Recent discussions
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Markus Skrifvars
Markus Skrifvars for the ALS Task Force
In the conducted randomized controlled trials on out-of-hospital cardiac arrest (OHCA) patients where different mean arterial pressures have been targeted, the majority of patients have required a vasopressor to achieve the required pressure (1-4). Therefore, it is unlikely that spontaneous hypertension would have been common during the first 72 hours. However, it needs to be noted that most trials thus far have focused on patients with a cardiac cause of the arrest and the patient have received targeted temperature management and sedation (which may decrease blood pressure). There are some observational studies examining the association between a high blood pressure (spontaneous or induced) and outcome (5,6). In these studies, it appears that hypertension is more common than in the aforementioned randomized trials. In observational trials the blood pressure is commonly collected as a part of a severity of illness score i.e. APACHE/SAPS and is thus the most abnormal (lowest and highest) value over the first 24 hours in the intensive care unit (ICU) (5,6). In general, a high blood pressure (MAP > 104 mmHg, SAP > 156 mmHg) appears associated with worse outcome but the opposite has also been shown (7). There are no RCT examining treatment of hypertension after OHCA. In patients with other types of brain injury the threshold for treating hypertension varies based on the etiology (8). In patients with a haemorrhagic stroke a systolic blood pressure of 140 mmHg is targeted. In patients with ischaemic stroke treatment is not recommended unless the blood pressure is extremely high (>220/120 mmHg) with the exception of those patients who undergo thrombolytic where the target is a blood pressure less than 185/110 mmHg (8). In general ICU patients the general threshold for treatment has been proposed to be 180 mmHg (9). In conclusion, there is insufficient evidence to recommend a specific upper threshold for blood pressure treatment in OHCA patients. Based on indirect evidence one proposed threshold where treatment is considered could be 180 mmHg.
- Niemelä et al. Resuscitation 189: 109862
- Kjaergaard et al. N Engl J Med 387: 1456-1466
- Ameloot et. Eur Heart J 40: 1804-1814
- Jakkula et al. Intensive Care Med 44: 2091-2101
- Huang et al. Resuscitation. 120:146–52.
- McGuigan et al. Crit Care. 27(1):4.
- Bro-Jeppesen et al. Crit Care Med. 43(2):318–27.
- Guo et al. Am J Hypertens. 35(6):483-499.
- Salgado et al. Ann Intensive Care 3(1): 17.
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Jacob Jentzer
While I would expect that there is limited evidence to support such a recommendation, it would be important to establish whether a blood pressure “ceiling” exists, i.e. a MAP above which worse outcomes occur that could justify blood pressure lowering therapy.
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Joyce Yeung
Thank you for your comment.
There was insufficient evidence from the studies included in our review for our taskforce to make a recommendation on triage policies or transfer protocols.
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Joyce Yeung
Thank you for your comment. We look forward to your publication and including evidence from your work in future evidence synthesis. There was insufficient evidence for our taskforce to make specific recommendations about different geographical areas.
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Krisa Van Meurs
We recommend that cooling should be considered, initiated, and conducted under clearly defined protocols similar to the randomized controlled trials (RCTs) previously conducted in high-income countries. Furthermore, we believe a cord or baby blood gas and a neurologic exam demonstrating moderate to severe encephalopathy are essential entry criteria for cooling. Careful consideration of the differential diagnoses of neonatal encephalopathy is important.
In addition to the treatment recommendations listed we suggest the use of amplitude integrated EEG (aEEG) or continuous video EEG (vEEG) throughout the cooling and rewarming periods in order to improve the accuracy of seizure diagnosis. Misdiagnosis of seizures can lead either to overtreatment or inadequate treatment of seizures. With overtreatment, potential brain injury secondary to the use of antiepileptic drugs may occur, and with inadequate treatment, brain injury can be associated with increased seizure burden.
We emphasize the use of brain monitoring may be particularly crucial in LMICs, where there is a heightened incidence of seizures. A recent study published by Variane et. al. (1), describes a cohort of 872 infants with HIE monitored with video aEEG/EEG, demonstrating the feasibility of applying such monitoring in a LMIC.
- Variane, G. F. T., Dahlen, A., Pietrobom, R. F., et al. Remote monitoring for seizures during therapeutic hypothermia in neonates with hypoxic-ischemic encephalopathy. JAMA Network Open, 6(11), e2343429-e2343429.
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Jeremias Bordon
Excellent topic!... continuous monitoring of the temperature of the newborn in the delivery room is essential... I think it is a huge gap even today to give the importance it deserves to thermoregulation and its impact on neonatal outcomes. One of the main difficulties, especially in low-resource centers, is precisely the lack of equipment that allows continuous temperature monitoring, which could increase the cases of admissions of newborns with hyperthermia in those where rapid rewarming is performed. It is very important to cover thermoregulation and hypothermia prevention measures in order to improve neonatal outcomes.
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Kristine Karlsen
The most at-risk for moderate to severe hypothermia are preterm and low-birth-weight infants. Hypothermia can impair immune function. Rates of early-onset-sepsis should be included in any future study. Hypothermia impairs coagulation. In addition to IVH, pulmonary hemorrhage should be an outcome that is looked at. Too rapid rewarming can cause vasodilation and reduce cardiac output. Any future study should look at whether any colloids or pressors are required during or soon after rewarming has started. An ideal study for rewarming of preterm infants would use an incubator with humidity and set on air temperature mode to best control the speed of rewarming (setting the air to 1 to 1.5 deg C above the infant's core temperature - or axillary if preterm). For term infants, a therapeutic hypothermia blanket could be used to control the speed of rewarming. Becoming hypothermic after birth is one thing - but the depth of hypothermia is not likely to be as severe as the preterm infant in the pre-transport environment and retrieved by the neonatal transport team, or the preterm infant delivered at home and is severely hypothermic and admitted to the hospital. Those patients should be included in any rewarming study and randomized to slow versus rapid rates. Preterm infants may be experiencing the effects of severe hypothermia with a body temperature of 35 deg Celsius and below, whereas term infants are severely hypothermic at 32 deg. Celsius. Establishing the range for mild, moderate, severe hypothermia for preterm infants would be a wonderful outcome of any study on rewarming of preterm infants. I am glad this topic is receiving attention. The S.T.A.B.L.E. Program Temperature module has contained precautions about the risks of rapid rewarming for many years and our recommendation has been and continues to be – rewarm slowly and steadily while monitoring vital signs and intermittently blood glucose and blood gas. Knowing that we really don't know if fast is better. But, also knowing that sudden vasodilation as occurs with using a radiant warmer or applying warm packs around the body (or both) can lead to a sudden drop in cardiac output, wide swings in blood pressure, and increased risk for brain hemorrhage.
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PATRICIA LARANJEIRA
The umbilical cord clamping time, the importance of placental transfusion and the physiological changes that occur during the transition from intrauterine to extrauterine life and the possible short, medium and long term repercussions of this procedure, returned to the center of discussions in different populations. Based on existing evidence in the literature, the recommendations to indicate delayed clamping after 60 seconds in full-term and healthy newborns, vigorous at birth, and after 30 seconds in PTNBs who do not require resuscitation procedures at birth, are safe. However, more studies will be needed to evaluate whether other alternative strategies are more effective than the strategies proposed to date.
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Martin Fagan
The principal of ‘Personal defibrillators’ is valid. Whether Ultraportable devices are the answer is open for debate. There are traditional devices that will meet this need.
As a charity, we were interested in this area and have requested on many occasions over the past 18 months, and in Zoom/telephone/face to face meetings, for copies of clinical data to support the marketing claims being made. These have never been provided, whether by the manufacturer or their UK sales agents. What has been provided is marketing and sales documentation, with challengeable statements.
RCUK advise ‘caution’ over using this device due to the lack of performance data.
We do have concerns, that need addressing, before we can consider this device. Namely;
- is 70J sufficient energy to overcome TTI?
- Is having a max energy ⅔ that of other devices clinically effective?
- Is the experimental dual exponential energy curve valid?
- Is use on neonates dangerous for a community device, given their normal HR is 120-220 and some devices shock at 130 bpm, suggesting that a shock could be given to an otherwise normal baby?
- What are the pads adhesion data?
- The explanation in the manual over use on paediatrics seems to conflict with advice from elsewhere.
- Is a cellphone type battery ⅓ that of a standard cell phone going to give sufficient energy for multiple shocks, and also what are the degradation studies on the battery over time?
- What data is there to support the marketing claim of “equal or better than existing devices”?
- How does the rescue data get transmitted to the hospital?
Until the basic questions are answered with peer reviews data, these types of product should be restricted in their use. We understand the FIRST trail is not looking at clinical efficacy, and therefore further evidence needs to be provided that shows efficacy, and in particular efficacy in relation to existing equipment that is available.
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Silvia Heloisa Moscatel Loffredo
Evaluating the favorable outcomes of therapeutic hypothermia using non-servo-controlled cooling methods in limited resource settings, I agree with the preliminar recommendations, including the definition of minimum resources for the safety and effectiveness of the method, emphasizing the importance of adhering to good practice statement.