Letter to the Director
Extracorporeal cardiopulmonary resuscitation in accidental hypothermia
Reanimación cardiopulmonar extracorpórea en hipotermia accidental
R. Blasco Mariñoa,b,
, M. Martín Orejasa, M.Á. González Posadaa,c, Í. Soteras Martinezb,d,e
Corresponding author
a Servicio de Anestesiología y Reanimación, Hospital Universitario Vall d’Hebron, Barcelona, Spain
b Facultad de Medicina, Departamento de Ciencias Médicas, Universidad de Girona, Gerona, Spain
c Facultad de Medicina, Universidad Autónoma de Barcelona, Barcelona, Spain
d Servicio de Urgencias, Hospital Transfrontarer de la Cerdanya, Gerona, Spain
e Sistema d’Emergencies Mèdiques (SEM) de Cataluña, Barcelona, Spain
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(B) Intraoperative image of 2 large thrombi.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Garví López" "autores" => array:1 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Garví López" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S234119292300029X?idApp=UINPBA00004N" "url" => "/23411929/0000007000000002/v1_202303141745/S234119292300029X/v1_202303141745/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Director</span>" "titulo" => "Extracorporeal cardiopulmonary resuscitation in accidental hypothermia" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "118" "paginaFinal" => "119" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "R. Blasco Mariño, M. Martín Orejas, M.Á. González Posada, Í. Soteras Martinez" "autores" => array:4 [ 0 => array:4 [ "nombre" => "R." "apellidos" => "Blasco Mariño" "email" => array:1 [ 0 => "roblasc.rb@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Martín Orejas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "M.Á." "apellidos" => "González Posada" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Í." "apellidos" => "Soteras Martinez" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Universitario Vall d’Hebron, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Facultad de Medicina, Departamento de Ciencias Médicas, Universidad de Girona, Gerona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Facultad de Medicina, Universidad Autónoma de Barcelona, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Urgencias, Hospital Transfrontarer de la Cerdanya, Gerona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Sistema d’Emergencies Mèdiques (SEM) de Cataluña, Barcelona, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Reanimación cardiopulmonar extracorpórea en hipotermia accidental" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read with great interest the article published by Zarragoikoetxea et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In this article the authors give an extensive explanation of the most current recommendations for the use of ECMO and provide the experience of the main centres in Spain.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Among the different indications in which the ECMO system can be used as life support is severe accidental hypothermia (AH), which we would like to examine in more detail. AH is a clinical entity defined as the unintentional lowering of core temperature <35<span class="elsevierStyleHsp" style=""></span>°C. A primary diagnosis of hypothermia is usually not easy to reach without clearly precipitating environmental conditions, even in regions with a higher incidence and mortality from AH. Once diagnosed or suspected, management depends heavily on the patient's clinical manifestations and core temperature. In severe cases, where there is haemodynamic instability and an altered level of consciousness, or in cases of cardiorespiratory arrest (CRA), transfer to an ECMO centre for extracorporeal cardiopulmonary resuscitation (eCPR) is recommended, provided it can be performed in less than 6<span class="elsevierStyleHsp" style=""></span>h<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>.</p><p id="par0015" class="elsevierStylePara elsevierViewall">ECMO is the current gold standard for rewarming and supportive therapy. The use of extracorporeal systems provides survival data of 20%–100%, of which 61%–100% have good or moderate neurological outcomes at hospital discharge (Cerebral Performance Category 1–2)<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a>. Despite these encouraging results, the decision to resuscitate and refer these patients can be complex, especially if we take into account that the indications and contraindications for eCPR in out-of-hospital CPR due to AH are not the same as for normothermic patients<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a>.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Evidence has recently been published that may help us to manage the particularities of this entity<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>. Therefore, we would like to complement some aspects that should be considered in eCPR in patients with severe AH:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0025" class="elsevierStylePara elsevierViewall">In the case of CRA due to AH, the use of prognostic scales is recommended as a bridge to the decision of whether or not to continue CPR, thus avoiding futile actions. There are currently 2 scales: ICE and HOPE, the latter being the most widely used. Favourable values of these scales predict the probability of survival with eCPR. HOPE (hypothermiascore.org) values of less than 10% have a negative predictive value of 97% and, therefore, little probability of success below this cut-off point<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>. These scales take over from the old cut-off points for isolated potassium levels.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0030" class="elsevierStylePara elsevierViewall">The decision whether or not to perform eCPR should not be based on the existence of adverse blood gas values (pH<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>6.8). Findings on physical examination or monitoring that may simulate poor clinical prognosis or unequivocal signs of death (bilateral unresponsive mydriasis apparent rigor mortis, very low BIS values, EtCO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>mmHg or systolic blood pressure<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>mmHg) should not be used to stop or not perform eCPR.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0035" class="elsevierStylePara elsevierViewall">The decision to initiate eCPR should not follow the classical contraindications of the normothermic patient. A first heart rhythm in asystole, absence of chest compressions in the first 10<span class="elsevierStyleHsp" style=""></span>min after the absence of vital signs, intermittent CPR, advanced age or unwitnessed CPR are not an absolute contraindication for eCPR. The usual rules of termination of resuscitation should not apply to AH cases: the axiom “no hypothermic victim in cardiac arrest is dead until he or she is warm and dead” prevails.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0040" class="elsevierStylePara elsevierViewall">There is currently no ideal rewarming rate. Current data indicate that slow rewarming provides survival data with better neurological outcomes. The rewarming target should be less than 5<span class="elsevierStyleHsp" style=""></span>C/h, maintaining a veno-arterial temperature gradient, if possible, <4<span class="elsevierStyleHsp" style=""></span>C and always less than 10<span class="elsevierStyleHsp" style=""></span>C to avoid formation of gas emboli.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0045" class="elsevierStylePara elsevierViewall">During resuscitation, if the core temperature is <30<span class="elsevierStyleHsp" style=""></span>C, a maximum of 3 defibrillations can be performed and the use of vasopressor drugs is not recommended. After 30<span class="elsevierStyleHsp" style=""></span>C, it is recommended to double the pharmacological CPR intervals until 35<span class="elsevierStyleHsp" style=""></span>C is reached and, from this point, follow standard protocols.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0050" class="elsevierStylePara elsevierViewall">eCPR should not be performed only in the following cases: existence of life-threatening injuries, severe associated comorbidities or chest incompressible due to frostbite. A core temperature >30<span class="elsevierStyleHsp" style=""></span>C associated with the absence of vital signs makes a hypothermic origin of the episode highly improbable, so alternative causes must be assessed<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>.</p></li></ul></p><p id="par0055" class="elsevierStylePara elsevierViewall">Lastly, we would like to emphasise the importance of creating local multidisciplinary protocols for rare resuscitation situations. The implementation of standardised working structures and debriefing systems for all subjects in the AH chain of survival improves care and creates a favourable climate for proactive work<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Documento de consenso SEDAR/SECCE sobre el manejo de ECMO" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "I. Zarragoikoetxea" 1 => "A. Pajares" 2 => "I. Moreno" 3 => "J. Porta" 4 => "T. Koller" 5 => "V. 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