scholarly journals Therapeutic Hypothermia after Cardiac Arrest: Experience at an Academically Affiliated Community-Based Veterans Affairs Medical Center

2011 ◽  
Vol 2011 ◽  
pp. 1-8 ◽  
Author(s):  
Maulik P. Shah ◽  
Leslie Zimmerman ◽  
Jean Bullard ◽  
Midori A. Yenari
Keyword(s):  
Cardiac Arrest ◽  
Therapeutic Hypothermia ◽  
Medical Center ◽  
Cerebral Performance Category ◽  
Case Series ◽  
Pulseless Electrical Activity ◽  
Community Setting ◽  
Veterans Affairs ◽  
Community Based ◽  
Mean Time

At laboratory and clinical levels, therapeutic hypothermia has been shown to improve neurologic outcomes and mortality following cardiac arrest. We reviewed each cardiac arrest in our community-based Veterans Affairs Medical Center over a three-year period. The majority of cases were in-hospital arrests associated with initial pulseless electrical activity or asystole. Of a total of 100 patients suffering 118 cardiac arrests, 29 arrests involved comatose survivors, with eight patients completing therapeutic cooling. Cerebral performance category scores at discharge and six months were significantly better in the cooled cohort versus the noncooled cohort, and, in every case except for one, cooling was offered for appropriate reasons. Mean time to initiation of cooling protocol was 3.7 hours and mean time to goal temperature of 33∘C was 8.8 hours, and few complications clearly related to cooling were noted in our case series. While in-patient hospital mortality of cardiac arrest was high at 65% mortality during hospital admission, therapeutic hypothermia was safe and feasible at our center. Our cooling times and incidence of favorable outcomes are comparable to previously published reports. This study demonstrates the feasibility of implementing, a cooling protocol a community setting, and the role of neurologists in ensuring effective hospital-wide implementation.

Abstract P65: Community Based Application of Therapeutic Hypothermia for Survivors of Cardiac Arrest

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Roger Getts ◽  
David Fedor ◽  
Vincent J Vanston ◽  
Mary Triano ◽  
John Prior
Keyword(s):  
Cardiac Arrest ◽  
Therapeutic Hypothermia ◽  
Spontaneous Circulation ◽  
Mild Therapeutic Hypothermia ◽  
Community Based ◽  
Simple Protocol ◽  
The Us ◽  
Good Neurologic Outcome ◽  
The Mean ◽  
Mean Time

Objectives: To demonstrate that the application of therapeutic hypothermia is technically feasible in a community-based setting. Background: Implementation of therapeutic hypothermia for survivors of cardiac arrest in the US has been slow, at least partially because of the perception that this therapy is technically difficult, especially at the community level. Scranton, Pennsylvania is a just such a community. It has 75,000 people served by 3 hospitals with 700 acute care beds. Methods: At three community hospitals, after return of spontaneous circulation (ROSC) survivors of cardiac arrest were treated with mild therapeutic hypothermia using ice and cooling blankets or suits in order to achieve a goal temperature of 32 to34 degrees C for 24 hours. After ROSC, the timing goals of therapeutic hypothermia were to cool patients within 4 hours, to achieve goal temperature within 8 hours, and to maintain goal temperature for 24 hours. Results: Beginning in 2004, 27 survivors of cardiac arrest were managed with therapeutic hypothermia. The mean time from ROSC to initiation of therapeutic hypothermia was 2.8 hours (range, 0.4 – 6.3 hours), the mean time from ROSC to goal temperature was 6.9 hours (range, 1.9 –15 hours), and the mean time maintained at goal temperature was 26.7 hours (range, 12–39 hours). Once patients achieved goal temperature, 4.3% of the temperature readings were above 34 degrees C, reflecting undercooling, while 13.4% of the readings were below 32 degrees C, indicative of overcooling. Overall survival until hospital discharge with good neurologic outcome was 52%, compared to only 12% (p < 0.001) among historical controls with cardiac arrest. There were no major complications attributable to the procedure. Conclusion: A simple protocol of mild therapeutic hypothermia using locally-available resources is technically feasible and safe in a community-based setting.

Abstract 052: Improved Hospital Outcomes With Hypokalemia on Admission in Cardiac Arrest Survivors Treated With Therapeutic Hypothermia

2017 ◽  
Vol 10 (suppl_3) ◽  
Author(s):  
Angelo de la Rosa ◽  
Manuel Tapia ◽  
Yong Ji ◽  
Basil Saour ◽  
Mikhail Torosoff
Keyword(s):  
Logistic Regression ◽  
Cardiac Arrest ◽  
Ventricular Fibrillation ◽  
Hospital Mortality ◽  
Electrical Activity ◽  
Therapeutic Hypothermia ◽  
Multivariate Logistic Regression Analysis ◽  
Pulseless Electrical Activity ◽  
Older Age ◽  
Chi Square

Purpose: We hypothesized that advanced circulatory compromise, as manifested by acidosis and hyperkalemia should be associated with worsened clinical outcomes in cardiac arrest patients treated with therapeutic hypothermia. Methods: Results of initial admission laboratory studies, medical history, and echocardiogram in 203 consecutive cardiac arrest patients (59 females, 59+/- 15 years old) undergoing therapeutic hypothermia were reviewed. Mortality was ascertained through hospital records. ANOVA, chi-square, Kaplan-Meier, and logistic regression analyses were used. The study was approved by the institutional IRB. Results: Increased mortality was noted with older age, decreased admission pH, elevated admission lactate, lower admission hemoglobin, and pulseless electrical activity or asystole as presenting rhythms (Table). Admission hypokalemia and ventricular fibrillation/tachycardia were associated with improved hospital mortality (Table). Potassium was significantly lower in patients admitted with ventricular fibrillation/tachycardia (3.897+/-0.92) as compared to patients with asystole (4.674+/-1.377) or pulseless electrical activity (4.491+/-1.055 mEq/dL, p<0.0001). In multivariate logistic regression analysis, independent predictors of increased hospital mortality included increased admission potassium (OR 2.0, 95%CI 1.291-3.170, p=0.002)), older age (OR 1.04, 95%CI 1.007-1.071, p=0.017), admission PEA (OR 3.7, 95%CI 1.358-10.282, p=0.011 when compared to ventricular fibrillation/tachycardia) or asystole (OR 17.2, 95%CI 4.423-66.810, p<0.001 when compared to ventricular fibrillation/tachycardia); while decreased mortality was associated with higher hemoglobin (OR 0.8, 95%CI 0.665-0.997, p=0.047). Conclusions: Hyperkalemia, pulseless electrical activity, and asystole are predictive of increased hospital mortality in survivors of cardiac arrest. An association between low or low-normal potassium, observed VT-VF, and better outcomes is unexpected and may be used for prognostic purposes. More prospective investigations of mortality predictors in these critically ill patients are needed.

Abstract 19427: Epidemiology and Outcomes of Out-of-hospital Cardiac Arrest in Qatar

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Furqan B Irfan ◽  
Zain A Bhutta ◽  
Tooba Tariq ◽  
Loua A Shaikh ◽  
Pregalathan Govender ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Incidence Rate ◽  
Hospital Discharge ◽  
Middle Eastern ◽  
Cerebral Performance Category ◽  
Pulseless Electrical Activity ◽  
Final Analysis ◽  
National Registry ◽  
Bystander Cpr ◽  
Hospital Cardiac Arrest

Aim: There is a scarcity of population based studies on out-of-hospital cardiac arrest (OHCA) in the Middle East and the wider Asian region. This study describes the Epidemiology and outcomes of OHCA in Qatar, a Middle Eastern country. Methods: Data was extracted retrospectively from a national registry on all adult cardiac origin OHCA patients attended by Emergency Medical Services (EMS) in Qatar, from June 2012 - May 2013. Results: The annual crude incidence rate of cardiac origin OHCA attended by EMS was 23.5 per 100,000. The age-sex standardized incidence rate was 87.83 per 100,000 population. The annual sex-standardized incidence rate for males and females was 91.5 and 84.25 per 100,000 population respectively. Of 447 adult, cardiac origin OHCA patients included in the final analysis, most were male (n=360, 80.5%) with median age of 51 years (IQR = 39-66). Frequently observed nationalities of OHCA cases were Qatari (n=89, 19.9%), Indian (n=74, 16.6%) and Nepalese (n=52, 11.6%). Common initial cardiac arrest rhythms were asystole (n=301, 67.3%), ventricular fibrillation (n=82, 18.3%) and pulseless electrical activity (n=49, 11%). OHCA was unwitnessed (n=220, 49%) in nearly half of the cases while bystanders witnessed it in 170 (38%) patients. Bystander CPR was carried out in 92 (20.6%) of the cases. Of 187 (41.8%) patients who were given shocks, bystander defibrillation was delivered to 12 (2.7%) patients. Prehospital outcomes; 332 (74.3%) patients did not achieve return of spontaneous circulation (ROSC), 40 (8.9%) patients achieved unsustainable ROSC, 58 (13%) achieved ROSC till Emergency department (ED) handover and 5 patients achieved ROSC but rearrested again before reaching ED. Survival to hospital discharge occurred in 38 (8.5%) patients. Neurological outcomes were assessed utilizing Cerebral Performance Category [CPC] scores with a favorable CPC score of 1-2 at discharge in 27 (6%) patients, while 11 (2.5%) patients had a poor CPC score of 3-4. Of those with CPC score 1-2 at hospital discharge, 59% and 26% had CPC score 1-2, at 1 and 3 years follow-up respectively. Overall survival was 9.7%. Conclusion: Standardized rates are comparable to western countries, there are significant opportunities to improve outcomes, including better bystander CPR.

scholarly journals Prognostic Value of the Neurological Examination in Cardiac Arrest Patients After Therapeutic Hypothermia

2017 ◽  
Vol 8 (2) ◽  
pp. 66-73 ◽  
Author(s):  
Elizabeth A. Matthews ◽  
Jessica Magid-Bernstein ◽  
Evie Sobczak ◽  
Angela Velazquez ◽  
Cristina Maria Falo ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Therapeutic Hypothermia ◽  
Neurological Examination ◽  
Prognostic Value ◽  
Strong Predictor ◽  
Cerebral Performance Category ◽  
Light Response ◽  
Columbia University ◽  
Predictive Values ◽  
Poor Outcome

Objectives: Current prognostication guidelines for cardiac arrest (CA) survivors predate the use of therapeutic hypothermia (TH). The prognostic value and ideal timing of the neurological examination remain unknown in the setting of TH. Design: Patients (N = 291) admitted between 2007 and 2015 to Columbia University intensive care units for TH following CA had neurological examinations performed on days 1, 3, 5, and 7 postarrest. Absent pupillary light response (PLR), absent corneal reflexes (CRs), and Glasgow coma scores motor (GCS-M) no better than extension were considered poor examinations. Poor outcome was recorded as cerebral performance category score ≥3 at discharge and 1 year. Predictive values of examination maneuvers were calculated for each time point. Main Results: Among the 137 survivors to day 7, sensitivities and negative predictive values were low at all time points. The PLR had false positive rates (FPRs) of 0% and positive predictive values (PPV) of 100% from day 3 onward. For the CR and GCS-M, the FPRs decreased from day 3 to 5 (9% vs 3%; 21% vs 9%), while PPVs increased (91% vs 96%; 90% vs 95%). Excluding patients who died due to withdrawal of life-sustaining therapy (WLST) did not significantly affect FPRs or PPVs, nor did assessing outcome at 1 year. Conclusions: A poor neurological examination remains a strong predictor of poor outcome, both at hospital discharge and at 1 year, independent of WLST. Following TH, the predictive value of the examination is insufficient at day 3 and should be delayed until at least day 5, with some additional benefit beyond day 5.

scholarly journals Adoption and utilization of NGS-based molecular profiling in community-based oncology practices: Insights from Sarah Cannon.

2019 ◽  
Vol 5 (suppl) ◽  
pp. 34-34
Author(s):  
Howard A. Burris III ◽  
Daniel Schlauch ◽  
Andrew McKenzie ◽  
Yasha Sharma ◽  
David R. Spigel ◽  
...  
Keyword(s):  
Medical Center ◽  
Clinical Care ◽  
Academic Medical Center ◽  
Community Setting ◽  
Standard Of Care ◽  
Molecular Profiling ◽  
Community Based ◽  
Primary Tumors ◽  
Sequencing Technologies ◽  
Tumor Types

34 Background: The price of NGS-based sequencing technologies is falling, and the adoption of NGS-based testing is increasing in oncology practices. To date, a survey of the adoption and utilization of NGS-based technologies as a part routine oncology clinical care has not been performed. Thus, a comprehensive analysis of physician adoption and utilization of commercial NGS testing in the non-academic medical center, community-setting between 2012 and 2018 was performed. Methods: Medical Oncologists in the Sarah Cannon Research Institute network ordered commercially-available NGS-based molecular profiling for their patients as standard of care. Data use agreements were initiated between SCRI, affiliated medical oncology practices, and commercial NGS testing providers, and patient NGS data was subsequently analyzed starting in 2012. Results: Community-based NGS testing rates with the Sarah Cannon network were 5.75/month in 2012 and 440/month in 2018. Plasma-based NGS testing began in 2014 and comprised 4.9% of total testing compared to 40.1% in 2018. The number of oncologist ordering molecular profiles increased from 11 in 2012 to 269 in 2018. Physician test utilization grew from an average of 6 tests/physician to 22 tests/physician in 2012 and 2018, respectively. NGS tests were performed on 34 different tumor types and biopsies were taken from both primary tumors (~40%) and metastatic sites (~60%). Tissue-based tests averaged 14 mutations/sample while plasma-based tests averaged 4 mutations/sample. There was a 74% decrease in median time between biopsy collection and NGS test results between 2012 and 2018 (131 and 34 days, respectively), indicating a shift toward the use of fresh – non-archival – tissue in recent years. Conclusions: These data establish NGS-based testing trends in community oncology practices and show that NGS-based tumor testing utilization has increased in the community-setting between 2012 and 2018. NGS testing is performed on a wide array of tumor types and oncologists order tests earlier and utilize fresher biopsies.

Abstract 310: Validation of the Cardiac Arrest Hospital Prognosis (CAHP) Score in an American Out-of-hospital Cardiac Arrest Cohort: Results From a Large Single Center Cardiac Arrest Registry

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_4) ◽  
Author(s):  
Jason J Grady ◽  
Katie A Atwell ◽  
Tomo Oshimura ◽  
Nima Ghasemzadeh
Keyword(s):  
Cardiac Arrest ◽  
Medical Center ◽  
Cerebral Performance Category ◽  
Serum Lactate ◽  
Neurologic Outcome ◽  
Temperature Management ◽  
Single Center ◽  
Neurologic Outcomes ◽  
Increased Risk ◽  
Hospital Cardiac Arrest

Background: The cardiac arrest hospital prognosis (CAHP) score has been shown in French studies to predict neurologic outcomes in patients who suffer an out-of-hospital cardiac arrest (OHCA), but this score has not been studied in an American cohort. We aimed to validate the CAHP score in an independent, single center, large cardiac arrest registry. Methods: Between January 2015 to June 2020 there were 925 patients who suffered OHCA and were transferred to Northeast Georgia Medical Center out of whom 450 patients survived to hospital admission. Cerebral Performance Category (CPC) score was used for assessment of neurologic outcome at discharge ranging from 1-5. The primary endpoint was poor neurologic outcome defined as CPC 3-5. Logistic regression was performed to identify independent predictors of poor neurologic outcome. Results: Included patients were mostly male 57% (256 of 450) with a mean age of 52±15. STEMI was present on 11% (51 of 450) and a shockable rhythm on 35% (150 of 450) of patients. Targeted temperature management (TTM) and a mechanical compression device (MCD) were used in 72% (327 of 450) and 74% (336 of 450) respectively. 76% (344 of 450) had a CPC of 3-5 at discharge. After adjusting for covariates, including gender, BMI, serum lactate level, witnessed arrest status, STEMI on ECG, and use of MCD and TTM, the only independent predictors of a CPC of 3-5 were CAHP score (p<0.001), witnessed cardiac arrest, (p=0.039, OR: 0.45) and STEMI on admission ECG (P=0.001, OR: 0.22). Compared with CAHP< 150, CAHP 150-200 and CAHP>200 were associated with a 12-fold (p<0.00001) and 79-fold (p<0.00001) increased risk of poor neurologic outcome. Area under ROC curve for CAHP score predicting neurologic outcome was 0.92 (95% CI: 0.89-0.94). Conclusion: Here we show, for the first time, in an independent, large American cardiac arrest registry that CAHP score predicts neurologic outcomes in patients with OHCA. Further research is needed to assess how this prognostication tool would help clinicians decide on early vs. delayed invasive strategy in patients with OHCA admitted to hospitals across the U.S.

Delayed gratification and adherence to exercise among patients with claudication

2019 ◽  
Vol 24 (6) ◽  
pp. 519-527
Author(s):  
Sherene E Sharath ◽  
MinJae Lee ◽  
Panos Kougias ◽  
Wendell C Taylor ◽  
Nader Zamani ◽  
...  
Keyword(s):  
Behavioral Economics ◽  
Primary Outcome ◽  
Medical Center ◽  
Complex Problem ◽  
Veterans Affairs ◽  
P Value ◽  
Complex Problem Solving ◽  
Delayed Gratification ◽  
Community Based ◽  
Logistic Regression Models

Few studies have explicitly identified factors that explain an individual’s willingness to engage in community-based exercise for claudication. Identifying the unique characteristics of those inclined toward physical activity would inform interventions that encourage walking. We examined the utility of behavioral economics-related concepts in understanding walking among Veterans with claudication. Patients who received care at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, were surveyed on symptom severity, behavioral economics, stress, and depression. The primary outcome was a binary variable measuring current walking for exercise and defined as walking for at least 30 minutes every day. Multivariable logistic regression models were used to identify variables, both clinically and statistically significant, at a p-value < 0.05. Between April 2017 and March 2018, we received 148 (30%) responses. A total of 35% ( n = 51) of respondents indicated that they walked recreationally for exercise compared to 65% ( n = 94) who did not. Characteristics that were significantly associated with walking included regularly saving money (adjusted odds ratio (aOR) = 10.7, p = 0.001), seeking complex problem-solving (aOR = 0.12, p = 0.002), and severe symptoms (aOR = 0.24, p = 0.017). Individuals describing a preference for the future rather than immediate benefit also reported currently walking for exercise. Defining the characteristics of those who exercise may help inform strategies designed to increase walking among those who do not adhere to recommendations.

scholarly journals Effect of prehospital initiation of therapeutic hypothermia in adults with cardiac arrest on time-to-target temperature

CJEM ◽  
2015 ◽  
Vol 17 (3) ◽  
pp. 240-247 ◽  
Author(s):  
Eric M. Schenfeld ◽  
Jonathan Studnek ◽  
Alan C. Heffner ◽  
Marcy Nussbaum ◽  
Kathi Kraft ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Therapeutic Hypothermia ◽  
Treatment Protocol ◽  
Pulseless Electrical Activity ◽  
Control Group ◽  
Target Temperature ◽  
Urban Hospital ◽  
Initial Rhythm ◽  
New Treatment ◽  
The Impact

AbstractObjective: Despite growing adoption, the impact of prehospital initiation of therapeutic hypothermia on outcomes of cardiac arrest patients is unknown. The objective of this study was to determine if prehospital administration of cold intravenous fluids improved the time-to-target temperature.Methods: All patients enrolled in an institutional post– cardiac arrest treatment pathway were prospectively registered into a quality assurance database. Patients undergoing cooling induction on hospital arrival were compared to those receiving a new treatment protocol initiated during the study period involving prehospital cooling with 4°C (39.2°F) normal saline. The primary outcome was the time-to-target temperature. Secondary outcomes included emergency medicine system transport time metrics, mortality, and neurologic status at discharge and 1 year.Results: One hundred thirty-two patients were enrolled during the study period. The initial rhythm was ventricular fibrillation/tachycardia in 63% and asystole/pulseless electrical activity in 36%. Eighty patients received prehospital cooling and 52 patients did not and comprised the historical control group. Time-to-target temperatures were not significantly different between prehospital and hospital cooled groups (256 v. 271 minutes, respectively, p=0.64), nor was there any improvement in hospital survival (54% v. 50%, p=0.67), good neurologic outcome (49% v. 44%, p=0.61), or 1- year survival (49% v. 42%, p=0.46) between the two groups. Transport times were longer in the prehospital cooled group.Conclusions: Out-of-hospital cardiac arrest patients treated with prehospital cooling before arrival at our urban hospital did not have faster time-to-target temperature or improvement in outcomes compared to patients cooled immediately on emergency department arrival. Further research is needed to determine if any benefits exist from prehospital cooling prior to its widespread adoption.

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