Arrest Time Research Articles

Clinical features and outcomes of in-hospital cardiac arrest in code blue events: a retrospective observational study.

In-hospital cardiac arrest (IHCA) is a critical medical event with outcomes less researched compared to out-of-hospital cardiac arrest. This retrospective observational study aimed to investigate key aspects of IHCA epidemiology and prognosis in patients with Code Blue activation. This retrospective observational study enrolled patients with Code Blue events in our hospital between January 2010 and October 2019. Participant characteristics, including age and sex, and IHCA characteristics, including the time of cardiac arrest, witnessed event, bystander cardiopulmonary resuscitation (CPR), initial shockable rhythm, vital signs at 1 and 6 h before IHCA, survival to hospital discharge (SHD), and the cardiac arrest survival postresuscitation in-hospital (CASPRI) score were included in univariate and multivariate logistic regression analyses with SHD as the primary endpoint. From the 293 Code Blue events that were activated during the study period, 81 participants were enrolled. Overall, the SHD rate was 28.4%, the median CPR duration was 14 (interquartile range, 6-28) min, and the rate of initial shockable rhythm was 19.8%. There were significant intergroup differences between the SHD and non-SHD groups in the CPR duration, shockable rhythm, and CASPRI score on univariate logistic regression analysis. Multivariate logistic regression analysis showed that the CASPRI score was the most accurate predictive factor for SHD (OR = 0.98, p = 0.006). The CASPRI score is associated with SHD in patients with IHCA during Code Blue events. Therefore, the CASPRI score of IHCA patients potentially constitutes a simple, useful adjunctive tool for the management of post-cardiac arrest syndrome.

The Effect of Preloaded Compressive Stress and Curvature of Defect on Blast-Induced Fracture Behavior by Caustic and Numerical Models

In this study, the effects of preloaded uniaxial compressive stress and defect (prefabricated by laser cutting) curvature on blast-induced cracks and stress wave propagation were investigated in polymethyl methacrylate (PMMA) specimens using caustics theory. Based on the mathematical relationship between stress and optics, the fracture behavior (the propagation path, dynamic stress intensity factors (DSIFs), propagation velocity, initiation angle of the main crack, and damage degree between the defect and the blasthole) was calculated and analyzed quantitatively. The results show that the preloaded stress could mainly restrain the main crack propagation in the horizontal direction and reduce the initiation angle and damage degree at the defects. Meanwhile, the crack initiation position of the positive curvature defect was not at the end of the defect. In addition, the curvature of the defect significantly affected the blast-induced fracture compared to preloaded stresses. Comparing the main crack with other curvature defects, the DSIFs, velocity, crack arrest time, crack length, and horizontal offset distance of the main crack with negative curvature defect were the largest. The variation in the full stress field in the specimen under blasting and preloaded stress was simulated by a numerical model. The results show that the curvature of the defect has a significant effect on tensile waves at the end of defects, and the tensile stress from high to low was C-25, C0, and C25, in that order.

A ventricular fibrillation cardiac arrest model with extracorporeal cardiopulmonary resuscitation in rats: 8 minutes arrest time leads to increased myocardial damage but does not increase neuronal damage compared to 6 minutes.

Extracorporeal cardiopulmonary resuscitation (ECPR) is an emerging strategy in highly selected patients with refractory cardiac arrest (CA). Animal models can help to identify new therapeutic strategies to improve neurological outcome and cardiac function after global ischemia in CA. Aim of the study was to establish a reproducible ECPR rat model of ventricular fibrillation CA (VFCA) that leads to consistent neuronal damage with acceptable long-term survival rates, which can be used for future research. Male Sprague Dawley rats were resuscitated with ECPR from 6 min (n = 15) and 8 min (n = 16) VFCA. Animals surviving for 14 days after return of spontaneous resuscitation (ROSC) were compared with sham operated animals (n = 10); neurological outcome was assessed daily until day 14. In the hippocampal cornu ammonis 1 region viable neurons were counted. Microglia and astrocyte reaction was assessed by Iba1 and GFAP immunohistochemistry, and collagen fibers in the myocardium were detected in Azan staining. QuPath was applied for quantification. Of the 15 rats included in the 6 min CA group, all achieved ROSC (100%) and 10 (67%) survived to 14 days; in the 8 min CA group, 15 (94%) achieved ROSC and 5 (31%) reached the endpoint. All sham animals (n = 10) survived 2 weeks. The quantity of viable neurons was significantly decreased, while the area displaying Iba1 and GFAP positive pixels was significantly increased in the hippocampus across both groups that experienced CA. Interestingly, there was no difference between the two CA groups regarding these changes. The myocardium in the 8 min CA group exhibited significantly more collagen fibers compared to the sham animals, without differences between 6- and 8-min CA groups. However, this significant increase was not observed in the 6 min CA group. Our findings indicate a uniform occurrence of neuronal damage in the hippocampus across both CA groups. However, there was a decrease in survival following an 8-min CA. Consequently, a 6-min duration of CA resulted in predictable neurological damage without significant cardiac damage and ensured adequate survival rates up to 14 days. This appears to offer a reliable model for investigating neuroprotective therapies.

The Learning Curve of Total Arch Replacement via Single Upper Hemisternotomy Approach in Aortic Dissection.

Upper hemisternotomy (UHS) has benefits over conventional full sternotomy because it ameliorates trauma during cardiac surgery. Owing to its challenging and technically demanding nature, this incision in acute type A aortic dissection (ATAAD) has rarely been reported. This study aimed to analyze the learning curve of total arch replacement (TAR) with moderate hypothermic circulatory arrest via a single UHS approach, which is necessary to guide the training of surgeons in adopting minimally invasive procedures. A total of 202 consecutive patients who were definitively diagnosed with ATAAD between July 2016 and June 2021 were enrolled in this retrospective analysis. Patients were divided into three groups based on cumulative sum plots for circulatory arrest time in chronological order. Perioperative characteristics were compared between the groups. There was significant difference in the circulatory arrest time and cross-clamp time respectively among three groups (39.0 min vs 28.0 min vs 15.0 min, P < 0.001; 104.5 min vs 106.2 min vs 84.1 min, P < 0.001). The ventilation time and first 24-h chest tube drainage were statistically different among groups (35.5 h vs 24.0 h vs 19.0 h, P = 0.031; 220.0 mL vs 192.5 mL vs 125.5 mL, P = 0.043). No other clinical outcome was observed as significant difference. A cardiac surgeon can convert a conventional full sternotomy to a single UHS for TAR after experiencing a learning curve, to ensure patient safety. The mastery of this minimally invasive surgical technique may be beneficial for the prognosis of patients with ATAAD.

Risk Factors for Acute Kidney Injury after Moderate Hypothermic Circulatory Arrest in Hemiarch Replacement

Background. The aim of this study was to clarify the incidence and risk factors for acute kidney injury (AKI) in patients undergoing hemiarch replacement (HAR) under moderate hypothermic circulatory arrest (MHCA) with retrograde cerebral perfusion (RCP). Methods. We retrospectively analyzed patients who underwent HAR under MHCA with RCP at our institution between April 2015 and July 2022. Exclusion criteria were preoperative dialysis, single kidney, and lack of preoperative plasma creatinine data. The study endpoint was the incidence of postoperative AKI, defined using the Kidney Disease: Improving Global Outcomes criteria. Multivariate logistic regression analysis was performed to identify the risk factors for postoperative AKI. Results. One hundred and seventy-nine patients were included in this study. The most common indications for HAR were thoracic aortic aneurysm (n = 107) and acute aortic dissection (n = 57). Concomitant procedures, most frequently aortic valve surgery, were performed in 104 (60.5%) patients. Median circulatory arrest time and minimum rectal temperature were 15 minutes (interquartile range, 11 to 19) and 27.4°C (interquartile range, 25.9 to 28.1), respectively. Operative mortality was 1.1%. The incidence of postoperative AKI was 37.8%. Multivariate analysis showed that acute aortic dissection (odds ratio, 4.57; 95% confidence interval (CI), 2.13–10.14; P &lt; 0.001) and longer operating time (odds ratio, 1.01; 95% CI, 1.00-1.01; P = 0.001) were independent predictors for postoperative AKI. Conclusions. Acute aortic dissection and longer operating time were risk factors for postoperative AKI in patients undergoing HAR under MHCA with RCP. In contrast, neither circulatory arrest time nor minimum rectal temperature was a risk factor for AKI. This may be due to the short duration of circulatory arrest.

Zone 2 arch repair for acute type A dissection: Evolution from arch-first to proximal-first repair.

With growing experience of acute type A aortic dissection repair, Zone 2 arch repair has been advocated. The aim of this study is to compare the outcome between "proximal-first" and "arch-first" Zone 2 repair. From January 2015 to March 2023, 45 patients underwent Zone 2 arch repair out of 208 acute type A aortic dissection repairs: arch-first, N=19, and proximal-first technique, N=26, since January 2021. Indications were aortic arch or descending tear, complex dissection in neck vessels, cerebral malperfusion, or aneurysm of the aortic arch. The lowest bladder temperature was higher in the proximal-first technique (24.9 °C vs 19.7 °C, P<.001). Cardiopulmonary bypass (230 vs 177.5minutes, P<.001), myocardial ischemic (124 vs 91minutes, P<.001), and lower-body circulatory arrest (87 vs 28minutes, P<.001) times were shorter in the proximal-first technique. The arch-first group required more packed red blood cells (arch-first, 2 units vs proximal-first, 0 units, P=.048), platelets (arch-first, 4 units vs proximal-first, 2 units, P=.003), and cryoprecipitates (arch-first, 2 units vs proximal-first, 1 unit, P=.024). Operative mortality and major morbidities were higher in the arch-first group (57.9% vs 11.5%, P=.001). One-year survival was comparable (arch-first, 89.5% ± 7.0% vs proximal-first, 92.0% ± 5.5%, P=.739). Distal intervention was successfully performed in 5 patients (endovascular, N=3, and open repair, N=2). Zone 2 arch repair using the proximal-first technique for acute type A aortic dissection repair yields shorter lower-body ischemic time with a warmer core temperature, resulting in shorter cardiopulmonary bypass time, less blood product use, and fewer morbidities when compared with the arch-first technique.

Use of Alginate Polymer Polysaccharide Hemostatic Hydrogel &#x0D; in the Treatment of Simulated Bleeding Stomach Defects

The aim of the study was to develop in vivo technique and study the potential of alginate polymer polysaccharide hemostatic hydrogel application in the treatment of experimental bleeding stomach ulcers.Materials and methods. The in vivo experiment was conducted in the Laboratory of Experimental Surgery, the Research Institute of Experimental Biology and Medicine, N.N. Burdenko Voronezh State Medical University. Twelve healthy laboratory animals (dog) weighed 7-10.5 kg were selected for the study. Each animal was exposed to two bleeding stomach defects: one of which was experimental, and the other was control. Bleeding arrest in the experimental group of animals was carried out by insufflation of powdered alginate polymer polysaccharide hemostatic for a bleeding defect (Patent RF №2762120). Control stomach defects were not subjected to endoscopic treatment. The results of the experimental study were evaluated according to the following parameters: the time of experimental bleeding arrest, the presence of repeated bleeding, the timing and quality of healing simulated defects.Results. Experimental studies have demonstrated that the alginate polymer polysaccharide hemostatic hydrogel applied in the endoscopic treatment of simulated bleeding stomach defects can significantly (P=0.000001) reduce the time of experimental bleeding, from 26.5(25.3-32.0) sec to 6.0(4.0-8.0) sec, and helps to reduce the regeneration time of experimental defects from 14.5(13.5-16.5) days up to 8.0(7.5-8.5) days (P=0.000001), while improving the quality of their healing.Conclusion. Thus, the use of alginate polymer polysaccharide hemostatic hydrogel is an effective method of treating simulated bleeding stomach defects.

Therapeutic Hypothermia for Hypoxic-Ischemic Brain Injury Is More Effective in Newborn Infants than in Older Patients: Review and Hypotheses.

Posthypoxic therapeutic hypothermia has been tested in newborn infants, with seven randomized trials showing consistent evidence of reduction in death, cerebral palsy, and cognitive impairment at school age. In contrast, randomized trials of hypothermia after cardiac arrest in adults have not shown consistent evidence of lasting neurological protection. The apparently greater effectiveness of therapeutic hypothermia in newborns may be due to important biological and clinical differences. One such difference is that adults are heavily colonized with microbes, and many have active inflammatory processes at the time of arrest, but few newborns are heavily colonized or infected at the time of birth. Inflammation can interfere with hypothermia's neuroprotection. A second difference is that apoptosis is more commonly the pathway of neuronal death in newborns than in adults. Hypothermia inhibits apoptosis but not necrosis. Newborns have a larger endogenous supply of stem cells (which reduce apoptosis) than adults and this may favor regeneration and protection from hypothermia and regeneration. A third difference is that immature oligodendroglia are more sensitive to free radical attack then mature oligodendroglia. Hypothermia reduces free radical release. In addition, immature brain has increased N-methyl-D-aspartate receptor subunits compared with adults and hypothermia reduces excitotoxic amino acids. Adults suffering cardiac arrest often have comorbidities such as diabetes, hypertension, and atherosclerosis, which complicate recovery, but newborn infants rarely have comorbidities before asphyxia. Adult hypothermia treatment may have been too short as no trial has cooled for longer than 48 hours, some only 24 or 12 hours, but neonatal therapeutic hypothermia has routinely lasted 72 hours. We hypothesize that this combination of differences favors the effectiveness of therapeutic hypothermia in newborn infants compared with adults.

Myocardial Priority Promotes Cardiovascular Recovery for Acute Type A Aortic Dissection Combined with Coronary Artery Disease Undergoing Aortic Arch Surgery.

The optimal surgical strategy for acute type A aortic dissection (ATAAD) with coronary artery disease (CAD) remains unclear. The goal of this study was to investigate the cardiovascular protective effects of the myocardial priority (MP) strategy or traditional selective cerebral perfusion (SCP) in ATAAD with CAD. A total of 214 adults were analyzed retrospectively, of which 80 underwent the MP strategy intraoperatively. Seventy-nine pairs were propensity-score-matched and divided into SCP and MP groups. The follow-up period ranged from 6 to 36 months. The MP group had a significantly shorter myocardial ischemic time, higher perfusion flow, higher radial artery pressure, and lower incidence of NIRS decrease >20% of the base value, but a longer lower limb circulatory arrest and bypass time than the SCP group. Although similar adverse cardiac and cerebrovascular events were observed in both groups, a shorter posthospital stay, less blood loss and transfusion, higher postoperative hemoglobin, lower creatinine, and higher PaO2/FiO2 were observed in the MP group. Subgroup analysis showed that when the TIMI Risk Score was <4, the MP group had a lower incidence of low cardiac output and lower postoperative cTnI level. The follow-up patients had similar morbidities between the two groups. The novel MP strategy is associated with a shortened myocardial ischemic time, better maintained perfusion of vital organs, and postoperative recovery after surgery for ATAAD combined with non-severe CAD.

Influence of a regional network combined with a systematic multidisciplinary approach on the outcomes of patients with acute type A aortic dissection

BackgroundWhether in patients with acute type A aortic dissection reduction of intervals between onset of symptoms and diagnosis influences patient outcomes is still not completely defined. MethodsIn 199 patients with acute type A aortic dissection, the efficacy of a systematic multidisciplinary approach and institution of a regional network were evaluated; 90 patients operated before 2016 (Group1) were compared with 109 repaired after 2016 (Group2) for early and late outcomes. ResultsMortality was reduced from 13% in Group1 to 4% in Group2 (p = 0.013). In Group2 a more patients (46%) had arch replacement compared to Group1 (29%)(p = 0.06). In Group2 axillary artery cannulation was almost routinely used (91% vs 67%, p < 0.001) with shorter circulatory arrest time (37 vs 44 min, p < 0.001). The interval from diagnosis to surgery dropped from 210 min in Group1 to 160 min in Group2 (p < 0.001); this reduction was evident both in patients admitted to the emergency department of a spoke and/or a hub center. Patients presenting with or developing shock were reduced from Group1 to Group2 and in particular those reaching the hub center from spoke centers. Survival at 1 and 5 years was 82 ± 4% and 70 ± 5% in Group1 vs 92 ± 3% and 87 ± 8% in Group2 (p = 0.007). ConclusionsOutcomes of patients with acute type A aortic dissection improved using a systematic multidisciplinary approach while a network between spoke and hub centers reduced intervals between diagnosis, transportation to hub center and repair, limiting the incidence of tamponade and shock.

Comparison of the outcomes between total arch replacement and nontotal arch replacement in patients with acute type A aortic dissection

ObjectiveTo compare the outcomes between total arch replacement (TAR) and nontotal arch replacement (non-TAR) in patients with acute type A aortic dissection (ATAAD).MethodsBetween 2006 and 2018, 275 ATAAD patients were divided into 2 groups, the TAR group (n = 63) and the non-TAR group (n = 212), and multiple variables were analyzed.ResultsThe TAR patients were older than the non-TAR patients (61.5 ± 11.8 vs. 57.4 ± 14.5 years, p = 0.024). The TAR group had longer operative, cardiopulmonary bypass, aortic clamping, and circulatory arrest times than the non-TAR group (all p < 0.001). The overall hospital mortality rate was 8.7% with no statistically significant difference between the TAR and non-TAR groups (9.5% vs. 8.5%, p = 0.799). There was no significant difference in the incidence of acute kidney injury (AKI), intubation time, incidence of postoperative atrial fibrillation (AF), or reoperation for bleeding or reintervention rates between the TAR and non-TAR groups (68.3% vs. 65.7% (p = 0.912), 44.8% vs. 33.8% (p = 0.127), 30.2% vs. 22.6% (p = 0.222), 9.5% vs. 9.5% (p = 0.189), and 7.9% vs. 7.1% (p = 0.077), respectively). The TAR group had a higher rate of new permanent neurological deficit (PND) than the non-TAR group and longer median length of hospital stay (17.5% vs. 6.1% (p < 0.001) and 9 vs. 12 days (p = 0.049), respectively). TAR (relative risk (RR) 3.66, p = 0.005) and preoperative cardiopulmonary resuscitation (CPR) (RR 6.60, p = 0.019) were risk factors of PND. Survival rate was similar between the two groups.ConclusionThe mortality rates in ATAAD patients with TAR and non-TAR were similar. However, the incidence of new permanent postoperative neurological deficit was significantly higher, and the length of hospital stay was longer in patients with TAR. TAR in ATAAD should be avoided especially in patients who have experienced preoperative CPR to abate risk of PND.

Management of the left subclavian artery during aortic arch replacement using a frozen elephant trunk approach: a review.

The frozen elephant trunk (FET) technique for total aortic arch replacement extends repair into the proximal portion of the descending thoracic aorta. Several techniques and modifications of total arch replacement have been described in the literature, and many of these iterations are related to facilitating the distal anastomosis while preserving flow to the left subclavian artery (LSCA), as well as maintaining posterior circulation of the brain via the vertebral artery, by reducing the circulatory arrest time during reconstruction. Because of the LSCA's posterior and deep anatomic location in the chest, particularly in obese patients, this revascularization is often challenging; additional concerns regarding LSCA revascularization include patients with large aortic arch aneurysms, those with dissected or calcified arteries, and reoperation. A careful plan for reconstruction is necessary. Whether revascularization is performed preoperative, intraoperative, or postoperatively, every effort should be made to include the left subclavian artery as part of the operational approach. Revascularization techniques include reimplantation as part of the island patch or direct anastomosis, stenting, bypass, transposition or a hybrid approach. The importance of maintaining circulation of the LSCA cannot be overstated. Preserving flow to the spinal cord via collaterals minimizes the risk of cord injury during FET procedure. In patients with a patent left internal mammary artery bypass, left arm arteriovenous fistula for hemodialysis, dominant circulation, or direct aortic origin of the left vertebral artery, revascularization is necessary as well. In the case of initial sacrifice, arm claudication or steal syndrome usually dictates delayed extra-anatomic revascularization in the postoperative period.

Short- and long-term results of total arch replacement: Comparison between island and debranching techniques.

The 2 most acceptable techniques for reimplantation of the supra-aortic vessels in total arch replacement include the branched graft technique (debranching)or en bloc technique (island). We aim to review our experience with total arch replacement and report short- and long-term outcomes from a high-volume center dedicated to surgery for the thoracic aorta. The aortic surgery database was queried to identify all consecutive patients undergoing total arch replacement between 1997 and 2022. Of the 426 patients who underwent total arch replacement, 303 (71%) received the island technique and 123 (29%) received the debranching approach. Operative and long-term outcomes were compared using multivariable models. The debranching group was younger (64 ± 14 years vs 69 ± 12 years, P=.001), had undergone more previous cardiac operations (54.5% vs 27.4%, P<.001), and had more connective tissue disorder (20.3% vs 4.6%, P<.001). The debranching approach was associated with longer total circulatory arrest time (47 ± 15 minutes vs 37 ± 10minutes, P<.001) and cardiac ischemic time (116 ± 41 minutes vs 100 ± 37minutes, P<.001). More patients in the debranching group received blood products intraoperatively or postoperatively (56.1% vs 42.9%, P=.018). All other early outcomes did not differ between groups. Overall operative mortality was 1.4% (2.4% vs 1%, P=.486); the incidence of major postoperative complications was 6.3% (5.7% vs 6.6%, P=.897). Ten-year survival was 80% (78% vs 80.9%, log-rank P=.356). Multivariable Cox regression analysis demonstrated that neither surgical approach was associated with survival advantage (hazard ratio, 1.18; 0.73-1.89; P=.495). Debranching requires a longer operative time, with similar early and long-term outcomes. Preoperative comorbidity, not surgical technique, predicts major adverse events and long-term survival.

Out-of-hospital cardiac arrest survival when CPR is initiated by first responders

BackgroundIn most patients with out-of-hospital cardiac arrest (OHCA), cardiopulmonary resuscitation (CPR) is initiated by first responders (non-transporting firefighters or police) or emergency medical service (EMS) personnel. Whether survival outcomes differ when CPR is initiated by first responders vs. EMS is unclear. MethodsWithin the CARES registry, we identified 162,896 adult patients with a non-traumatic OHCA in whom CPR was initiated by first responders or EMS during 2013–2021. Using multivariable hierarchical logistic regression to adjust for demographics, cardiac arrest characteristics and time to first CPR, we compared rates of survival to hospital admission and to discharge in patients with CPR initiated by first responders and EMS. ResultsCPR was initiated by first responders in 70,889 (43.5%) and by EMS in 92,007 (56.5%) patients. Time to first CPR was shorter when first responders initiated CPR (median: 8.0 [5.0–13.0] vs. 10.0 minutes [IQR: 6.0–14.0]; standardized difference 16.1%). The likelihood of survival to hospital admission was similar when CPR was initiated by first responders (27.1% [first responders] vs. 26.8% [EMS]; adjusted OR: 0.98 [0.96, 1.01], P = 0.15) whereas survival rates to discharge were higher with CPR initiated by first responders (9.4% [first responders] vs. 7.7% [EMS]; adjusted OR: 1.17 [1.02, 1.21], P < 0.001). After adjustment for time to first CPR, rates of survival to discharge were similar between the first responder and EMS groups (adjusted OR: 1.04 [1.00–1.08]; P = 0.07). ConclusionsCPR initiated by first responders for OHCA is associated with higher overall survival rates and higher survival was largely mediated by earlier response times.

Out-of-Hospital Cardiac Arrest in Individuals With Human Immunodeficiency Virus: A Nationwide Population-Based Cohort Study.

Little data exist on the risk and outcomes of out-of-hospital cardiac arrest (OHCA) in people with HIV (PWH). We aimed to describe OHCA in PWH as compared with the general population in terms of incidence, characteristics, and survival. This nationwide study assessed all individuals aged 18-85 years between 2001 and 2019 in Denmark. The cumulative incidence of OHCA was computed using cause-specific Cox models accounting for competing risk of death. Among 6 565 309 individuals, 6 925 (median age: 36; interquartile range [IQR]: 28-44 y; 74% males) were infected at some point with HIV. The incidence of OHCA was 149 (95% CI: 123-180)/100 000 person-years in PWH versus 64 (95% CI: 64-65)/100 000 person-years in people without HIV (P < .001). Age at the time of cardiac arrest was 52 (IQR: 44-61) years in PWH versus 69 (IQR: 59-77) years in individuals without HIV (P < .001). In a multivariable model adjusted for age, sex, hypertension, diabetes, heart failure, ischemic heart disease, atrial fibrillation, chronic obstructive pulmonary disease, cancer, and renal failure, PWH had a 2-fold higher risk of OHCA (hazard ratio: 2.84; 95% CI: 2.36-3.43; P < .001). Thirty-day mortality (89% vs 88%; P = .80) was comparable to individuals without HIV. HIV is an independent risk factor for OHCA, and those who experience OHCA with HIV are much younger than those without HIV. Almost 90% of PWH died 1 month after OHCA. Further research should strive to find out how to reduce OHCA occurrence in this population.

Epinephrine Dosing Use During Extracorporeal Cardiopulmonary Resuscitation: Single-Center Retrospective Cohort.

During pediatric cardiac arrest, contemporary guidelines recommend dosing epinephrine at regular intervals, including in patients requiring extracorporeal membrane oxygenation (ECMO). The impact of epinephrine-induced vasoconstriction on systemic afterload and venoarterial ECMO support is not well-defined. Nested retrospective observational study within a single center. The primary exposure was time from last dose of epinephrine to initiation of ECMO flow; secondary exposures included cumulative epinephrine dose and arrest time. Systemic afterload was assessed by mean arterial pressure and use of systemic vasodilator therapy; ECMO pump flow and Vasoactive-Inotrope Score (VIS) were used as measures of ECMO support. Clearance of lactate was followed post-cannulation as a marker of systemic perfusion. PICU and cardiac ICU in a quaternary-care center. Patients 0-18 years old who required ECMO cannulation during resuscitation over the 6 years, 2014-2020. Patients were excluded if ECMO was initiated before cardiac arrest or if the resuscitation record was incomplete. None. A total of 92 events in 87 patients, with 69 events having complete data for analysis. The median (interquartile range) of total epinephrine dosing was 65 mcg/kg (37-101 mcg/kg), with the last dose given 6 minutes (2-16 min) before the initiation of ECMO flows. Shorter interval between last epinephrine dose and ECMO initiation was associated with increased use of vasodilators within 6 hours of ECMO (p = 0.05), but not with mean arterial pressure after 1 hour of support (estimate, -0.34; p = 0.06). No other associations were identified between epinephrine delivery and mean arterial blood pressure, vasodilator use, pump speed, VIS, or lactate clearance. There is limited evidence to support the idea that regular dosing of epinephrine during cardiac arrest is associated with increased in afterload after ECMO cannulation. Additional studies are needed to validate findings against ECMO flows and clinically relevant outcomes.

High level of intraoperative lactate might predict acute kidney injury in aortic arch surgery via minimally invasive approach in patients with type A dissection.

A high incidence of acute kidney injury (AKI) has been recorded in total arch replacement (TAR) combined with frozen elephant trunk (FET) implantation in patients with acute type A dissection (ATAAD) via median sternotomy approach with some risk factors. However, the independent risk factors for AKI via a minimally invasive approach have not yet been identified. A total of 207 patients with ATAAD were enrolled from January 2018 and November 2019 and were divided into AKI and non-AKI groups. The current surgical strategy was TAR combined with FET via a single upper hemisternotomy approach, a minimally invasive method. An increase in the serum creatinine (Cr) level to ≥2 times the baseline level 48 h post-surgery was defined as AKI. The morbidity of AKI was investigated with a step-by-step backward multivariate analysis of its independent risk factors and a receiver-operating characteristic curve analysis. Postoperative AKI was observed in 39 (18.8%) patients, and the total hospital mortality was 8.7%. Univariate analysis found that preoperative Cr, weight, circulatory arrest time ≥60 min, intraoperative highest lactate (Lac), and intraoperative transfusion had significant differences between the two groups. However, multivariate step-by-step backward logistic regression analysis identified intraoperative highest Lac and transfusion as independent risk factors for postoperative AKI and intraoperative highest Lac was identified as the most critical independent risk factor estimated by the partial chi-square statistic minus the predicted degrees of freedom with 4.3 mmol/L as the optimal cut-off point for prediction for AKI. Intraoperative highest Lac and transfusion were independent risk factors for postoperative AKI, which led to high hospital mortality. Moreover, intraoperative highest Lac was the most critical independent risk factor and high level of intraoperative highest Lac (4.3 mmol/L) might predict for postoperative AKI.

Mid-Term Outcomes of "Complete Aortic Repair": Surgical or Endovascular Total Arch Replacement With Thoracoabdominal Fenestrated-Branched Endovascular Aortic Repair.

To describe a single-center experience of "complete aortic repair" consisting of surgical or endovascular total arch replacement/repair (TAR) followed by thoracoabdominal fenestrated-branched endovascular aortic repair (FB-EVAR). We reviewed 480 consecutive patients who underwent FB-EVAR with physician-modified endografts (PMEGs) or manufactured stent-grafts between 2013 and 2022. From those, we selected only patients treated with open or endovascular arch repair and distal FB-EVAR for aneurysms involving the ascending, arch and thoracoabdominal aortic segments (zones 0-9). Manufactured devices were used under an investigational device exemption protocol. Endpoints included early/in-hospital mortality, mid-term survival, freedom from secondary intervention, and target artery instability. There were 22 patients, 14 men and 8 women with a median age of 72±7 years. Thirteen postdissection and 9 degenerative aortic aneurysms were repaired with a mean maximum diameter of 67±11 mm. Time from index aortic procedure to aneurysm exclusion was 169 and 270 days in those undergoing 2- and 3-stage repair strategies, respectively. The ascending aorta and aortic arch were treated with 19 surgical and 3 endovascular TAR procedures. Three (16%) surgical arch procedures were performed elsewhere, and perioperative details were unavailable. Mean bypass, cross-clamp, and circulatory arrest times were 295±57, 216±63, and 46±11 minutes, respectively. There were 4 major adverse events (MAEs) in 2 patients: both required postoperative hemodialysis, 1 had postbypass cardiogenic shock necessitating extracorporeal membrane oxygenation, and the other required evacuation of an acute-on-chronic subdural hematoma. Thoracoabdominal aortic aneurysm repair was performed with 17 manufactured endografts and 5 PMEGs. There was no early mortality. Six (27%) patients experienced MAEs. There were 4 (18%) cases of spinal cord injury with 3 (75%) experiencing complete symptom resolution before discharge. Mean follow-up was 30±17 months in which there were 5 patient deaths-0 aortic related. Eight patients required ≥1 secondary intervention, and 6 target arteries demonstrated instability (3 IC, 1 IIIC endoleaks; 2 TA stenoses). Kaplan-Meier 3-year estimates of patient survival, freedom from secondary intervention, and target artery instability were 78±8%, 56±11%, and 68±11%, respectively. Complete aortic repair with staged surgical or endovascular TAR and distal FB-EVAR is safe and effective with satisfactory morbidity, mid-term survival, and target artery outcomes. The presented study demonstrates that repair of the entirety of the aorta - via total endovascular or hybrid means- is safe and effective with low rates of spinal cord ischemia. Cardiovascular specialists within comprehensive aortic teams at should feel confident that staged repair of the most complex degenerative and post-dissection thoracoabdominal aortic aneurysms can be safely performed in their patients with complication profile similar to that of less extensive repairs. Meticulous and intentional case planning is imperative for immediate and long-term success.

Effect of prestress on propagation of blasting-induced main crack in specimens with empty hole

In-situ stresses have a significant effect on blast results in deep rock mass. In this paper, firstly, the effect of a prestress (similar to an in-situ stress) on the propagation of blasting-induced main crack in the specimens with an empty hole was studied by dynamic caustic method, considering reflected stress wave. Then, the effect of prestress on the stresses around the empty hole during blasting was studied using numerical analysis. The results show that the prestress can significantly increase (1) the hoop tensile stresses on the upper and lower side of the empty hole, (2) the length of the main crack, (3) the dynamic stress intensity factor (DSIF), (4) the propagation velocity of the main crack, and (5) the crack arrest time when the prestress is parallel to the co-axis direction of the empty hole and the blasthole. Moreover, the prestress promotes the attenuation of DSIFs in the early stage of blasting and limits the increase of DSIFs under vertical reflected stress wave. The lower side of the empty hole is easier to be fractured than that of the upper side. Meanwhile, the peak compressive hoop stress on the upper side of the empty hole does not appear closest to the empty hole.

Incidences and outcomes of intra-operative vs. postoperative paediatric cardiac arrest: A retrospective cohort study of 42 776 anaesthetics in children who underwent noncardiac surgery in a Thai tertiary care hospital.

The reported incidence of paediatric perioperative cardiac arrest (PPOCA) in most developing countries ranges from 2.7 to 22.9 per 10 000 anaesthetics, resulting in mortality rates of 2.0 to 10.7 per 10 000 anaesthetics. The definitions of 'peri-operative' cardiac arrest often include the intra-operative period and extends from 60 min to 48 h after anaesthesia completion. However, the characteristics of cardiac arrests, care settings, and resuscitation quality may differ between intra-operative and early postoperative cardiac arrests. To compare the mortality rates between intraoperative and early postoperative cardiac arrests (<24 h) following anaesthesia for paediatric noncardiac surgery. A retrospective cohort study. In a tertiary care centre in Thailand during 2014 to 2019, the peri-operative period was defined as from the beginning of anaesthesia care until 24 h after anaesthesia completion. Paediatric patients aged 0 to 17 years who underwent anaesthesia for noncardiac surgery. Mortality rates. A total of 42 776 anaesthetics were identified, with 63 PPOCAs and 23 deaths (36.5%). The incidence (95% confidence interval) of PPOCAs and mortality were 14.7 (11.5 to 18.8) and 5.4 (3.6 to 8.1) per 10 000 anaesthetics, respectively. Among 63 PPOCAs, 41 (65%) and 22 (35%) occurred during the intra-operative and postoperative periods, respectively. The median [min to max] time of postoperative cardiac arrest was 3.84 [0.05 to 19.47] h after anaesthesia completion. Mortalities (mortality rate) of postoperative cardiac arrest were significantly higher than that of intra-operative cardiac arrest at 14 (63.6%) vs. 9 (22.0%, P = 0.001). Multivariate analysis of risk factors for mortality included emergency status and duration of cardiopulmonary resuscitation with adjusted odds ratio 5.388 (95% confidence interval (1.031 to 28.160) and 1.067 (1.016 to 1.120). Postoperative cardiac arrest resulted in a higher mortality rate than intra-operative cardiac arrest. A high level of care should be provided for at least 24 h after the completion of anaesthesia. None. NA.