The influence of early intensified rehabilitation on the clinical outcome of critically ill patients

1 Exekutivní souhrn Hlavním cílem této práce bylo posoudit účinnost a bezpečnost inovativní fyzioterapeutické metody využívající moderních technologií - funkční elektrickou stimulací asistovanou bicyklovou ergometrii - u kriticky nemocných. Nejprve jsme (projekt A) zkoumali fyziologické změny vyvolané touto technikou u skupiny 14 zdravých dobrovolníků a porovnávali jsme ji ve zkříženém uspořádání s běžným volním cvičením na ergometru s nízkou intenzitou. Prokázali jsme zvýšení celotělového energetického výdeje podobné cvičení o výkonu 25 W. Dále (projekt B) jsme provedli metaanalýzu dosud dostupných randomizovaných kontrolovaných studií, abychom v populaci kriticky nemocných porovnali účinek neuromuskulární elektrické stimulace, pasivního cvičení na bicyklovém ergometru a časné protokolizované fyzioterapie. Zjistili jsme, že pozitivní vliv na výsledky zaměřené na pacienta má pouze časná protokolizovaná fyzioterapie. Nebyly publikovány žádné studie využívající funkční elektrickou stimulací asistovanou bicyklovou ergometrii. Nakonec (projekt C) jsme ve velké jednocentrové randomizované kontrolované studii testovali inovativní protokol časné fyzioterapie založený na využití funkční elektrickou stimulací asistované bicyklové ergometrie ve srovnání se standardní péčí u kriticky nemocných. Nezjistili jsme žádné...1 Executive Summary The overarching goal of this thesis was to assess the efficacy and safety of an innovative rehabilitation technique - functional electrical stimulation-assisted cycle ergometry - in critically ill patients. We firstly (Project A) investigated physiological changes induced by this technique in a group of 14 healthy volunteers and compared it, in a cross-over design, to normal volitional low intensity exercise. We have shown an increase in whole-body energy expenditure similar to 25 W exercise. Then (Project B) we have performed a meta-analysis of randomised-controlled studies available to date to compare in the population of critically ill patients the effect of neuromuscular electrical stimulation, passive cycling, and early goal-directed rehabilitation. We found that only goal directed rehabilitation has positive effects on patient-centred outcomes. There were no published studies using functional electrical stimulation-assisted cycle ergometry. Lastly (Project C) in a large, single centre randomised controlled trial we have tested an innovative functional electrical stimulation-assisted cycle ergometry-based early rehabilitation protocol compared to standard of care in critically ill patient. We have not found any significant differences in the physical function after six months of...Department of Anaesthesia and Intensive Care Medicine 3FM CU and UHKVKlinika anesteziologie a resuscitace 3. LF UK a FNKV3. lékařská fakultaThird Faculty of Medicin

Targeting out-of-hospital cardiac arrest: the effect of heparin administered during cardiopulmonary resuscitation (T-ARREST)

Introduction. Heparin administration during cardiopulmonary resuscitation (CPR) may prevent activation of coagulation after successful resuscitation for out-of-hospital cardiac arrest (OHCA). We hypothesize that such an approach is not associated with an increased rate of bleeding, but it has not been evaluated. We performed a pilot randomized clinical study assessing the safety of intra-arrest heparin administration in OHCA patients with suspected acute myocardial infarction (AMI) and its impact on their prognosis. Materials and Methods. OHCA patients were randomized during CPR to 10 000 units of intra-arrest intravenous heparin (Group H) or to treatment without heparin (Group C). The occurrence of major bleeding and the presence of a favourable neurological result 3 months after OHCA, were analyzed. Results. Out of 88 randomized patients, AMI was subsequently confirmed in 63 of them (71.6 %). There were 30 patients in group H and 33 in group C. No major bleeding event was observed in either group. Return of spontaneous circulation (ROSC, Group H: 40.0%, Group C: 45.4%, p=0.662) and a good neurological result 3 months after OHCA (Group H: 6.7 %, Group C: 9.1 %, p=0.921) did not differ between groups. Conclusions. Intravenous administration of 10 000 units of heparin during CPR for OHCA in patients with supposed AMI was safe. We did not find any improvement in prognosis for our sample of limited size. Though the procedure proved safe, we recommend postponing the administration of heparin until ROSC, assessment of clinical state and recording of a twelve-lead ECG

Functional electrical stimulation-assisted cycle ergometry in the critically ill: protocol for a randomized controlled trial

This is the final version. Available from BMC via the DOI in this record. Background: Intensive care unit (ICU)-acquired weakness is the most important cause of failed functional outcome in survivors of critical care. Most damage occurs during the first week when patients are not cooperative enough with conventional rehabilitation. Functional electrical stimulation-assisted cycle ergometry (FES-CE) applied within 48 h of ICU admission may improve muscle function and long-term outcome. Methods: An assessor-blinded, pragmatic, single-centre randomized controlled trial will be performed. Adults (n = 150) mechanically ventilated for 7 days of critical care will be randomized (1:1) to receive either standard of care or FES-CE-based intensified rehabilitation, which will continue until ICU discharge. Primary outcome: quality of life measured by 36-Item Short Form Health Survey score at 6 months. Secondary outcomes: functional performance at ICU discharge, muscle mass (vastus ultrasound, N-balance) and function (Medical Research Council score, insulin sensitivity). In a subgroup (n = 30) we will assess insulin sensitivity and perform skeletal muscle biopsies to look at mitochondrial function, fibre typing and regulatory protein expression. Trial registration: ClinicalTrials.gov, NCT02864745. Registered on 12 August 2016.Grant Agency for Research in Healthcar

A randomized comparison of HBP versus RVP: Effect on left ventricular function and biomarkers of collagen metabolism

Background: Right ventricular pacing (RVP) can result in pacing-induced cardiomyopathy (PICM). It is unknown whether specific biomarkers reflect differences between His bundle pacing (HBP) and RVP and predict a decrease in left ventricular function during RVP. Aims: To compare the effect of HBP and RVP on the LV ejection fraction (LVEF) and to study how they affect serum markers of collagen metabolism. Methods: Ninety-two high-risk PICM patients were randomized to HBP or RVP. Their clinical characteristics, echocardiography, and serum levels of TGF-β1, MMP-9, ST2-IL, TIMP-1, and Gal-3 were studied before and six months after pacemaker implantation. Results: Fifty-three patients were randomized to HBP and 39 patients to RVP. HBP failed in 10 patients, which crossed over to the RVP group. Patients with RVP had significantly lower LVEF compared to HBP after six months of pacing (−5% and −4% in as-treated and intention-to-treat analysis, respectively). Levels of TGF-β1 after 6 months were lower in HBP than RVP (mean difference −6 ng/ml; P = 0.009) and preimplant Gal-3 and ST2-IL levels were higher in RVP patients with a decline in the LVEF ≥ 5% compared to those with a decline of < 5% (mean difference 3 ng/ml and 8 ng/ml; P = 0.02 for both). Conclusion: In high-risk PICM patients, HBP was superior to RVP in providing more physiological ventricular function, as reflected by higher LVEF and lower levels of TGF-β1. Among RVP patients, LVEF declined more in those with higher baseline Gal-3 and ST2-IL levels than those with lower levels

Fabrication and characterisation of hybrid photodiodes based on PCPDTBT–ZnO active layers

We report the fabrication and characterisation of an organic–inorganic hybrid photodiode (HPD) based on PCPDTBT and Zinc Oxide (ZnO) photoactive layers. The main benefit of using these materials is that multi spectral light sensing from the UV through to the Near Infrared is achieved, encompassing wavelengths ∼350–870 nm. To our knowledge, this is one of the widest range responses reported for an inorganic–organic hybrid photodiode. The evaluation of the technology shows the devices exhibit one of the lowest levels of dark currents reported for a HPD, but some limitations exist due to a low on–off ratio and non-linearity of the responsivity at low incident power. The stability of devices made with PCPDTBT:ZnO active layers is compared to more commonly reported P3HT:ZnO devices in dark and it is shown that using PCPDTBT substantially improves lifetime

Left Ventricular Myocardial Septal Pacing in Close Proximity to LBB Does Not Prolong the Duration of the Left Ventricular Lateral Wall Depolarization Compared to LBB Pacing

Background: Three different ventricular capture types are observed during left bundle branch pacing (LBBp). They are selective LBB pacing (sLBBp), non-selective LBB pacing (nsLBBp), and myocardial left septal pacing transiting from nsLBBp while decreasing the pacing output (LVSP). Study aimed to compare differences in ventricular depolarization between these captures using ultra-high-frequency electrocardiography (UHF-ECG). Methods: Using decremental pacing voltage output, we identified and studied nsLBBp, sLBBp, and LVSP in patients with bradycardia. Timing of ventricular activations in precordial leads was displayed using UHF-ECGs, and electrical dyssynchrony (e-DYS) was calculated as the difference between the first and last activation. The durations of local depolarizations (Vd) were determined as the width of the UHF-QRS complex at 50% of its amplitude. Results: In 57 consecutive patients, data were collected during nsLBBp (n = 57), LVSP (n = 34), and sLBBp (n = 23). Interventricular dyssynchrony (e-DYS) was significantly lower during LVSP 16 ms (21; 11), than nsLBBp 24 ms (28; 20) and sLBBp 31 ms (36; 25). LVSP had the same V1d-V8d as nsLBBp and sLBBp except for V3d, which during LVSP was shorter than sLBBp; the mean difference 9 ms (16; 1), p = 0.01. LVSP caused less interventricular dyssynchrony and the same or better local depolarization durations than nsLBBp and sLBBp irrespective of QRS morphology during spontaneous rhythm or paced QRS axis. Conclusions: In patients with bradycardia, LVSP in close proximity to LBB resulted in better interventricular synchrony than nsLBBp and sLBBp and did not significantly prolong depolarization of the left ventricular lateral wall