The effect of high frequency oscillatory ventilation combined with tracheal gas insufflation on extravascular lung water in patients with acute respiratory distress syndrome: a randomized, crossover, physiological study.

Purpose: High frequency oscillation combined with tracheal gas insufflation (HFO-TGI) improves oxygenation in patients with Acute Respiratory Distress Syndrome (ARDS). There is limited physiologic data regarding the effects of HFO-TGI on hemodynamics and pulmonary edema during ARDS. The aim of this study was to investigate the effect of HFO-TGI on extravascular lung water (EVLW). Materials and Methods: We conducted a prospective, randomized, crossover study. Consecutive eligible patients with ARDS received sessions of conventional mechanical ventilation (CMV) with recruitment maneuvers (RMs), followed by HFO-TGI with RMs, or vice versa. Each ventilatory technique was administered for 8 hours. The order of administration was randomly assigned. Arterial/central venous blood gas analysis and measurement of hemodynamic parameters and EVLW were performed at baseline and after each 8-hour period using the single-indicator thermodilution technique. Results: Twelve patients received 32 sessions. PaO2/FiO2 and respiratory system compliance were higher (p<0.001 for both), while EVLW indexed to predicted body weight (EVLWI) and oxygenation index were lower (p=0.021 and 0.029, respectively) in HFO-TGI compared with CMV. There was a significant correlation between PaO2/FiO2 improvement and EVLWI drop during HFO-TGI (Rs=-0.452, p= 0.009). Conclusions: HFO-TGI improves gas exchange and lung mechanics in ARDS, and potentially attenuates EVLW accumulation

High-frequency oscillation and tracheal gas insufflation in patients with severe acute respiratory distress syndrome and traumatic brain injury: an interventional physiological study

In acute respiratory distress syndrome (ARDS), combined high-frequency oscillation (HFO) and tracheal gas insufflation (TGI) improves gas exchange compared with conventional mechanical ventilation (CMV). We evaluated the effect of HFO-TGI on PaO2/fractional inspired O2 (FiO2) and PaCO2, systemic hemodynamics, intracranial pressure (ICP), and cerebral perfusion pressure (CPP) in patients with traumatic brain injury (TBI) and concurrent severe ARDS

Current Pharmacological Advances in the Treatment of Cardiac Arrest

Cardiac arrest requires immediate treatment, in order to prevent patient death. Cardiac arrest outcomes still remain very poor, especially when the patient requires vasopressor treatment. Vasopressors have been advocated, in order to increase the coronary and cerebral perfusion pressure during cardiopulmonary resuscitation (CPR). Recent data suggest an epinephrine-related benefit with respect to short- and long-term outcomes, only when epinephrine is administered within the first 10 min of collapse. Also, increasing the epinephrine dosing interval from 3-5 to 6-10 min during CPR may be associated with improved long-term outcomes. In the in-hospital setting, the combination of vasopressin, epinephrine, and corticosteroid supplementation during and after CPR (in the presence of postresuscitation shock) may be superior to epinephrine alone during CPR. The use of new formulations of amiodarone, potentially devoid of serious hypotensive effects, may contribute to increased rates of sustained return of spontaneous circulation in patients with ventricular fibrillation / pulseless ventricular tachycardia cardiac arrest. Encouraging preliminary results have been reported on the use of beta blockers in patients with shockable cardiac arrest. Other potentially promising pharmacological interventions include the use of cariporide, nitrates (and particularly inhaled nitric oxide), noble gases, levosimendan, and erythropoietin. The purpose of the current paper is to review the clinical and laboratory evidence that support new and potentially useful pharmacological interventions during CPR

Advances in the Clinical Management of Cardiac Arrest

Cardiac arrest constitutes an extremely life-threatening condition that inevitably and promptly results in death if left untreated. Cardiac arrest outcomes still remain very poor, especially when the presenting cardiac rhythm is nonshockable. Important, recent, clinical research has focused on the quality of cardiopulmonary resuscitation (CPR), the mechanical augmentation of the circulation during CPR, CPR drugs, and therapeutic hypothermia. Chest compression depth of at least 51 mm increases the probability of neurologically favorable survival. Despite initially promising results, a large effectiveness study failed to confirm the efficacy of the mechanical augmentation of the circulation. Epinephrine has finally been shown to slightly improve functional outcome after out-of-hospital cardiac arrest, especially when given early. In a recent, in-hospital study of 268 patients, the addition of vasopressin and methylprednisolone during CPR and the administration of hydrocortisone in postresuscitation shock improved functional outcome after vasopressor-requiring cardiac arrest; however, corticosteroid efficacy still needs to be separately confirmed in a large, international trial. Lastly, preliminary human data may support the conduct of high quality trials evaluating the efficacy of beta adrenergic antagonists in shockable cardiac arrest. The purpose of this paper is to review these potentially important advances in the management of cardiac arrest.

Advances in Post-Resuscitation Care: the Role of Therapeutic Hypothermia

Mild therapeutic hypothermia (32&deg;C-34&deg;C) is the only therapy that improved neurological outcome after cardiac arrest in randomized, controlled trials. It protects the brain after ischemia by reduction of brain metabolism, attenuation of reactive oxygen species formation, inhibition of excitatory amino acid release, attenuation of the immune response during reperfusion and inhibition of apoptosis. Its use is recommended by the American Heart Association and the International Liaison Committee on Resuscitation for unconscious adult patients with spontaneous circulation after out-of-hospital ventricular fibrillation cardiac arrest , 12 to 24 hours following resuscitation.&nbsp; The role of therapeutic hypothermia is uncertain when the initial cardiac rhythm is asystole or pulseless electrical activity, or when the cardiac arrest is primarily due to a noncardiac cause, such as asphyxia or drug overdose. Therefore, in patients with anoxic brain injury after nonventricular fibrillation cardiac arrest, clinicians will need to balance the possible benefit of therapeutic hypothermia with the possible side effects of this therapy. Mild hypothermia is a safe and effective therapy after cardiac arrest, even in hemodynamically compromised patients and in patients undergoing percutaneous coronary intervention. Because the induction of therapeutic hypothermia has become more feasible with the development of simple intravenous cooling techniques and specialized equipment for improved temperature control in the critical care unit, it is expected that therapeutic hypothermia will become more widely used in the management of anoxic neurological injury whatever the presenting cardiac rhythm. Potential side effects have to be kept in mind and treated accordingly

Pulmonary Hypertension Due to Chronic Thromboembolic Disease Complicated with Hemoptysis and Infection

A 45 year old woman developed exertional dyspnea after surgical removal of uterine fibroids. Heart ultrasound suggested the presence of right heart enlargement and stress due to pulmonary arterial hypertension, whereas the subsequent CT angiography revealed pulmonary embolism. Anticoagulants were initiated. Perfusion defects were noticeable in lung perfusion scan 6 months after the initiation of anticoagulant therapy, while CT angiography was negative for pulmonary embolism. The diagnosis of chronic thromboembolic pulmonary hypertension was initially set and subsequently confirmed by right heart catheterization. Deterioration of dyspnea and right heart dysfunction led to administration of intravenous epoprostenol through a tunneled central venous catheter. After 6 months the patient was admitted to the intensive care unit with fever, hemoptysis, lung infiltrates, and acute-on-chronic hypoxemic respiratory failure. Bronchial artery embolization, oxygen therapy, and antibiotics led to clinical improvement

Evolution of European Resuscitation and End-of-Life Practices from 2015 to 2019 : a survey-based comparative evaluation

In concordance with the results of large, observational studies, a 2015 European survey suggested variation in resuscitation/end-of-life practices and emergency care organization across 31 countries. The current survey-based study aimed to comparatively assess the evolution of practices from 2015 to 2019, especially in countries with "low" (i.e., average or lower) 2015 questionnaire domain scores. The 2015 questionnaire with additional consensus-based questions was used. The 2019 questionnaire covered practices/decisions related to end-of-life care (domain A); determinants of access to resuscitation/post-resuscitation care (domain B); diagnosis of death/organ donation (domain C); and emergency care organization (domain D). Responses from 25 countries were analyzed. Positive or negative responses were graded by 1 or 0, respectively. Domain scores were calculated by summation of practice-specific response grades. Domain A and B scores for 2015 and 2019 were similar. Domain C score decreased by 1 point [95% confidence interval (CI): 1-3; = 0.02]. Domain D score increased by 2.6 points (95% CI: 0.2-5.0; = 0.035); this improvement was driven by countries with "low" 2015 domain D scores. In countries with "low" 2015 domain A scores, domain A score increased by 5.5 points (95% CI: 0.4-10.6; = 0.047). In 2019, improvements in emergency care organization and an increasing frequency of end-of-life practices were observed primarily in countries with previously "low" scores in the corresponding domains of the 2015 questionnaire

What change in outcomes after cardiac arrest is necessary to change practice? Results of an international survey

Background: Efficient trials of interventions for patients with out-of-hospital cardiac arrest (OHCA) should have adequate but not excess power to detect a difference in outcomes. The minimum clinically important difference (MCID) is the threshold value in outcomes observed in a trial at which providers should choose to adopt a treatment. There has been limited assessment of MCID for outcomes after OHCA. Therefore, we conducted an international survey of individuals interested in cardiac resuscitation to define the MCID for a range of outcomes after OHCA. Methods: A brief survey instrument was developed and modified by consensus. Included were open-ended responses. The survey included an illustrative example of a hypothetical randomized study with distributions of outcomes based on those in a public use datafile from a previous trial. Elicited information included the minimum significant difference required in an outcome to change clinical practice. The population of interest was emergency physicians or other practitioners of acute cardiovascular research. Results: Usable responses were obtained from 160 respondents (50% of surveyed) in 46 countries (79% of surveyed). MCIDs tended to increase as baseline outcomes increased. For a population of patients with 25% survival to discharge and 20% favorable neurologic status at discharge, the MCID were median 5 (interquartile range [IQR] 3, 10) percent for survival to discharge; median 5 (IQR 2, 10) percent for favorable neurologic status at discharge, median 4 (IQR 2, 9) days of ICU-free survival and median 4 (IQR 2, 8) days of hospital-free survival. Conclusion: Reported MCIDs for outcomes after OHCA vary according to the outcome considered as well as the baseline rate of achieving it. MCIDs of ICU-free survival or hospital-free survival may be useful to accelerate the rate of evidence-based change in resuscitation care. (C) 2016 Elsevier Ireland Ltd. All rights reserved.Peer reviewe