Extracorporeal Rewarming Research Articles

Difficulties in funding of VA-ECMO therapy for patients with severe accidental hypothermia

Severe accidental hypothermia is defined as a core temperature below 28 Celsius degrees. Within the last years, the issue of accidental hypothermia and accompanying cardiac arrest has been broadly discussed and European Resuscitation Council (ERC) Guidelines underline the importance of Extracorporeal Rewarming (ECR) in treatment of severely hypothermic victims. The study aimed to evaluate the actual costs of ECR with VA-ECMO and of further management in the Intensive Care Unit of patients admitted to the Severe Accidental Hypothermia Centre in Cracow, Poland. We carried out the economic analysis of 31 hypothermic adults in stage III-IV (Swiss Staging) treated with VA ECMO. Twenty-nine individuals were further managed in the Intensive Care Unit. The actual treatment costs were evaluated based on current medication, equipment, and dressing pricing. The costs incurred by the John Paul II Hospital were then collated with the National Health Service (NHS) funding, assessed based on current financial contract. In most of the cases, the actual treatment cost was greater than the funding received by around 10000 PLN per patient. The positive financial balance was achieved in only 4 (14%) individuals; other 25 cases (86%) showed a financial loss. Performed analysis clearly shows that hospitals undertaking ECR may experience financial loss due to implementation of effective treatment recommended by international guidelines. Thanks to new NHS funding policy since January 2017 such loss can be avoided, what shall encourage hospitals to perform this expensive, yet effective method of treatment.

Clinical course and prognostic factors of patients in severe accidental hypothermia with circulatory instability rewarmed with veno-arterial ECMO - an observational case series study

BackgroundRecently, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has become the rewarming treatment of choice in hypothermic cardiac arrest. The detailed indications for extracorporeal rewarming in non-arrested, severely hypothermic patients with circulatory instability have not been established yet. The primary purpose of the study was a preliminary analysis of all aspects of the treatment process, as well as initial identification of mortality risk factors within the group of severely hypothermic patients, treated with arteriovenous extracorporeal membrane oxygenation (VA-ECMO). The secondary aim of the study was to evaluate efficacy of VA-ECMO in initial 6-h period of treatmentMethodsFrom July 2013 to June 2016, thirty one hypothermic patients were accepted for extracorporeal rewarming at Severe Accidental Hypothermia Center, Cracow. Thirteen patients were identified with circulatory instability and were enrolled in the study. The evaluation took into account patients’ condition on admission, the course of therapy, and changes in laboratory and hemodynamic parameters.ResultsNine out of 13 analyzed patients survived (69%). Patients who died were older, had lower both systolic and diastolic pressure, and had increased creatinine an potassium levels on admission. In surviving patients, arterial blood gases parameters (pH, BE, HCO3) and lactates would normalize more quickly. Their potassium level was lower on admission as well. The values of the core temperature on admission were comparable. Although normothermia was achieved in 92% of patients, none of them had been weaned-off VA-ECMO in the first 6 h of treatment.Discussion and ConclusionsIn our preliminary study more pronounced markers of cardiocirculatory instability and organ hypoperfusion were observed in non-survivors. Future studies on indications to extracorporeal rewarming in severely hypothermic, non-arrested patients should focus on the extent of hemodynamic disturbances. Short term (<6 h) treatment in severe hypothermic, non-arrested patients seems to be not clinically appropriate.

Profound Accidental Hypothermia: Systematic Approach to Active Recognition and Treatment.

We sought to organize a functional system of recognition and advanced treatment of hypothermic patients with extracorporeal rewarming as a treatment option. All patients with suspected hypothermia are consulted with the hypothermia coordinator (HC), whose role is to provide expertise on hypothermia recognition and treatment to all rescue and medical services. Patients with Swiss staging system of hypothermia class III and IV are subjected to extracorporeal rewarming. Patients with class I and II are managed in local hospitals, after the HC provides instructions. From program initiation (July 29, 2013) to November 1, 2015, HC consulted 104 hypothermic patients; 21 in hypothermia class III and IV were subjected to extracorporeal rewarming in the John Paul II Hospital in Cracow, Poland. The remaining people were rewarmed in the referring hospitals. Cardiac arrest upon referral was present in 10 cases (resuscitation times from arrest to extracorporeal membrane oxygenation implantation ranged 107–345 minutes). Seven patients died, and the remaining 14 have been rewarmed with the restoration of hemodynamic stability. Systematic approach to active recognition and treatment of profound accidental hypothermia patients, on the basis of HC cooperation with emergency medical services, enables advanced management with good outcomes, especially in patients with cardiac arrest.

Hypothermia and targeted temperature management in cats and dogs

To review current knowledge surrounding the effects, treatment, and prognosis of hypothermia in people, dogs, and cats, as well as the application of therapeutic hypothermia in clinical medicine. Hypothermia may be a primary or secondary condition, and may be due to environmental exposure, illness, medications, anesthesia, or trauma. Hypothermia has been applied therapeutically in human medicine for a variety of conditions, including postcardiac arrest. In veterinary medicine, the technique has been applied in cardiac surgeries requiring bypass and in a patient with intractable seizures. Hypothermia can be diagnosed based on presenting temperature or clinical signs, and appropriate diagnosis may require nontraditional thermometers. Rewarming is the primary treatment for accidental hypothermia, with intensity ranging from passive surface rewarming to extracorporeal rewarming. The goal is to return the core temperature to a level that restores normal physiologic function of all body processes. Other supportive therapies such as intravenous fluids are typically indicated, and if cardiopulmonary arrest is present, prolonged resuscitation may be required. In cases of secondary hypothermia, reversal of the underlying cause is important. There are few prognostic indicators in human and veterinary patients with hypothermia. Even the most severely affected individuals, including those presenting in cardiopulmonary arrest, have potential for complete recovery with appropriate therapy. Therapeutic hypothermia has been shown to improve outcome in people following cardiac arrest. Further studies are needed to examine this application in veterinary medicine, as well as appropriate therapy and prognosis for cases of spontaneous hypothermia.

The chain of survival in hypothermic circulatory arrest: encouraging preliminary results when using early identification, risk stratification and extracorporeal rewarming.

BackgroundThe prognosis in hypothermic cardiac arrest is frequently good despite prolonged period of hypoperfusion and cardiopulmonary resuscitation. Apart from protective effect of hypothermia itself established protocols of treatment and novel rewarming techniques may influence on outcome.The purpose of the study was to assess the outcome of patients with hypothermic circulatory arrest treated by means of arterio-venous extracorporeal membrane oxygenation (ECMO) according to locally elaborated protocol in Severe Accidental Hypothermia Center in Cracow, Poland.MethodsProspective observational case-series study – all patients with confirmed hypothermic cardiac arrest consulted with hypothermia coordinator were accepted for extracorporeal rewarming, unless contraindications for ECMO were observed (active bleeding).ResultsThe study population consisted of 10 patients (7 male, median age 48.5 years). The core temperature measured esophageally was 16.9–28.4 °C, median 22 °C. On admission 5 patients presented with asystole and 5 with ventricular fibrillation. Duration of circulatory arrest before ECMO implantation was 107 to 345 min (median 156 min). The duration of ECMO support was 1.5 to 91 h (median 22 h). Cardiorespiratory stability and full neurologic recovery was achieved in 7 patients. The duration of mechanical ventilation was 88–437 h (median 177 h) and the length of stay in the ICU was 8–26 days (median 15 days). All survivors had mildly impaired (1 patient, LVEF 40 %) or preserved (6 patients, LVEF 55–65 %) left ventricular systolic function at the time of discharge from ICU. The cause of death of non-survivors (three patients) was acute myocarditis, massive retroperitoneal bleeding, and massive gastrointestinal bleeding.Discussion and ConclusionsOur data confirm the high survival rate (70 %) and excellent neurologic outcome in hypothermic cardiac arrest. The following key elements seem to impact the final prognosis: the appropriate coordination of the rescue operation, immediate high-quality CPR (preferably using mechanical chest compression system) and application of ECMO for rewarming and cardiorespiratory support.

Problems and Pitfalls of Qualification for Extracorporeal Rewarming in Severe Accidental Hypothermia.

When establishing the Severe Hypothermia Treatment Centre, certain problems and pitfalls regarding the qualification for extracorporeal rewarming were encountered. The authors shared their experience and opened a discussion with other centers that deal with severe, accidental hypothermia. Retrospective analysis of medical records of all patients examined by the hypothermia coordinator. Patients consulted and treated by the Severe Hypothermia Treatment Centre. Patients who underwent accidental hypothermia. From July 2013 until January 2016, hypothermia coordinators at the Severe Hypothermia Treatment Centre examined the cases of 152 hypothermic patients. Of those cases, 127 patients were subjected to noninvasive rewarming in referral hospitals and 25 were accepted to the center for extracorporeal rewarming. Difficulties that deferred or delayed the implementation of extracorporeal membrane oxygen rewarming were identified and addressed, including low platelet/red blood count, intraperitoneal fluid of unknown origin, abnormal results of head computed tomography, extremes of age, bleeding from the external auditory meatus, inaccuracy of infrared-based thermometers, iatrogenic trauma to the femoral vessels, chronic/terminal comorbidities, poisonings, pregnancy, hypoglycemia, hemodynamic stability despite severe hypothermia, and decontamination protocol. The problems discussed may delay the use of extracorporeal membrane oxygen rewarming in hypothermic patients but should not discourage medical teams from the implementation of extracorporeal rewarming. The prognosis for severe hypothermia is favorable, even with a long resuscitation time and low core temperatures.

GUIDELINES FOR MANAGEMENT OF ACCIDENTAL HYPOTHERMIA IN A UNIVERSITY HOSPITAL IN NORTHERN NORWAY.

Accidental hypothermia is defined as a trauma. Collaboration on the treatment of victims of accidental hypothermia shouldfollow a communication protocol for the seriously injured. Aim is to establish earliest possible contact with the doctor on duty at the regional University hospital to enable participation in the further communication and decision making process with relevance to technical and logistical issues. Victims of accidental hypothermia with adequate circulation and core temperature < 35⁰C can be treated with active remote heating (hot air blanket) at all hospitals providing emergency surgical care; active external warming should be started during transport to the nearest hospital. Hypothermic patients showing no signs of life, patients with inadequate circulation or hypothermia-induced circulatory arrest with core temperature < 32⁰C and serum K⁺ < 12 mmol-l⁻' should be transported directly to University hospital. Advanced life support in all these cases should be started immediately and continued without interruption during transportation until the patient is connected to a heart-lung machine for rewarming. If core temperature is < 28⁰C and/or the patient has inadequate circulation contact should be taken with the regional University hospital to discuss extracorporeal rewarming.

Management of hypothermia — Severe Accidental Hypothermia Centre in Krakow

Severe accidental hypothermia is a condition associated with significant morbidity and mortality. In the years 2009–2012 the Polish National Statistics Department reported 1836 deaths due to exposure to excessive natural cold. The Severe Accidental Hypothermia Centre (CLHG, Centrum Leczenia Hipotermii Glebokiej) was set up in Krakow in 2013. It is a unit functioning within the structure of the Cardiac Surgery Clinic, established in order to improve the effectiveness of the treatment of patients in the advanced stages of severe hypothermia. Early identification of hypothermia, binding algorithm and coordination leading to extracorporeal rewarming, are the most important elements in the deep hypothermia management.

Accidental hypothermia in Poland – estimation of prevalence, diagnostic methods and treatment.

BackgroundThe incidence of hypothermia is difficult to evaluate, and the data concerning the morbidity and mortality rates do not seem to fully represent the problem. The aim of the study was to estimate the actual prevalence of accidental hypothermia in Poland, as well as the methods of diagnosis and management procedures used in emergency rooms (ERs).MethodsA specially designed questionnaire, consisting of 14 questions, was mailed to all the 223 emergency rooms (ER) in Poland. The questions concerned the incidence, methods of diagnosis and risk factors, as well as the rewarming methods used and available measurement instruments.ResultsThe analysis involved data from 42 ERs providing emergency healthcare for the population of 5 305 000. The prevalence of accidental hypothermia may have been 5.05 cases per 100.000 residents per year. Among the 268 cases listed 25% were diagnosed with codes T68, T69 or X31, and in 75% hypothermia was neither included nor assigned a code in the final diagnosis. The most frequent cause of hypothermia was exposure to cold air alongside ethanol abuse (68%). Peripheral temperature was measured in 57%, core temperature measurement was taken in 29% of the patients. Peripheral temperature was measured most often at the axilla, while core temperature measurement was predominantly taken rectally. Mild hypothermia was diagnosed in 75.5% of the patients, moderate (32-28°C) in 16.5%, while severe hypothermia (less than 28°C) in 8% of the cases. Cardiopulmonary resuscitation was carried out in 7.5% of the patients. The treatment involved mainly warmed intravenous fluids (83.5%) and active external rewarming measures (70%). In no case was extracorporeal rewarming put to use.ConclusionsThe actual incidence of accidental hypothermia in Polish emergency departments may exceed up to four times the official data. Core temperature is taken only in one third of the patients, the treatment of hypothermic patients is rarely conducted in intensive care wards and extracorporeal rewarming techniques are not used. It may be expected that personnel education and the development of management procedures will brighten the prognosis and increase the survival rate in accidental hypothermia.

Is extracorporeal rewarming indicated in avalanche victims with unwitnessed hypothermic cardiorespiratory arrest?

International guidelines recommend using extracorporeal rewarming in all hypothermic avalanche victims with prolonged cardiac arrest if they have patent airways and a plasma potassium level≤12 mmol/L. The aim of this study was to evaluate outcome data to determine if available experience with extracorporeal rewarming of avalanche victims supports this recommendation. At Innsbruck Medical University Hospital, 28 patients with hypothermic cardiac arrest following an avalanche accident were resuscitated using extracorporeal circulation. Of these patients, 25 were extricated from the snow masses with no vital signs and did not survive to hospital discharge. Three patients had witnessed cardiac arrest after extrication and a core temperature of 21.7°C, 22°C, and 24.0°C, two of whom survived long-term with full neurological recovery. A search of the literature revealed only one asystolic avalanche victim with unwitnessed hypothermic cardiac arrest (core temperature 19°C) surviving long-term. All other avalanche victims in the medical literature surviving prolonged hypothermic cardiac arrest suffered witnessed arrest after extrication with a core temperature below 24°C. Our results suggest that prognosis of hypothermic avalanche victims with unwitnessed asystolic cardiac arrest and a core temperature>24°C is extremely poor. Available outcome data do not support the use of extracorporeal rewarming in these patients.

Therapeutic peritoneal lavage with warm saline solution as an option for a critical hypothermic trauma patient

In this paper, we present the case of a 63-year-old woman, who was found in her flat lying unconscious on the floor for an unknown time. At the time of admission, her core temperature was 24 °C and ventricular fibrillation was detected on the electrocardiogram (ECG). Because of the unstable conditions, the persistent nonperfusing cardiac rhythm and the dramatically inhibited coagulation cascade, a peritoneal lavage connected to a rapid infuser was performed for rewarming, instead of using a transportable heart-lung machine and a haemodialysis device. After a prolonged cardiopulmonary resuscitation (CPR), the patient could be transferred to the intensive care unit (ICU) in a stable condition. After 40 days in the ICU, recovery was fast, and another month of treatment later, she could be discharged back home without any discomfort. This report illustrates the successful use of the peritoneal lavage for rewarming a severely hypothermic patient without any extracorporeal rewarming device. Furthermore, it can be used in nearly every hospital if the necessary equipment is affordable. It is demonstrated that this technique is able to provide good outcomes for all victims of accidental hypothermia.

Resuscitation of avalanche victims: Evidence-based guidelines of the international commission for mountain emergency medicine (ICAR MEDCOM): Intended for physicians and other advanced life support personnel

BackgroundIn North America and Europe ∼150 persons are killed by avalanches every year. MethodsThe International Commission for Mountain Emergency Medicine (ICAR MEDCOM) systematically developed evidence-based guidelines and an algorithm for the management of avalanche victims using a worksheet of 27 Population Intervention Comparator Outcome questions. Classification of recommendations and level of evidence are ranked using the American Heart Association system. Results and conclusionsIf lethal injuries are excluded and the body is not frozen, the rescue strategy is governed by the duration of snow burial and, if not available, by the victim's core-temperature. If burial time ≤35min (or core-temperature ≥32°C) rapid extrication and standard ALS is important. If burial time >35min and core-temperature <32°C, treatment of hypothermia including gentle extrication, full body insulation, ECG and core-temperature monitoring is recommended, and advanced airway management if appropriate. Unresponsive patients presenting with vital signs should be transported to a hospital capable of active external and minimally invasive rewarming such as forced air rewarming. Patients with cardiac instability or in cardiac arrest (with a patent airway) should be transported to a hospital for extracorporeal membrane oxygenation or cardiopulmonary bypass rewarming. Patients in cardiac arrest should receive uninterrupted CPR; with asystole, CPR may be terminated (or withheld) if a patient is lethally injured or completely frozen, the airway is blocked and duration of burial >35min, serum potassium >12mmolL−1, risk to the rescuers is unacceptably high or a valid do-not-resuscitate order exists. Management should include spinal precautions and other trauma care as indicated.

Outcome of accidental hypothermia with or without circulatory arrest: Experience from the Danish Præstø Fjord boating accident

BackgroundResuscitation guidelines for the treatment of accidental hypothermia are based primarily on isolated cases. Mortality rates are high despite aggressive treatment aimed at restoring spontaneous circulation and normothermia. MethodsThe present report is based on a boating accident where 15 healthy subjects (median age 16 (range 15–45) years) were immersed in 2°C salt water. Seven victims were recovered in circulatory arrest with a median temperature of 18.4°C (range 15.5–20.2°C). They were all rewarmed with extracorporeal membrane oxygenation (ECMO) and were subsequently evaluated with advanced neuroradiological and functional testing. The remaining 7 had established spontaneous circulation without the use of ECMO. One victim drowned in the accident. ResultsThe victims that survived the accident without circulatory arrest were predominantly females with a higher body mass index. Victims with circulatory arrest pH on arrival was a median of 6.61 (range 6.43–6.94), with ECMO being established a median of 226 (178–241)min after the accident. Magnetic resonance spectroscopy showed neuronal dysfunction in five. In five victims initial normal white matter spectra progressed to show evidence of abnormal axonal membranes. Based on the seven-level Functional Independence Measure test functional outcome was good in six circulatory arrest victims and in all without circulatory arrest. Mild to moderate cognitive dysfunction was seen in six and severe dysfunction in one circulatory arrest victim. ConclusionSeven patients with profound accidental hypothermic circulatory arrest were successfully resuscitated using a management approach that included extracorporeal rewarming, followed by successive periods of therapeutic hypothermia and sedated normothermia and intensive neurorehabilitation. Seven other hypothermic victims (core temperature as low as 23°C) that did not suffer circulatory arrest also survived the accident.

Severe hypothermia in myxoedema coma: A rewarming by extracorporeal circulation

Myxoedema coma is the most lethal manifestation of hypothyroidism. It represents a true medical emergency, especially in the case of cardiovascular instability. Extracorporeal circulation is usually used for rewarming and for providing cardiac support in patients with severe hypothermia and, in addition, cardiovascular instability. We report the case of an 84-year-old woman who presented to the ED with accidental hypothermia associated with myxoedema that was successfully managed by veno-arterial extracorporeal blood rewarming. This case suggests that veno-arterial extracorporeal rewarming appears to achieve a rapid and consistent rewarming rate and is less invasive and more readily available than cardiopulmonary bypass.

Prehospital Resuscitation of the Buried Avalanche Victim

In North America and Europe, approximately 150 people die of avalanches per year, and fatalities are presumed to be many times higher in developing countries. Four factors are decisive for survival: grade of burial, duration of burial, presence of an air pocket and a free airway, and severity of trauma. According to Swiss data, the overall mortality rate with avalanche burial is 23%, but it largely depends on the grade of burial. While the mortality rate is 52.4% in completely buried (head below the snow) victims in the Swiss population, it is only 4.2% in partially buried (head free) victims. Additionally, survival in completely buried victims drops to 30% within the first 35 min, initially due to death from lethal trauma, followed by asphyxia in 20-35 min. Thereafter, survival decreases more gradually and victims who are not fatally injured and are able to breath under the snow slowly succumb to hypoxia, hypercapnia, and hypothermia. In the absence of fatal injuries, rescue strategies depend on the duration of burial and the victim's core temperature. With a burial time<35 min, survival depends on preventing asphyxia by rapid extrication, adequate airway management, and cardiopulmonary resuscitation. With a burial time>35 min, tackling hypothermia is of utmost importance. Therefore, gentle extrication and continuous core temperature and electrocardiogram monitoring are recommended. Pulseless victims with a patent airway and a core temperature<32°C should receive uninterrupted cardiopulmonary resuscitation and be transported to a hospital with extracorporeal rewarming facilities.

Experience with Helicopter Rescue Missions for Crevasse Accidents

We retrospectively studied incidence, patterns, and severity of injury and hypothermia in 95 victims of crevasse accidents. Fifteen (16%) victims were already dead when the rescue team arrived on the scene. Asphyxia (8 victims) was typically caused by snow burial owing to a collapse of snow bridges covering crevasses and was observed only during winter sports activities on glaciers. In 7 patients, death was caused by lethal trauma. Severe or critical multisystem trauma (ISS ≥ 16) was found in an additional 16 victims (17%). Severe or critical injuries were predominantly thoracic injuries and injuries of the extremities and/or pelvic region. Severe accidental hypothermia was observed in 9 of the 95 victims (10%). Three of these suffered from hypothermic sudden cardiac arrest during rescue and were immediately evacuated with ongoing CPR; all 3 made a full recovery after extracorporeal rewarming. More than two-thirds of all victims were still trapped in the crevasse when the rescue team arrived. However, the majority of them could be relatively easily extricated using standard mountaineering equipment and improvised rescue techniques. Prolonged and difficult extrication efforts were needed in less than 10% of victims. Summing up, trauma and asphyxia are the most important causes of mortality and acute life-threatening medical problems in this study, but asphyxia will be far less common in mountain regions offering fewer glacier sport activities in the winter months. Hypothermic sudden cardiac arrest could not be prevented during the difficult conditions of crevasse extrication in one-third of all hypothermic victims; however, prognosis was excellent with advanced life support at the scene and immediate helicopter evacuation to extracorporeal rewarming.

Ertrinkungsunfälle – Präklinische und klinische Behandlungsstrategien

Rescue and medical care of people in a drowning accident is a rather rare incident which still needs special attention. The rescue process can be technically challenging and only a well experienced team will be able to act professionally without any time loss. At a first step all team members have to protect themselves. Especially close collaboration of technical and medical rescue teams are of high significance and should be part of future exercises. Hypothermic persons should be protected from further cooling and gently rescued in a horizontally way. If a patient has no circulation continued cardiopulmonary resuscitation and immediate transport as soon as possible to the nearest hospital with an extracorporeal rewarming device is recommended. To avoid any time loss it is essential that the respective hospital is informed immediately and the fastest mode of transport selected. Astonishing cases show that this procedure is very promising even after long time submersion.

Should strategies for care of avalanche victims change?

Should strategies for care of avalanche victims change?

Treatment of Severe Hypothermia With Intravascular Temperature Modulation

Treatment of Severe Hypothermia With Intravascular Temperature Modulation

Survival after 5-h resuscitation attempt for hypothermic cardiac arrest using CVVH for extracorporeal rewarming

Hypothermic cardiac arrest is associated with a high mortality despite advances in pre-hospital rescue, rewarming techniques and intensive care management. Prolonged resuscitation is justified and full neurological recovery has been described using various methods of extracorporeal rewarming (Vretenar DF, Urschel JD, Parrott JCW et al. Ann Thorac Surg 1994; 58: 895-898; Hughes A, Riou P, Day C. Emerg Med J 2007; 24: 511-512). Extracorporeal rewarming is usually required at temperatures below 32 degrees C or in the presence of cardiovascular instability or neurological dysfunction (Wilkey SA. Am J Clin Med 2004; 1: 4-11). Resuscitation guidelines suggest cardiopulmonary bypass (CPB) as the method of choice in cardiac arrest, but in practice availability is restricted (Soar J, Deakin CD, Nolan JP et al. Resuscitation 2005; 67: S135-S170). Continuous veno-venous haemofiltration (CVVH) is an alternative, but underutilized approach which warrants further consideration given its ease and wider availability.