RATIONALE:Arterial blood gas analysis is a key component of the initial assessment for patients with cardiac arrest. In accidental hypothermia, temperature effects on gas solubility and hemoglobin-oxygen affinity confound oxygenation status. It remains unclear whether these values can be used to exclude patients from extracorporeal cardiopulmonary resuscitation in hypothermic cardiac arrest. AIM OF THE STUDY:To determine whether initial arterial oxygenation parameters predict favorable neurological outcomes in patients with hypothermic cardiac arrest treated with extracorporeal cardiopulmonary resuscitation. METHODS:We conducted a retrospective analysis of data from a national registry of patients with severe accidental hypothermia treated between 2014 and 2025. The study included adult patients with core temperature ≤28 °C who underwent extracorporeal cardiopulmonary resuscitation for hypothermic cardiac arrest. Arterial blood samples drawn on arrival, before extracorporeal support, were temperature-corrected using established equations. The primary outcome was survival to hospital discharge with good neurological status (Cerebral Performance Category 1-2). Associations were evaluated with multivariable generalized additive models to allow non-linear effects. RESULTS:In our cohort of 89 patients, neither arterial oxygen partial pressure nor saturation were independent predictors of a favorable neurological outcome. When corrected for temperature, severe hypoxemia <50 mmHg was present in two-thirds of patients with a good neurological outcome. CONCLUSIONS:A single arterial blood gas analysis is unreliable for determining prognosis in patients with non-asphyxial hypothermic cardiac arrest. Initial hypoxemia does not preclude a favorable neurological outcome; therefore, oxygenation metrics should not serve as sole exclusion criterion for ECPR in hypothermic cardiac arrest.

The aim of this study was to develop a scoring tool to estimate the probability of survival following extracorporeal rewarming in patients suffering hypothermic cardiac arrest. This is a multicenter retrospective study based on registry data. We included adult patients with hypothermic cardiac arrest not associated with asphyxia, with a core temperature of ≤28°C, who underwent extracorporeal rewarming. A multivariable logistic regression model was developed to serve as the predictive tool. Internal validation with bootstrap resampling was performed to adjust model parameters and reduce model optimism. Our study population included 141 patients. The survival rate was 46% (65/141). A total of 88% of the survivors (57/65) had a favorable neurological outcome (Cerebral Performance Category 1–2). The predictive model includes four variables. Outdoor occurrence of hypothermia and a higher hemoglobin level raise survival odds while higher concentrations of potassium and lactate reduce survival odds. The area under the receiver operating characteristic (ROC) curve was 0.812 and p value of the Hosmer-Lemeshow test was 0.8. We developed a prognostic model to estimate the probability of survival in adult patients with non–asphyxia-related hypothermic cardiac arrest. This model may aid in identifying candidates suitable for extracorporeal rewarming, though it should not be used as the sole deciding factor.

OBJECTIVE:Prolonged hypoglycemia can cause irreversible brain damage. Clinicians may thus be reluctant to initiate extracorporeal cardiopulmonary resuscitation in hypothermic cardiac arrest patients with severe hypoglycemia. The aim of this study was to evaluate the survival rate with good neurologic outcomes of patients with hypothermic cardiac arrest and severe hypoglycemia. DESIGN:Retrospective study. SETTING:Multicenter study based on data from the HELP Registry. PARTICIPANTS:Adult victims of accidental hypothermia with a core temperature ≤28°C and cardiac arrest who had undergone extracorporeal rewarming between January 2014 and June 2024 were included in the study. INTERVENTIONS:Patients with initial blood glucose concentration <3 mmol/L (<54 mg/dL) (severe hypoglycemia) were compared with those with glucose level ≥3 mmol/L (≥54 mg/dL). Survival to hospital discharge with favorable neurologic outcome was considered the primary outcome. MEASUREMENTS AND MAIN RESULTS:The study population consisted of 127 patients, of whom 21 (17%) presented with glucose concentration <3 mmol/L (<54 mg/dL) on admission to the hospital. By hospital discharge, 8 of 21 patients (38%) with severe hypoglycemia had survived in good neurologic condition. The lowest blood glucose level in a patient who survived without neurologic deficit was 0.9 mmol/L (16 mg/dL). There was no statistically significant difference in survival rates between patients with and without severe hypoglycemia (38% v 43%, p = 0.7). CONCLUSIONS:In patients with hypothermic cardiac arrest, severe hypoglycemia on admission to the hospital does not rule out survival with good neurologic outcomes after extracorporeal rewarming.

CPR-induced consciousness (CPRIC) is defined as consciousness during CPR, ranging from eye opening to combative behaviour and vocalisation, despite the absence of spontaneous circulation. CPRIC has not previously been reported in hypothermic cardiac arrest. A middle-aged man who was pulled from cold water appeared conscious during CPR, despite confirmed cardiac arrest and severe accidental hypothermia. An additional factor that could have influenced the victim’s behaviour was severe hypoglycaemia. The patient was rewarmed with veno-arterial extracorporeal membrane oxygenation (V-A ECMO) and discharged from the hospital without any neurological deficits. In hypothermic cardiac arrest, the paradoxical preservation of consciousness may be a consequence of adequate cerebral perfusion during cardiopulmonary resuscitation and the neuroprotective effect of hypothermia, despite other risk factors for brain injury.

Aim of the study Predictive factors for poor outcomes in hypothermic cardiac arrest (HCA) differ from those in normothermic out-of-hospital cardiac arrest (OHCA). This study aimed to evaluate the outcomes of extracorporeal life support (ECLS) in HCA patients who may not be considered eligible based on the guidelines set by the Extracorporeal Life Support Organization (ELSO). Methods A retrospective multicentre study included 127 HCA patients, divided into two groups: those meeting the ELSO eligibility criteria for ECLS, and those with at least one of the following ELSO exclusion criteria: age over 70 years, unwitnessed cardiac arrest, or asystole. Results Among the 62 patients who met the ELSO criteria, 38 (61 %) survived to hospital discharge, with 34 (89 %) achieving a favourable neurological outcomes. Of the 65 patients who received ECLS despite not meeting ELSO criteria, 24 (37 %) survived to discharge, with 20 (83 %) demonstrating a favourable neurological outcomes. In patients not meeting one or two ELSO criteria, survival rates were 18 of 47 (38 %) and 6 of 16 (38 %) respectively, with 83 % of survivors in both groups achieving favourable neurological outcomes. The two patients who failed to meet all three ELSO criteria did not survive. Conclusion Qualification of patients with hypothermic cardiac arrest for ECLS rewarming should not be strictly based on guidelines for normothermic cardiac arrest, as this may result in not initiating potentially life-saving treatment for patients who could have favourable prognoses for survival with good neurological outcomes.

Study objective: To indicate predictors of witnessed hypothermic cardiac arrest. Methods: We conducted a retrospective analysis of 182 patients with severe accidental hypothermia (i.e., with core body temperature of <= 28( degrees)C) who presented with preserved spontaneous circulation at first contact with medical services. We divided the study population into two groups: patients who suffered hypothermic cardiac arrest (HCA) at any time between encounter with medical service and restoration of normothermia, and those who did not sustain HCA. The analyzed outcome was the occurrence of cardiac arrest prior to achieving normothermia. Hemodynamic and biochemical parameters were analyzed with regard to their association with the outcome. Results: Fifty-two (29%) patients suffered HCA. In a univariable analysis, four variables were significantly associated with the outcome, namely heart rate (p < 0.001), systolic blood pressure (p = 0.03), ventricular arrhythmia (p = 0.001), and arterial oxygen partial pressure (p = 0.002). In the multivariable logistic regression the best model predicting HCA included heart rate, PaO2, and Base Excess (AUROC = 0.78). In prehospital settings, when blood gas analysis is not available, other multivariable model including heart rate and occurrence of ventricular arrhythmia (AUROC = 0.74) can be used. In this study population, threshold values of heart rate of 43/min, temperature -corrected PaO2 of 72 mmHg, and uncorrected PaO2 of 109 mmHg, presented satisfactory sensitivity and specificity for HCA prediction. Conclusions: In patients with severe accidental hypothermia, the occurrence of HCA is associated with a lower heart rate, hypoxemia, ventricular arrhythmia, lower BE, and lower blood pressure. These parameters can be helpful in the early selection of high-risk patients and their allocation to extracorporeal rewarming facilities. (c) 2024 Elsevier Inc. All rights reserved.

Abstract Objective To indicate factors predicting return of spontaneous circulation in patients with hypothermic cardiac arrest in the pre-rewarming period. Methods A multicenter retrospective study was conducted. We included patients who had suffered cardiac arrest caused by severe accidental hypothermia with a core body temperature of ≤ 28 °C. Patients who had achieved return of spontaneous circulation before commencement of active rewarming at the hospital were compared to those who remained in cardiac arrest. Results A total of 156 patients suffering hypothermic cardiac arrest were included in the study. In 14 of them (9%) resuscitation was successful before rewarming. Factors associated with return of spontaneous circulation were as follows: witnessed onset of cardiac arrest (p = 0.04); a higher core body temperature (p = 0.005) with a prognostic threshold of 24.6 °C; and a higher arterial oxygen partial pressure (p = 0.04) with a prognostic threshold of 81 mmHg. One patient after successful resuscitation sustained recurrence of cardiac arrest during rewarming. Conclusions Patients with core body temperature < 25 °C, hypoxemia, and those who sustained unwitnessed hypothermic cardiac arrest have weak chances for successful resuscitation before rewarming. They can benefit from immediate transportation to an extracorporeal life support facility under continuous cardiopulmonary resuscitation. Effective rewarming and oxygenation during the prehospital period can increase the chances for return of spontaneous circulation. Recurrence of cardiac arrest during rewarming is uncommon.

Background: Despite its importance, prehabilitation has only been implemented in very few cardiac surgery centers. Aims: The Pre Surgery Check (PreScheck) Team study was designed to evaluate the impact of comprehensive interdisciplinary assessment and implementation of the prehabilitation program on the incidence of postoperative pulmonary complications after elective cardiac surgery. Material and methods: 725 adult patients (338 in the study group, 387 in the control group) were included in this single-center, prospective, observational study. Multimodal prehabilitation involves four elements: interdisciplinary medical assessment by a cardiologist, an anesthesiologist, and a cardiac surgeon, pulmonary assessment for patients at high risk of postoperative pulmonary complications, psychological assessment, and physiotherapeutic assessment and training. The primary endpoint was the occurrence of postoperative pulmonary complications, and the secondary outcomes were surgical site infection, rethoracotomy, length of stay in the intensive care unit, and length of hospital stay. Results: Prehabilitation reduced the number of postoperative complications by 23%. Postoperative pneumonia was almost 3-fold less common (5.33% vs. 14.21%), and surgical site infection - 1.4 times less common in the PreScheck group (8.28 vs. 11.37%). In the logistic regression model, prehabilitation reduced the odds of postoperative pneumonia (by 0.346) and the odds of respiratory failure (by 0.479). Prehabilitation had no direct effect on the length of stay in the intensive care unit. Conclusions: Prehabilitation, according to the Pre Surgery Check Team standard, reduces the incidence of postoperative pulmonary complications and the total number of postoperative complications in patients undergoing elective cardiac surgery. The main benefit of participating in the PreScheck Team program is the opportunity to receive supportive preoperative interventions.

Purpose: Several initiatives have recently focused on raising awareness about limitations of treatment in Poland. We aimed to assess if the propensity to limit LST among elderly patients in 2018-2019 increased compared to 2016-2017.Methods: We analysed Polish cohorts from studies VIP1 (October 2016 -May 2017) and VIP2 (May 2018 -May 2019) that enrolled critical patients aged >80. We collected data on demographics, clinical features limitations of LST. Primary analysis assessed factors associated with prevalence of limitations of LST, A secondary analysis explored differences between patients with and without limitations of LST.Results: 601 patients were enrolled. Prevalence of LST limitations was 16.1% in 2016-2017 and 20.5% in 2018-2019. No difference was found in univariate analysis (p = 0.22), multivariable model showed higher propensity towards limiting LST in the 2018-2019 cohort compared to 2016-2017 cohort (OR 1.07;95%CI, 1.01-1.14). There was higher mortality and a longer length of stay of patients with limitations of LST compared to the patients without limitations of LST. (11 vs. 6 days, p = 0.001).Conclusions: The clinicians in Poland have become more proactive in limiting LST in critically ill patients >= 80 years old over the studied period, however the prevalence of limitations of LST in Poland remains low.

Background: Elderly patients pose a significant challenge to intensive care unit (ICU) clinicians. In this study we attempted to characterise the population of patients over 80 years old admitted to ICUs in Poland and identify associations between clinical features and short-term outcomes. Methods: The study is a post -hoc analysis of the Polish cohort of the VIP2 European prospective observational study enrolling patients > 80 years old admitted to ICUs over a 6 -month period. Data including clinical features, clinical frailty scale (CFS), geriatric scales, interventions within the ICU, and outcomes (30 -day and ICU mortality and length of stay) were gathered. Univariate analyses comparing frail (CFS > 4) to non -frail patients and survivors to non -survivors were performed. Multivariable models with CFS, activities of daily living score (ADL), and the cognitive decline questionnaire IQCODE as predictors and ICU or 30 -day mortality as outcomes were formed. Results: A total of 371 patients from 27 ICUs were enrolled. Frail patients had significantly higher ICU (58% vs. 44.45%, P = 0.03) and 30 -day (65.61% vs. 54.14%, P = 0.01) mortality compared to non -frail counterparts. The survivors had significantly lower SOFA score, CFS, ADL, and IQCODE than non -survivors. In multivariable analysis CFS (OR 1.15, 95% CI: 1.00-1.34) and SOFA score (OR 1.29, 95% CI: 1.19-1.41) were identified as significant predictors for ICU mortality; however, CFS was not a predictor for 30 -day mortality (P = 0.07). No statistical significance was found for ADL, IQCODE, polypharmacy, or comorbidities. Conclusions: We found a positive correlation between CFS and ICU mortality, which might point to the value of assessing the score for every patient admitted to the ICU. The older Polish ICU patients were characterised by higher mortality compared to the other European countries.

Background:The main purpose of the study was to assess the impact of preoperative interdisciplinary assessment by the PreScheck Team on optimization of the final selection for elective cardiac surgery. Methods:This is a single -centre prospective observational study. The examined population consisted of 933 adult patients planned for cardiac surgery. After the exclusion of urgent operations, the study group consisted of 288 patients planned for elective cardiac surgery within 3 months from 1.01.2023 with PreScheck assessment (PreScheck Team group 2) and a control group of 311 patients scheduled for elective cardiac surgery between 1.03.2022 and 30.06.2022 (4 months), without preoperative interdisciplinary assessment (No PreScheck Team group 2). Results: Fifty-two patients (18.06%) from the study group were finally excluded from the surgery on the scheduled date. In 46 patients (88.46%) the temporary or permanent exclusion from surgery was a result of PreScheck Team assessment. In the control group 42 patients (13.5%) did not undergo surgery on the scheduled date. Twentyseven of those patients (8.97%) were permanently excluded from cardiac surgery after admission to the hospital and required additional tests before the final clinical decision, with total hospitalization time of 146 days. Conclusions: Pre Surgery Check (PreScheck) Team is an original concept that combines classical preoperative assessment and an outpatient prehabilitation clinic. The approach we are proposing here should be a complementary stage in the process of selection for elective cardiac surgery, in addition to the Heart Team recommendation. This two-step decision -making enables real individual risk assessment, selection of the most suitable intervention and better use of medical resources.

Background. Heart transplantation is the treatment of choice for selected patients with end-stage heart failure. Persistent donor organ shortage causes a growing demand for mechanical circulatory support not only as a bridge to transplantation but mainly as a destination therapy (DT). Methods. The aim of the study was to analyze the indications, comorbidities, and complications during the follow-up of all patients undergoing left ventricular assist device (LVAD) implantation with at least 12 months of follow-up time in one of the most experienced clinics in Poland between 2015 and 2023. Results. There were 125 individuals with LVAD implantation, from which 90 had full 12 months of follow-up (85 males - 94%, 5 females - 6%), with a median age of 58 (50.25-63.75) years. The median body mass index was 27.12 (25.27-29.68). The etiology of heart failure was ischemic (n = 44, 49%), dilated cardiomyopathy (n = 44, 49%), and others. Preoperative echocardiography revealed a mean LV ejection fraction of 13.8% and a median LV dimension of 7.55 (6.92-8.2) cm. In 61 patients (68%), imaging confirmed pulmonary hypertension. Thirty-four patients (38%) had diabetes and 16 (18%) were active smokers. Median follow-up was 30 (17.25-42) months, with the longest period being about 82 months. 40 (44%) patients had kidney failure before LVAD implantation, and in 43 cases (48%), we observed relevant, transient deterioration of kidney function. Almost all patients (n = 82, 91%) suffered from anemia (Hb <13 g/dL in males and <12 g/dL in females) in different periods after LVAD implantation due to perioperative bleeding, gastrointestinal bleeding or unknown causes. The lowest Hb level was observed in the first week after LVAD implantation in 53 cases (58%). Median red cell concentrate transfusion demand before the discharge after surgery was 6 (2-8, 5) units. Conclusions. Appropriate selection of candidates and timing of LVAD implantation are critical for improved outcomes of DT. Anemia and kidney failure are the most frequent follow-up complications. Improved results and increased applicability and durability of LVADs have established this treatment option as an excellent alternative for patients with end-stage heart failure.

BackgroundDonor organ shortages cause increasing demand for mechanical circulatory support in patients with end-stage heart failure not only as a bridge to heart transplantation but mainly as a destination therapy. Improved results and increased applicability and durability of left ventricular assist devices (LVADs) have established this treatment option as an alternative to heart transplantation in selected patients. One of the most common complications after LVAD implantation is driveline infections (DLIs).MethodsThis study aimed to expand the understanding of DLI epidemiology and potential changes in implantation techniques regarding optimizing DLI prevention and treatment among all patients undergoing LVAD (Medtronic's Heartware HVAD and HeartMate 3 Abbott LVAD system) implantation with at least 12 months of follow-up time between 2015 and 2022.ResultsThere were 120 individuals with LVAD implantation, of whom 90 had 12 months of follow-up (85 men [94%], 5 women [6%]) with a median age of 58 years (50.25-63.75). The median body mass index was 27.12 kg/m2 (25.27-29.68). Of the 90 patients, 43 had ischemic heart failure (48%), 43 had dilated cardiomyopathy (48%), and the remaining 3 had other etiologies (3%), such as postinflammatory, and the remaining 1 had congenital heart defect (1%). Preoperative echocardiography revealed a mean left ventricle ejection fraction of 13.8% and a median left ventricle dimension of 7.55 cm (6.92-8.2). Imaging confirmed pulmonary hypertension in 61 patients (68%). Thirty-four of the 90 patients had diabetes (38%), and 16 were active smokers (18%). Median follow-up was 30 months (17.25-42), with the longest period being 82 months. More than half of the patients (n = 52; 57%) experienced a DLI. The median time to the first episode of DLI was 13 months (6-25). The most common pathogen revealed in wound swab culture was methicillin-sensitive Staphylococcus aureus (n = 23; 44%), Pseudomonas aeruginosa (n = 9; 17%), Proteus mirabilis (n = 4; 7%), and others. We observed that deeper driveline implantation below the left rectus muscle and just above the posterior rectus sheath resulted in fewer DLIs and longer free-from-DLI follow-up time. There was no statistically significant difference in DLI frequency between patients with or without diabetes mellitus.ConclusionsAppropriate selection of candidates and timing of LVAD implantation are critical for improved outcomes of destination therapy. DLI is the most common complication after LVAD implantation. Optimal surgical techniques and early implementation of targeted antibiotics are crucial. Significant challenges remain in optimizing DLI prevention and treatment.

Treatment recommendations for rewarming patients in severe accidental hypothermia with preserved spontaneous circulation have a weak evidence due to the absence of randomized clinical trials. We aimed to compare the outcomes of extracorporeal versus less-invasive rewarming of severely hypothermic patients with preserved spontaneous circulation. We conducted a multicenter retrospective study. The patient population was compiled based on data from the HELP Registry, the International Hypothermia Registry, and a literature review. Adult patients with a core temperature <28°C and preserved spontaneous circulation were included. Patients who underwent extracorporeal rewarming were compared with patients rewarmed with less-invasive methods, using a matched-pair analysis. The study population consisted of 50 patients rewarmed extracorporeally and 85 patients rewarmed with other, less-invasive methods. Variables significantly associated with survival included: lower age; outdoor cooling circumstances; higher blood pressure; higher PaCO 2 ; higher BE; higher HCO 3 ; and the absence of comorbidities. The survival rate was higher in patients rewarmed extracorporeally ( p = 0.049). The relative risk of death was twice as high in patients rewarmed less invasively. Based on our data, we conclude that patients in severe accidental hypothermia with circulatory instability can benefit from extracorporeal rewarming without an increased risk of complications.

Accidental hypothermia, defined as an unintentional drop of the body core temperature below 35 °C, is one of the causes of cardiocirculatory instability and reversible cardiac arrest. Currently, extracorporeal life support (ECLS) rewarming is recommended as a first-line treatment for hypothermic cardiac arrest patients. The aim of the ECLS rewarming is not only rapid normalization of core temperature but also maintenance of adequate organ perfusion. Veno-arterial extracorporeal membrane oxygenation (ECMO) is a preferred technique due to its lower anticoagulation requirements and potential to prolong circulatory support. Although highly efficient, ECMO is acknowledged as an invasive treatment option, requiring experienced medical personnel and is associated with the risk of serious complications. In this review, we aimed to discuss the clinical aspects of ECMO management in severely hypothermic cardiac arrest patients.

This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially. Cardiology Journal 2023, Vol. 30, No. 4, 668–670 DOI: 10.5603/CJ.a2023.0044 Copyright © 2023 Via Medica ISSN 1897–5593 eISSN 1898–018X RESEARCH LETTER COVID-19