Mechanical assist devices for acute cardiogenic shock

This Cochrane Systematic Review was published during Summer 2020.
Background: Cardiogenic shock (CS) is a state of critical end‐organ hypoperfusion due to a primary cardiac disorder. For people with refractory CS despite maximal vasopressors, inotropic support and intra‐aortic balloon pump, mortality approaches 100%. Mechanical assist devices provide mechanical circulatory support (MCS) which has the ability to maintain vital organ perfusion, to unload the failing ventricle thus reduce intracardiac filling pressures which reduces pulmonary congestion, myocardial wall stress and myocardial oxygen consumption. This has been hypothesised to allow time for myocardial recovery (bridge to recovery) or allow time to come to a decision as to whether the person is a candidate for a longer‐term ventricular assist device (VAD) either as a bridge to heart transplantation or as a destination therapy with a long‐term VAD.
Objectives:  To assess whether mechanical assist devices improve survival in people with acute cardiogenic shock.
Search methods:  We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid) and Web of Science Core Collection in November 2019. In addition, we searched three trials registers in August 2019. We scanned reference lists and contacted experts in the field to obtain further information. There were no language restrictions.
Selection criteria:  Randomised controlled trials on people with acute CS comparing mechanical assist devices with best current intensive care management, including intra‐aortic balloon pump and inotropic support.
Data collection and analysis:  We performed data collection and analysis according to the published protocol.
Primary outcomes were survival to discharge, 30 days, 1 year and secondary outcomes included, quality of life, major adverse cardiovascular events (30 days/end of follow‐up), dialysis‐dependent (30 days/end of follow‐up), length of hospital stay and length of intensive care unit stay and major adverse events.
We used the five GRADE considerations (study limitations, consistency of effect, imprecision, indirectness, and publication bias) to assess the quality of a body of evidence as it relates to the studies which contribute data to the meta‐analyses for the pre-specified outcomes.
Summary statistics for the primary endpoints were risk ratios (RR), hazard ratios (HRs) and odds ratios (ORs) with 95% confidence intervals (CIs).
Main results:  The search identified five studies from 4534 original citations reviewed. Two studies included acute CS of all causes randomised to treatment using TandemHeart percutaneous VAD and three studies included people with CS secondary to acute myocardial infarction who were randomised to Impella CP or best medical management. Meta‐analysis was performed only to assess the 30‐day survival as there were insufficient data to perform any further meta‐analyses. The results from the five studies with 162 participants showed mechanical assist devices may have little or no effect on 30‐day survival (RR of 1.01 95% CI 0.76 to 1.35) but the evidence is very uncertain.
Complications such as sepsis, thromboembolic phenomena, bleeding and major adverse cardiovascular events were not infrequent in both the MAD and control group across the studies, but these could not be pooled due to inconsistencies in adverse event definitions and reporting.
We identified four randomised control trials assessing mechanical assist devices in acute CS that are currently ongoing.
Authors’ conclusions:  There is no evidence from this review of a benefit from MCS in improving survival for people with acute CS. Further use of the technology, risk stratification and optimising the use protocols have been highlighted as potential reasons for lack of benefit and are being addressed in the current ongoing clinical trials.
The full text of this review is available via this link

Targeted Temperature Management for Cardiac Arrest with Nonshockable Rhythm.

This article by Lascarrou and colleagues was published in the New England Journal of Medicine volume 381 number 24 during December 2019
Background:  Moderate therapeutic hypothermia is currently recommended to improve neurologic outcomes in adults with persistent coma after resuscitated out-of-hospital cardiac arrest. However, the effectiveness of moderate therapeutic hypothermia in patients with nonshockable rhythms (asystole or pulseless electrical activity) is debated.
Methods:  We performed an open-label, randomized, controlled trial comparing moderate therapeutic hypothermia (33°C during the first 24 hours) with targeted normothermia (37°C) in patients with coma who had been admitted to the intensive care unit (ICU) after resuscitation from cardiac arrest with nonshockable rhythm. The primary outcome was survival with a favorable neurologic outcome, assessed on day 90 after randomization with the use of the Cerebral Performance Category (CPC) scale (which ranges from 1 to 5, with higher scores indicating greater disability). We defined a favorable neurologic outcome as a CPC score of 1 or 2. Outcome assessment was blinded. Mortality and safety were also assessed.
Results:  From January 2014 through January 2018, a total of 584 patients from 25 ICUs underwent randomization, and 581 were included in the analysis (3 patients withdrew consent). On day 90, a total of 29 of 284 patients (10.2%) in the hypothermia group were alive with a CPC score of 1 or 2, as compared with 17 of 297 (5.7%) in the normothermia group (difference, 4.5 percentage points; 95% confidence interval [CI], 0.1 to 8.9; P = 0.04). Mortality at 90 days did not differ significantly between the hypothermia group and the normothermia group (81.3% and 83.2%, respectively; difference, -1.9 percentage points; 95% CI, -8.0 to 4.3). The incidence of prespecified adverse events did not differ significantly between groups.
Conclusions:  Among patients with coma who had been resuscitated from cardiac arrest with nonshockable rhythm, moderate therapeutic hypothermia at 33°C for 24 hours led to a higher percentage of patients who survived with a favorable neurologic outcome at day 90 than was observed with targeted normothermia.
The printed copy of the New England Journal of Medicine is available in the Health Care Library on D Level of Rotherham Hospital.
The full text of articles from issues older than sixty days is available via this link to an archive of issues of New England Journal of Medicine.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link Please speak to the library staff for more details.

Prevention of Early Ventilator-Associated Pneumonia after Cardiac Arrest.

This article by Francois et others was published in the New England Journal of Medicine in November 2019 (Volume 381 number 19).
Background:  Patients who are treated with targeted temperature management after out-of-hospital cardiac arrest with shockable rhythm are at increased risk for ventilator-associated pneumonia. The benefit of preventive short-term antibiotic therapy has not been shown.
Methods:  We conducted a multicenter, double-blind, randomized, placebo-controlled trial involving adult patients (>18 years of age) in intensive care units (ICUs) who were being mechanically ventilated after out-of-hospital cardiac arrest related to initial shockable rhythm and treated with targeted temperature management at 32 to 34°C. Patients with ongoing antibiotic therapy, chronic colonization with multidrug-resistant bacteria, or moribund status were excluded. Either intravenous amoxicillin-clavulanate (at doses of 1 g and 200 mg, respectively) or placebo was administered three times a day for 2 days, starting less than 6 hours after the cardiac arrest. The primary outcome was early ventilator-associated pneumonia (during the first 7 days of hospitalization). An independent adjudication committee determined diagnoses of ventilator-associated pneumonia.
Results:  A total of 198 patients underwent randomization, and 194 were included in the analysis. After adjudication, 60 cases of ventilator-associated pneumonia were confirmed, including 51 of early ventilator-associated pneumonia. The incidence of early ventilator-associated pneumonia was lower with antibiotic prophylaxis than with placebo (19 patients [19%] vs. 32 [34%]; hazard ratio, 0.53; 95% confidence interval, 0.31 to 0.92; P = 0.03). No significant differences between the antibiotic group and the control group were observed with respect to the incidence of late ventilator-associated pneumonia (4% and 5%, respectively), the number of ventilator-free days (21 days and 19 days), ICU length of stay (5 days and 8 days if patients were discharged and 7 days and 7 days if patients had died), and mortality at day 28 (41% and 37%). At day 7, no increase in resistant bacteria was identified. Serious adverse events did not differ significantly between the two groups.
Conclusions:  A 2-day course of antibiotic therapy with amoxicillin-clavulanate in patients receiving a 32-to-34°C targeted temperature management strategy after out-of-hospital cardiac arrest with initial shockable rhythm resulted in a lower incidence of early ventilator-associated pneumonia than placebo. No significant between-group differences were observed for other key clinical variables, such as ventilator-free days and mortality at day 28. (Funded by the French Ministry of Health; ANTHARTIC ClinicalTrials.gov number, NCT02186951.).
The printed copy of the New England Journal of Medicine is available in the Health Care Library on D Level of Rotherham Hospital.

Short, and long-term mortality among cardiac intensive care unit patients started on continuous renal replacement therapy

This article by Keleshian and others was published online in the Journal of Critical Care during November 2019.
Purpose:  Patients requiring continuous renal replacement therapy (CRRT) are at high risk of death. Predictors of hospital mortality and post-discharge survival in cardiac intensive care unit (CICU) patients requiring CRRT have not been reported.
Materials and methods:  Retrospective review of 198 CICU patients undergoing CRRT from 2006 to 2015. Multivariable regression identified predictors of hospital mortality and Cox proportional-hazards identified predictors of post-discharge mortality among hospital survivors.
Results:  The indication for CRRT was volume overload in 129 (65%) and metabolic abnormalities in 76 (38%). 105 (53%) subjects died in hospital, with 22% dialysis-free hospital survival. Cardiogenic shock was present in 159 (80%) subjects; 150 (76%) subjects received vasopressors and 101 (51%) subjects required mechanical ventilation. Hospital mortality was similar in cardiogenic and non-cardiogenic causes of CICU admission. Predictors of hospital death included semi-quantitative RV function, Braden score, VIS, and PaO2/FIO2 ratio. Median post-discharge Kaplan-Meier survival was 1.9 years. Predictors of post-hospital death included age, VIS, diabetes, Braden score, semi-quantitative RV function, prior heart failure, and dialysis dependence. The indication for CRRT was not predictive of survival.
Conclusion:  Mortality is high among CICU patients requiring CRRT, and is predicted by the Braden score, RV dysfunction, respiratory failure and vasopressor load.
The full text of this article is available to subscribers via this link to the journal’s homepage.  The full text of articles from issues older than sixty days is available via this link to an archive of issues of Journal of Critical Care.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.

Association between acute kidney injury and neurological outcome or death at 6 months in out-of-hospital cardiac arrest: A prospective, multicenter, observational cohort study

This paper by Oh and colleagues was first published online in the Journal of Critical Care during August 2019.
Purpose:  This study aimed to evaluate the association between acute kidney injury (AKI) and 6 months neurological outcome after out-of-hospital cardiac arrest (OHCA).
Materials and methods:  Prospective multi-center observational cohort included adult OHCA patients treated with targeted temperature management (TTM) across 20 hospitals in the South Korea between October 2015 and October 2017. The diagnosis of AKI was made using the Kidney Disease: Improving Global Outcomes criteria. The outcome was neurological outcome at 6 months evaluated using the modified Rankin scale (MRS).
Results:  Among 5676 patients with OHCA, 583 patients were enrolled. AKI developed in 348 (60%) patients. Significantly more non-AKI patients had good neurological outcome at 6 months (MRS 0–3) than AKI patients (134/235 [57%] vs. 69/348 [20%], P < .001). AKI was associated with poor neurological outcome at six months in multivariate logistic regression analysis (adjusted odds ratio: 0.206 [95% confidence interval: 0.099–0.426], P < .001]). Cox regression analysis with time-varying covariate of AKI showed that patients with AKI had a higher risk of death than those without AKI (hazard ratio: 2.223; 95% confidence interval: 1.630–3.030, P < .001).
Conclusions:  AKI is associated with poor neurological outcome (MRS 4–6) at 6 months in OHCA patients treated with TTM.

The full text of this article is available to subscribers via this link to the journal’s homepage.  The full text of articles from issues older than sixty days is available via this link to an archive of issues of Journal of Critical Care.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.

A pilot study evaluating a simple cardiac dysfunction score to predict complications and survival among critically-ill patients with traumatic brain injury

This research by Gibbons and others was published online in the Journal of Critical Care during August 2019.
Purpose:  To describe the frequency of cardiovascular complications and cardiac dysfunction in critically-ill patients with moderate-severe traumatic brain injury (msTBI) and cardiac factors associated with in-hospital survival.
Methods:  Retrospective analysis of a prospective cohort study at a single Level-1 trauma center with a dedicated neuro-trauma intensive care unit (ICU). Adult patients admitted to the ICU with msTBI were consecutively enrolled in the prospective OPTIMISM study between November 2009 and January 2017. Cardiac dysfunction was measured using a combination of EKG parameters, echocardiography abnormalities, and peak serum troponin-I levels during the index hospitalization. These items were combined into a cardiac dysfunction index (CDI), ranging from 0 to 3 points and modeled in a Cox regression analysis.
Results:  A total of 326 patients with msTBI were included. For every one-point increase in the CDI, the multivariable adjusted risk of dying during the patient’s acute hospitalization more than doubled (adjusted HR 2.41; 95% CI 1.29–4.53).
Conclusion:  Cardiac dysfunction was common in patients with msTBI and independently associated with more severe brain injury and a reduction in hospital survival in this population. Further research is needed to validate the CDI and create more precise scoring tools.
The full text of this article is available to subscribers via this link to the journal’s homepage.  The full text of articles from issues older than sixty days is available via this link to an archive of issues of Journal of Critical Care.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.

The impact of real-time chest compression feedback increases with application of the 2015 guidelines

This research by Davis and colleagues was published online in the Journal of Critical Care during August 2019.
Background:  Cardiac arrest survival depends upon chest compression quality. Real-time audiovisual feedback may improve compression guideline adherence, particularly with the more specific 2015 guidelines.
Methods:  Subjects included healthcare providers from multiple U.S. hospitals. Compression rate and depth were recorded using standard manikins and real-time audiovisual feedback defibrillators (ZOLL R Series). Subjects were enrolled before (n = 756) and after (n = 995) release of the 2015 guidelines, which define narrower compression targets. Subjects performed 2 min of continuous compressions before and after activation of feedback. The percentage of compressions meeting appropriate rate/depth targets was determined before and after release of the 2015 guidelines.
Results:  An increase in compression guideline adherence was observed with use of feedback before [68.7% to 96.3%, p < .001] and after [16.6% to 94.1%, p < .001] release of the 2015 guidelines. The proportion of subjects requiring feedback to achieve adherence was higher for the 2015 guidelines [28.6% vs. 78.5%, OR 9.12, 95% CI 7.33–11.35,p < .001].
Conclusions:  The use of real-time audiovisual feedback increases adherence to chest compression guidelines, particularly with application of the narrower 2015 guidelines targets for compression depth and rate.
The full text of this article is available to subscribers via this link to the journal’s homepage.  The full text of articles from issues older than sixty days is available via this link to an archive of issues of Journal of Critical Care.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.

Cardiac output during targeted temperature management and renal function after out-of-hospital cardiac arrest

This article by Grand and colleagues was published online in the Journal of Critical Care during July 2019.
Purpose:  After resuscitation from out-of-hospital cardiac arrest (OHCA), renal injury and hemodynamic instability are common. We aimed to assess the association between low cardiac output during targeted temperature management (TTM) and acute kidney injury (AKI) after OHCA.
Materials and methods:  Single-center substudy of 171 patients included in the prospective, randomized TTM-trial. Hemodynamic evaluation was performed with serial measurements by pulmonary artery catheter. AKI was the primary endpoint and was defined according to the KDIGO-criteria.
Results:  Of 152 patients with available hemodynamic data, 49 (32%) had AKI and 21 (14%) had AKI with need for renal replacement therapy (RRT) in the first three days. During targeted temperature management, patients with AKI had higher heart rate (11 beats/min, pgroup < 0.0001), higher mean arterial pressure (MAP) (4 mmHg, pgroup = 0.001) and higher lactate (1 mmol/L, pgroup < 0.0001) compared to patients without AKI. However, there was no difference in cardiac index (pgroup = 0.25). In a multivariate logistic regression model, adjusting for potential confounders, MAP (p = .03), heart rate (p = .01) and lactate (p = .006), but not cardiac output, were independently associated with AKI.
Conclusions:  Blood pressure, heart rate and lactate, but not cardiac output, during 24 h of TTM were associated with AKI in comatose OHCA-patients.
The full text of this article is available to subscribers via this link to the journal’s homepage.  The full text of articles from issues older than sixty days is available via this link to an archive of issues of Journal of Critical Care.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.

Critical Care Reviews Newsletter 345 22nd July 2018

The Critical Care Reviews Newsletter “brings you the best critical care research and open access articles from across the medical literature over the past seven days.”  “The big news this week is the publication of the landmark PARAMEDIC2 trial, comparing adrenaline with placebo in out-of-hospital cardiac arrest”.  Also included are other randomised controlled trials including “Plasma-first resuscitation to treat haemorrhagic shock during emergency ground transportation in an urban area”, systematic reviews such as “Neurologic Outcomes after Extracorporeal Membrane Oxygenation Assisted CPR for Resuscitation of Out-of-Hospital Cardiac Arrest Patients” and guidelines including “European Association for the Study of the Liver Clinical Practice Guidelines for the management of patients with decompensated cirrhosis.”
The full text of the newsletter can be accessed via this link.

Current issue of Critical Care Reviews Newsletter 279 16th April 2017

The Critical Care Reviews Newsletter provides the best critical care research and open access articles from across the medical literature.  The highlights of this issue are “the TRUE-critcal care reviewsAHF trial, examining ularitide in acute heart failure, an individual patient level meta-analysis evaluating tidal volumes used in three large ARDS randomized control trials and an observational study investigating early predictors of poor outcome after out-of-hospital cardiac arrest.”

The full newsletter can be accessed via this link.