Distribution of median time intervals between activation of the emergency team and care at the alert site.. The chronobiological analysis based on the simple cosine test in seek of h rhythms revealed a global acrophase at The grouping of cases over the hours of the day showed clear peaks, with a greater number of events at 10, 14 and 20 h..
Case curve standardized distributed over the hours of the day.. The chronobiological analysis based on the simple cosine test in seek of 7-day rhythms revealed a global acrophase on the third day of the week Wednesday , and a batyphase on day 7 Sunday.
The grouping of cases over the days of the week showed two peaks with a greater number of events, corresponding to Wednesday and Saturday Fig. Distribution of cases during the days of the week.. There were no statistically significant differences in the chronobiological analysis of daily rhythm, distinguishing between the cases of ROSC and death Fig.
Case curves standardized and adjusted data of ROSC and death, distributed over the hours of the day.. In the present study, based on a large population database, circadian variation was observed in the occurrence of OHCA, with no differences in relation to the initial outcome of the cases. A prevalent peak was recorded in the first hours of the morning, with another peak in the afternoon, as well as a clear decrease in the nighttime hours—in coincidence with the observations of other authors..
Regarding the analysis of the time variations in the presentation of OHCA, it should be noted that although a circadian rhythm had been described in , 6 very few further studies have been published, 7,8,11—14 and none have been conducted in our particular setting to date. In a recently published study in Asia, 18 a daily rhythm in appearance of the disorder has been reported—with two peak incidences at 8: Other publications on time variations in cardiovascular events have examined the hypotheses proposed to explain such variations.
In this context, certain triggering physiopathological factors have been suggested to intervene at certain times of the day, including sympathetic tone or platelet activity. On the other hand, a recent study 21 whose results have not been confirmed in our work reports that OHCA survivors—in contrast to non-survivors—present a circadian rhythm in the appearance of the disorder, with an increased frequency between 18 and the 22 h..
Regarding the time analysis of the differences observed in the course of the days of the week, our data do not coincide with the results of Brooks et al. On the other hand, there were no differences in relation to outcome according to the day of the week on which OHCA occurred. This lack of agreement among the different studies referred to the weekly variations of OHCA points to the need for larger and more specific studies capable of clarifying this issue..
The more frequent presentation of OHCA in the home of the victims, witnessed by relatives or cohabitants during the nighttime period between 0 h and 8 h , would justify the lesser tendency towards ROSC, probably due to a lesser availability of people trained in life support or of medical resuscitation teams in this particular scenario.. The data referred to the time intervals between the alerting call, activation of the EMS team, and the time of care at the alert site coincide with those published elsewhere.
This fact, and the observation of a lesser ROSC rate in that same period, suggest that delays in processing the alert call, in activating the EMS team, and in providing care at the alert site could have an influencing effect, along with other factors such as the known lesser incidence of rhythms amenable to defibrillation in OHCA occurring in the home.
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Our study offers information on the EMS activation circuits in cases of OHCA and on the time variations in the appearance of the disorder and in the times to intervention. Such data can be used to analyze and project new strategies for dealing with OHCA; in this context, specific registries are absolutely necessary in our setting, 25 in order to confirm the results obtained.
Emphasis also should be placed on the need to implement the first two links in the survival chain. In Spain, the response system has been developed in a generalized manner through the EMS, offering demonstrated quality and competence. Lastly, regarding the limitations of the study, mention must be made of the lack of information on the previous health condition of the patients, the time interval between the event and the alert call dial , the performance or not of resuscitation maneuvers by the witnesses, patient survival and neurological condition at hospital discharge, and possible data introduction errors, and the observational and retrospective nature of the study..
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The authors declare no conflicts of interest.. Please cite this article as: Circadian rhythm and time variations in out-hospital sudden cardiac arrest. Design A retrospective descriptive study was made. Chronobiological analysis by fast Fourier transform and Cosinor testing. Results We studied cases reported between January and June Conclusions We have demonstrated the presence of a daily rhythm of emergence of OHCA with a morning peak and a weekly rhythm with a peak on Wednesdays.
These results can guide the planning of resources and improvements in response in certain time periods. Resultados Se estudiaron casos registrados entre enero y junio However, adequate application of all these measures requires knowledge of the true situation of OHCA, determination of the response times of the installed devices, and knowledge of when and where they can be found.
Inclusion and exclusion criteria In order to study the patients with out-hospital cardiac arrest of strongly suspected cardiological origin in which resuscitation attempts were made, we selected the cases with the following final diagnostic codes ICDCM: Patients under 18 years of age were excluded, as were those in which a non-cardiac cause was established, patients who had been dead for a prolonged period of time in which the time of death could not be established, cases involving a clear history of terminal or untreatable disease, and episodes with incomplete information or in which data could not be obtained from the witnesses to precisely establish an underlying cardiological cause.
Study variables An analysis was made of the following variables based on the Utstein model Statistical analysis A univariate comparative study was made using analysis of variance ANOVA and the nonparametric Kruskal—Wallis test for continuous variables and the chi-squared test in the case of categorical variables, comparing the different parameters with respect to the three 8-h time periods.
A comparative analysis was thus made between the harmonics of the cases with an outcome corresponding to ROSC and death. A similar time analysis was made of the distribution of cases during the days of the week, in search of a circaseptan rhythm. The final study sample thus comprised cases, the general characteristics of which are shown in Table 1.
General characteristics of the cases. Median with percentiles 25 and Comparisons according to the time period of out-hospital cardiac arrest. Distribution of median time intervals between the alert call dial and emergency team care. Distribution of median time intervals between activation of the emergency team and care at the alert site.
Case curve standardized distributed over the hours of the day. Distribution of cases during the days of the week. Case curves standardized and adjusted data of ROSC and death, distributed over the hours of the day. Med Intensiva, 27 , pp. Med Intensiva, 25 , pp. Presentation, management, and outcome of out of hospital cardiopulmonary arrest: Heart, 89 , pp. Heart disease and stroke statistics update: Circulation, , pp. Circadian variations in the occurrence of cardiac arrests: Circulation, 98 , pp. Circadian variation and triggers of onset of acute cardiovacular disease. Circulation, 4 , pp.
Circadian variation in the frequency of sudden cardiac death. Circulation, 1 , pp. Time is of the essence. Vascular implications of the circadian clock. Association of out-of-hospital cardiac arrest with prior activity and ambient temperature. Resuscitation, 82 , pp. Physical activity as a trigger of sudden cardiac arrest: Int J Cardiol, , pp. Diurnal, weekly and seasonal rhythm of out of hospital cardiac arrest in Sweden. Resuscitation, 54 , pp.
Diurnal, weekly and seasonal variation of sudden death. Eur Heart J, 21 , pp. Weekly variation of acute myocardial infarction increased Monday risk in the working population. Circulation, 90 , pp. Finally, it has been suggested recently that HVHF can act directly on the cellular level, restoring the immune function of monocytes and neutrophils..
It is important to note that along these potential beneficial effects, HVHF can also show serious side effects. It increases the losses of valuable molecules drugs, electrolytes, vitamins or trace elements , 20 forcing a close monitoring of their clearance, a control difficult to perform accurately in clinical practice. Other known risks after CEBPT anticoagulant-related hemorrhage, infection, embolism, hemodynamic intolerance have also been reported. Complex techniques such as HVHF can compromise patient safety by multiplying the risk of errors, that may also have amplified consequences important even in small time periods.
It is therefore essential the use of these therapies with a rigorous quality and safety control. HVHF has been proposed as a mean for organ support in CIP with high risk of death, regardless of renal function, as can be for instance septic shock, post-resuscitation syndrome, post-surgery cardiac shock, acute pancreatitis or acute liver failure, especially when a severe hemodynamic compromise and dependence on high doses of vasoactive drugs are present, the rational resting in the clearance of circulating inflammatory mediators already discussed.. Various animal studies 47,48 have shown that HVHF decreases the plasma concentration of inflammatory mediators and improves hemodynamics and survival in sepsis and pancreatitis.
In some of them a dose—response relationship was found greater effectiveness at higher doses and frequent changes of filter and also a relationship with the membrane used polyacrylonitrile being found more effective than polysulfone. Nonetheless these studies should be interpreted cautiously because of the difficulty in translating results of animal studies to the clinical practice.
Many preliminary clinical studies have shown potential benefits with different techniques when comparing high versus conventional dose hemofiltration; however, these studies have considerable methodological problems.. In line with the initial animal studies on the usefulness of HVHF for severe systemic inflammation, 47,48 Journois et al. Nonetheless, experimental and preliminary clinical studies suggest that this technique can improve organ dysfunction and hemodynamics in septic shock and other clinical situations.. There are several other available studies that show positive results with the use of HVHF as a rescue therapy in severe sepsis and septic shock:.
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In a later study from Joannes-Boyau et al. More recently, Piccinni et al. Some other authors have proposed including HVHF in the management of patients in refractory septic shock, in order to stabilize the hemodynamic status and our group has proposed a similar algorithm 57 Fig. HVHF management algorithm in unstable critically ill patients. Extracorporeal blood purification therapies.. The study was conducted in 18 ICUs in France, Belgium and the Netherlands, looking for the impact of such therapy on mortality at 28 days.
The results of this study, and a recent meta-analysis based primarily on this study 59 show a lower than expected mortality in both groups In a study by Jiang et al. A similar benefit was found in the early treatment group. Meanwhile, the group of Zhu et al. Oddly enough, no hemodynamic benefit was demonstrated.. The similarities detected in MODS after recovered cardiac arrest with that of the sepsis patient motivated a randomized clinical trial to assess the usefulness of HVHF 62 in this setting. In this study, three groups were defined: Some promising studies have been conducted on the role of HVHF on patients with severe trauma or major burns 63,64 an also on patients in shock after cardiac surgery, but in this last population, the HEROICS study 65 have shown negatives results.
Although no differences in mortality or duration of mechanical ventilation were detected, patients under HVHF showed a faster correction of metabolic acidosis and a tendency toward fastest reversal of shock, but also had more often hypophosphatemia, thrombocytopenia and metabolic alkalosis.. In addition to HVHF, other forms of blood purification can be helpful: These techniques are promising, but nowadays they are still experimental. Future research should address both the understanding of the pathophysiology of severe inflammatory conditions along the effect of the different modalities of blood purification, besides the development and application of technical improvements and a greater attention to their safety..
In children, the most common indication for CEBPT is fluid overload resistant to diuretics early indication, anticipatory and more specifically, although uncommon, a blood purification indication in the context of inborn errors of metabolism hyperammonemia and organic acidemia , 66—68 which are more efficiently purified by CEBPT than by peritoneal dialysis.. The use of CEBPT in younger children differs significantly from adults because of the amount of blood that remains in the extracorporeal circuit designed for adult size. Vascular access and blood flows. These flows demand the use of a vascular access size of at least 6.
When using regional anticoagulation strategies it is possible to maintain flows in the lower range without these concerns. Selection of the filter in relation to weight Table 4. Although the extracorporeal circuits and filters try to adapt to pediatric size, they remain inadequate for the smallest patients.
CEBPT filters used in pediatrics.. Children lose heat more easily due to their greater body surface area in relation to their weight. This loss is increased by their diminished ability to compensate for it and is markedly enlarged by the oversized extracorporeal circuit when they are on CEBPT, so that the use of the heater is mandatory. It is usually placed in the return line but sometimes it is necessary to place another one in the input line. It is also possible to heat the fluids, but it is only effective for higher flows..
The amount of blood flow that remains in the extracorporeal circuit predisposes children to hypotension, hemodilution, and a high risk of cardiac arrest, especially in newborns and unstable infants at the time of connection, and principally when the priming volume of the circuit is discarded. Second priming with packed red blood cells is not recommended because of the risk of bradykinin release syndrome..
The volume of distribution of water-soluble drugs is higher in children than in adults because of significant changes in extracellular volume occurring in the first years of life. There are also differences in plasma protein binding and renal clearance of different drugs by age.
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Nevertheless, it may be corrected using phosphorus-enriched solutions. Blood transfusion is usually needed in newborns and small infants whenever blood clots in the system. This miniaturized machine could represent a significant improvement for CEBPT in neonates and young infants, although more studies are needed to validate it..
All authors have actively participated in the preparation of the article. Correspondence author has made the final editing of the manuscript. All authors have approved the final version of the article.. None, for all authors. Possible sources of funding have not been involved in the study design, data collection and in drafting the manuscript. Our acknowledgment to all members of the working group who contributed to this work: We also thank the people who have helped us in translating the manuscript..
Previous article Next article. October Pages Blood purification in the critically ill patient. Prescription tailored to the indication including the pediatric patient. Sanchez-Izquierdo Riera a ,. This item has received. Show more Show less. We review the possible indications of this technique, together with the peculiarities of implementing these therapies in children. Not Graded - When deciding on the initiation of an EBPT, the clinical context for each individual case must be taken into consideration as well as lab-test trends and how these can be modified by the EBPT, instead of a fixed value for a specific blood marker i.
AKI is a dynamic process that requires a dynamic approach. We propose to begin the EBPT if any of the following criteria are met: APE; Uremia; severe acidosis. Studies on dose have not taken into consideration the dynamic nature of AKI. Regardless of the chosen dose, we must monitor its effect and adjust accordingly. Extracorporeal blood purification therapies.
CEBPT filters used in pediatrics. We also thank the people who have helped us in translating the manuscript. Med Intensiva, 30 , pp. A randomized, controlled trial of early versus late initiation of dialysis. N Engl J Med, , pp. Med Intensiva, 19 , pp. Continuous renal replacement therapy: Int Care Med, 33 , pp. KDIGO clinical practice guidelines for acute kidney injury. Kidney Int Suppl, 2 , pp. Nephrol Dial Transplant, 28 , pp. A comparison of early versus late initiation of renal replacement therapy in critically ill patients with acute kidney injury: Crit Care, 15 , pp.
Timing of renal replacement therapy initiation by AKIN classification system. Crit Care, 17 , pp. Comparison of standard and accelerated initiation of renal replacement therapy in acute kidney injury. Kidney Int, 88 , pp. Earlier-start versus usual-start dialysis in patients with community-acquired acute kidney injury: Am J Kidney Dis, 62 , pp. Renal replacement therapy in acute kidney injury: Crit Care, 19 , pp. Plasma neutrophil gelatinase-associated lipocalin predicts recovery from acute kidney injury following community-acquired pneumonia. Kidney Int, 80 , pp. Urinary biomarkers and renal recovery in critically ill patients with renal support.
Clin J Am Soc Nephrol, 6 , pp. Development and standardization of a furosemide stress test to predict the severity of acute kidney injury.
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Comparison of two strategies for initiating renal replacement therapy in the intensive care unit: Trials, 16 , pp. Impact on mortality of the timing of renal replacement therapy in patients with severe acute kidney injury in sEBPTic shock: Trials, 15 , pp. Discontinuation of continuous renal replacement therapy: Crit Care Med, 37 , pp.
Intensity of renal support in critically ill patients with acute kidney injury. Handling continuous renal replacement therapy-related adverse effects in intensive care unit patients: Blood Purif, 34 , pp. Nephrology Carlton , 19 , pp. Fluid overload in critically ill patients with acute kidney injury. Blood Purif, 29 , pp. Curr Opin Crit Care, 13 , pp. Acute decompensated heart failure and the cardiorenal syndrome.
Crit Care Med, 36 , pp.
Kidney Int, 51 , pp. JACC, 46 , pp. Ultrafiltration versus intravenous diuretics for patients hospitalized for acute decompensated heart failure.
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J Am Coll Cardiol, 49 , pp. DIureticS on clinical, biohumoral and haemodynamic variables in patients with deCOmpensated heart failure: Eur J Heart Fail, 13 , pp. Ultrafiltration in decompensated heart failure with cardiorrenal syndrome. Improved cardiovascular stability during continuous modes of renal replacement therapy in critically ill patients with acute hepatic and renal failure.
Crit Care Med, 21 , pp. Poisonings and overdoses in the intensive care unit: Crit Care Med, 31 , pp. Extracorporeal treatment for metformin poisoning: Crit Care Med, 43 , pp. Management of metformin-associated lactic acidosis by continuous renal replacement therapy. Lactic acidosis treated with continuous hemodiafiltration and regional citrate anticoagulation. Crit Care Med, 20 , pp. Continuous renal replacement therapy in the intensive care unit. Int Care Med, 25 , pp. Treatment by continuous renal replacement therapy in patients with burns injuries. Acta Chir Plast, 43 , pp.
Intracranial pressure fluctuation during hemodialysis in renal failure patients with intracranial hemorrhage. Acta Neurochir Suppl, , pp. Acute kidney injury following cardiac surgery: Eur J Cardiothorac Surg, 35 , pp. Kidney Int, 53 , pp. The first international consensus conference on continuous renal replacement therapy. Kidney Int, 62 , pp. Report of the working party on high volume hemofiltration including definitions and classification. High-volume hemofiltration in the intensive care unit: Anesthesiology, , pp.