval, a 3-second reconfirmation analysis is performed using the artifact-free ECG to confirm the shock/no-shock advisory. The sensitivity and specificity of the ADC-FR algorithm in correctly identifying shockable/nonshockable rhythms during CCs were calculated. RESULTS In both data sets, the accuracy of the ADC-FR algorithm for each ECG rhythm exceeded the recommended performance goals, which apply to a standard artifact-free ECG analysis. Sensitivity and specificity were 97% and 99%, respectively, for the development data set and 95% and 99% for the test data set. CONCLUSION The ADC-FR algorithm is highly accurate in discriminating shockable and nonshockable rhythms and can be used to reduce CC pauses

Permanent safety measures (MISP): efficacy assessment through pumping test analysis, groundwater flow modeling and environmental isotope investigation

Heavy contaminated areas, Permanent Safety Measures, environmental isotopes, pumping tests, modelling

Ethical issues associated with in-hospital emergency from the medical emergency team's perspective: a national survey

Medical Emergency Teams (METs) are frequently involved in ethical issues associated to in-hospital emergencies, like decisions about end-of-life care and intensive care unit (ICU) admission. MET involvement offers both advantages and disadvantages, especially when an immediate decision must be made. We performed a survey among Italian intensivists/anesthesiologists evaluating MET's perspective on the most relevant ethical aspects faced in daily practice

2022: Are We Back to the pre-COVID-19 Pandemic Period in the Management of out-of-Hospital Cardiac Arrest?

Introduction: The COVID-19 pandemic caused a significant strain on the Emergency system, particularly for time-dependent diseases like Out of Hospital Cardiac Arrest (OHCA). Studies have shown an increase in the incidence of OHCA during different waves of the pandemic, but there is limited evidence on how survival rates and rescue efforts have been affected in the post-pandemic period. Methods: We performed a retrospective observational cohort study of all OHCA rescues by AREU (Agenzia Regionale Emergenza Urgenza), in the Lombardy region in March in three different years (2019, 2021 and 2022). We used rescue mission data collected in AREU’s database, where logistic information of patient rescue missions managed by the Lombardy Region’s 112 system is recorded.Results: This study was an epidemiology analysis of OHCA after the pandemic. The results showed no significant changes in the probability of receiving bystander cardiopulmonary resuscitation (22.5% vs 24.0%; p=0.41) and public access defibrillation (3.6 vs 3.2; p=0.50) compared to pre-pandemic period. However, there was a decrease in the probability of ROSC (11.5% vs 6.2%; p&lt;0.01).Conclusion: According to our analysis, there appears to be a return to the pre-pandemic phase with regard to the OHCA network. However, it remains to be pointed out that a careful study of disease networks is essential to understand the resilience of our health system and to understand whether we have returned to a system similar to the pre-pandemic phase after the COVID-19 pandemic

Point-of-care laboratory analyses of intraosseous, arterial and central venous samples during experimental cardiopulmonary resuscitation

Introduction: Screening and correcting reversible causes of cardiac arrest (CA) are an essential part of cardiopulmonary resuscitation (CPR). Point-ofcare (POC) laboratory analyses are used for screening pre-arrest pathologies, such as electrolyte disorders and acid-base balance disturbances. The aims of this study were to compare the intraosseous (10), arterial and central venous POC values during CA and CPR and to see how the CPR values reflect the pre-arrest state. Methods: We performed an experimental study on 23 anaesthetised pigs. After induction of ventricular fibrillation (VF), we obtained POC samples from the 10 space, artery and central vein simultaneously at three consecutive time points. We observed the development of the values during CA and CPR and compared the CPR values to the pre-arrest values. Results: The 10, arterial and venous values changed differently from one another during the course of CA and CPR. Base excess and pH decreased in the venous and 10 samples during untreated VF, but in the arterial samples, this only occurred after the onset of CPR. The 10, arterial and venous potassium values were higher during CPR compared to the pre-arrest arterial values (mean elevations 4.4 mmol/l (SD 0.72), 3.3 mmol/l (0.78) and 2.8 mmol/l (0.94), respectively). Conclusions: A dynamic change occurs in the common laboratory values during CA and CPR. POC analyses of lactate, pH, sodium and calcium within 10 samples are not different from analyses of arterial or venous blood. Potassium values in 10, arterial and venous samples during CPR are higher than the pre-arrest arterial values.Peer reviewe