Objective:Acute myocardial infarction (AMI) secondary to acute gastrointestinal bleeding (AGIB) is a common severe condition in emergency department. Currently, there is a lack of sufficient data regarding the use of emergency endoscopy in patients suffering from acute gastrointestinal bleeding (AGIB) complicated with acute myocardial infarction (AMI). The objective of this study is to examine the present status, effectiveness, and safety of emergency endoscopy in such patients, and to determine the factors that influence clinicians' decision-making regarding the use of emergency endoscopy.Methods:Clinical data of AGIB patients complicated with AMI who were admitted to the emergency department of the First Affiliated Hospital of Nanjing Medical University from January 2020 to June 2023 were respectively collected. Based on their survival status at discharge, patients were categorized into survival and non-survival groups. Additionally, according to whether emergency endoscopy was performed, patients were further classified into the emergency endoscopy group and the conventional treatment groupStabilized inverse probability of treatment weighting (SIPTW) and logistic regression analysis were used to explore the correlation between emergency endoscopy and prognosis. A paired wilcoxon test was used to analyze whether emergency endoscopy could worsen myocardial injury. A multiple logistic regression model was used to explore the factors influencing clinicians to make emergency endoscopic decisions.Results:A total of 106 patients with AMI secondary to AGIB were included, and 22 patients underwent emergency endoscopy. After weighing, logistic regression analysis showed that emergency endoscopy was a protective factor for patients' survival after discharge ( OR = 0.808, 95% CI: 0.6755-0.967, P = 0.022). In the emergency endoscopy group, there was no significant change in hypersensitive troponin T before and after emergency endoscopy [ 61.1 (35.4, 164.1) ng/L vs 69.8 (60.1, 159.5) ng/L, P = 0.078]. Previous history of coronary heart disease ( OR = 0.098, 95% CI: 0.015-0.381, P = 0.003) was an independent negative factor for emergency endoscopic decision-making. Glasgow Blatchford Score (GBS) on admission ( OR = 1.217, 95% CI: 1.019-1.482, P = 0.038) was an independent positive factor for emergency endoscopic decision-making. Conclusions:Emergency endoscopy is safe and effective in patients with AMI secondary to AGIB. GBS score and previous history of coronary heart disease were the main factors affecting emergency endoscopic decision-making.

Objective:To summarize the experience and effect of extracorporeal cardiopulmonary resuscitation (ECPR) in acute myocardial infarction (AMI) with in-hospital cardiac arrest (IHCA).Methods:The data of 70 patients with AMI-IHCA-ECPR in extracorporeal life support center of the first affiliated hospital of Nanjing medical university from January 2017 to December 2024 were retrospectively analyzed. The patients were grouped by Survival/death at 90 days, with/without combined intra-aortic balloon pump (IABP). Age, sex, Charlson comorbidity index, initial rhythm, Gensini score, ECPR initial blood gas pH and lactate value, no-flow time, time from cardiac arrest to extracorporeal membrane oxygenation (ECMO) initiation (CA-Pump On time), ECMO treatment time, 90-day survival rate were analyzed.Results:Among the 70 patients with AMI-IHCA-ECPR, 22 (31.4%) patients survived at 90 days, of whom 19 (86.4%) patients had good neurological outcomes. About 50% of AMI-IHCA-ECPR patients had severe multi-vessel coronary artery lesions, and there was no significant difference in survival outcomes among different vascular lesions. In the IABP group, the success rate of ECMO withdrawal was low, the duration of ECMO treatment was long, and the combination of IABP did not reduce the mortality. Compared with the death group, the 90-day survival group had a lower Gensini score, a higher ECPR initial blood gas pH and a lower lactic acid value.Conclusions:AMI-IHCA-ECPR combined with IABP did not show significant survival benefits, and about 50% of patients had severe lesions of multiple coronary arteries. It is difficult to evaluate the prognosis based on a single offender vessel. It is recommended to evaluate the outcome of patients by quantification of the severity of coronary artery lesions by Gensini score.

Objective:To summarize the experience and effect of extracorporeal cardiopulmonary resuscitation (ECPR) on the treatment of sudden cardiac death (SCD).Methods:The data of 120 adults with SCD-ECPR in emergency department of the first affiliated hospital of Nanjing Medical University from April 2015 to April 2023 were retrospectively analyzed. The patients were grouped by Survival/death at 90 days, OHCA/IHCA (out-of-hospital/in-hospital cardiac arrest), with/without acute myocardial infarction (AMI) and divided according to 60 min of the time from cardiac arrest to extracorporeal membrane oxygenation (ECMO) initiation (CA-Pump On time). Age, sex, Charlson comorbidity index, IHCA/OHCA, initial rhythm, no-flow time, CA-Pump On time, ECMO evacuation success rate, 90-day survival rate, ECMO treatment time were analyzed.Results:①Total of 114 adult patients with SCD-ECPR were enrolled, and 45 (39.5%) patients survived at 90 days, of whom 40 (88.9%) patients had good neurological outcomes.②Age and no-flow time were significantly lower in the 90-day survival group than that in death group, and the proportion of IHCA and shockable initial rhythm was higher. ③The no flow time in IHCA group was significantly lower than that in OHCA group, and the 90-day survival rate was higher. ④OHCA and regional interhospital transport prolonged CA-Pump On time and reduced the 90-day survival rate. ⑤The AMI group was older with a higher Charlson comorbidity index, and the 90-day survival rate was significantly lower than that in non-AMI group.Conclusions:ECPR improves the prognosis of patients with SCD, there are high benefits in patients with long healthy life expectancy, IHCA, shockable initial rhythm, and short no flow time. The smooth life-saving chain of SCD-ECPR improves survival rate, by screening high benefit candidates in patients with OHCA, delayed initiation of ECPR or requiring interhospital transport, despite CA-Pump On time > 60 min, there is still survival potential.

Objective:To investigate the major adverse kidney events (MAKE) in acute myocardial infarction (AMI) with extracorporeal cardiopulmonary resuscitation (ECPR).Methods:The data of 75 patients with AMI-ECPR in Emergency Medicine Department of the First Affiliated Hospital of Nanjing Medical University from April 2015 to April 2023 were retrospectively analyzed. The patients were grouped by survival/death at 90 days, with/without renal replacement therapy (RRT), and whether to initiate RRT because of acute kidney injury (AKI). age, sex, Charlson comorbidity index, OHCA/IHCA (out-of-hospital/in-hospital cardiac arrest), initial rhythm, Gensini score, ECPR initial blood gas pH and lactate value, no-flow time, time from cardiac arrest to extracorporeal membrane oxygenation (ECMO) initiation (CA-Pump On time), ECMO and RRT treatment time, 90-day survival rate were analyzed. Moreover, the renal function of the survivors was followed up.Results:① Total of 68 AMI-ECPR patients were enrolled, 22 (32.4%) patients survived at 90 days, 54 (79.4%) combined with RRT, and 48 (70.6%) MAKE within 90 days. ②Compared with the death group, the 90-day survival group had a higher proportion of initial shockable heart rhythm, a lower Gensini score, a higher ECPR initial blood gas pH and a lower lactic acid value. ③The severity of coronary artery disease, ECPR initial acidosis and hyperlactacemia in the RRT group was significantly higher than that in the non-RRT group, and all the non-RRT group patients survived. ④ There was no difference between the AKI-RRT group and the non-AKI-RRT group. Of 21 patients with stage 1 AKI initiating RRT, 5 survived, one of them still needs RRT for 90 days, and 7 patients with stage 2 to 3 AKI initiating RRT died.Conclusions:The 90-day MAKE rate in AMI-ECPR patients was as high as 70.6%, and the 90-day renal insufficiency rate in AMI-ECPR survivors with AKI was as high as 20.0%. Active initiation of RRT to avoid AKI or early initiation of RRT may improve the prognosis of AMI-ECPR patients.

Objective:To investigate the time characteristics from extracorporeal cardiopulmonary resuscitation (ECPR) initiation to termination.Methods:The data of ECPR patients in extracorporeal life support center of the First Affiliated Hospital of Nanjing Medical University from April 2015 to October 2023 were retrospectively analyzed. The patients were grouped by survival/death at 90 days, in-hospital/out-of-hospital cardiac arrest (IHCA/OHCA), daytime/evening initiation, and procedural/non-procedural termination. Data on age, sex, Charlson comorbidity index, interhospital transport, initial rhythm, ECPR initial blood gas pH and lactate value, no-flow time, time from cardiac arrest to extracorporeal membrane oxygenation (ECMO) initiation (CA-Pump On time), ECPR initiation/termination and ECMO treatment time, 90-day survival rate and so on were analyzed.Results:200 ECPR patients were enrolled, the cardiogenic etiologies were accounted for 70.5%, more men than women, 68 (34.0%) patients survived at 90 days, of whom 61 (89.7%) patients had good neurological outcomes. The 90-day survival group had a significantly lower of no-flow time, a higher proportion of IHCA and initial shockable heart rhythm, with a higher ECPR initial blood gas pH and a lower lactic acid value than those in the death group. 3. The no flow time in OHCA group was significantly longer than that in IHCA group, with a lower ECPR initial blood gas pH and a higher lactic acid value, 77.4% were non-procedural termination and the 90-day survival rate was 16.1%. ECPR were initiated in all time periods, IHCA-ECPR initiated at random, OHCA-ECPR were rare in the early morning, and the initiation time had no significant effect on ECPR outcomes. There were 75.5% of ECPR terminated at the daytime, 56.8% death cases were occurred within 3 days after ECPR, and 19.0% of patients in the procedural termination group died due to a combination of factors.Conclusions:ECPR had a potentially high benefit for patients with IHCA, initial shockable rhythm, and a short no-flow time. The ECPR initiation time were irregular and had no effect on ECPR outcomes. Death events tend to occur in the early days after ECPR, and ECPR terminated is mostly during the daytime working hours. The construction of full-time ECPR team should be strengthened.

Objective:To evaluate the prognostic value of coagulofibrinolytic changes in survivors of adult extracorporeal cardiopulmonary resuscitation (ECPR) in Chinese.Methods:133 cardiac arrest (CA) patients whose blood samples were collected after establishment of extracorporeal membrane oxygenation between January 2018 and April 2023 in Emergency Department of the First Affiliated Hospital of Nangjing Medical University were enrolled in this single-center study. The following were examined: platelet counts (PLT), prothrombin time (PT), activated partial thrombin time (APTT), thrombin time (TT), fibrinogen (Fib), and D-dimer (D-D). The prognostic values of these coagulation-related indicators in predicting poor outcomes (Cerebral Performance Category 3-5) were analyzed.Results:Among the 133 patients involved, 96 (72.2%) had poor outcomes after ECPR treatment. In the poor-outcome group, PLT and Fib were significantly decreased, while PT and APTT were significantly prolonged (all P < 0.05). ECPR survivors had a significantly higher risk of poor neurological outcomes in the high-level group than those in the low-level group for PT ( HR=1.87, 95% CI:1.17-2.99, P=0.009), APTT ( HR=1.95, 95% CI:1.26-3.00, P=0.003), and D-D levels ( HR=5.18, 95% CI:2.06-13.03, P<0.001). The risk of poor neurological outcomes was significantly lower in the high-level group for PLT ( HR=0.55, 95%CI:0.35-0.84, P=0.007). Conclusion:Coagulofibrinolytic changes can be promising tools to assess poor neurological outcomes in adult ECPR survivors.

Objective:To observe the effects of early energy intake and early enteral nutrition on prognosis of patients during extracorporeal membrane oxygenation (ECMO).Methods:Patients who received ECMO treatment in the emergency intensive care unit (EICU) of the Jiangsu Provincial Hospital (First Affiliated Hospital of Nanjing Medical University) from January 2021 to June 2022 were selected as subjects to summarize the early energy intake of ECMO patients. Logistic regression analysis and restricted cubic spline (RCS) analysis were used to determine the relationship between early energy intake and prognosis of ECMO patients. According to the results of RCS analysis, the patients were divided into energy-deficient group and energy-sufficient group. And according to whether early enteral nutrition (EEN) was initiated, the patients were divided into EEN group and non-EEN group. The differences of clinical outcomes between energy-deficient group and energy-sufficient group, EEN group and non-EEN group were compared.Results:There was no significant difference in age, sex, BMI, primary disease and ECMO pattern between energy-deficient group and energy-sufficient group, EEN group and non-EEN group. The ECMO conversion time (days) and hospitalization time (days) in the energy-deficient group were significantly lower than those in the energy-sufficient group, and the survival rate in the energy-deficient group was significantly lower than that in the energy-sufficient group [43.2% (19/44) vs. 66.0% (31/47), P=0.029]. Kaplan-Meier survival analysis showed that the 28-day survival rate in the energy-deficient group was significantly lower than that in the energy-sufficient group, and the risk of death was 2.595 times higher than that in the energy-sufficient group. The conversion time (days), hospital stay (days) and average daily energy intake [kcal/(kg·d)] in the EEN group were higher than those in the non-EEN group ( P<0.05), and the survival rate in the non-EEN group was significantly higher than that in the non-EEN group [66.1% (41/62) vs. 31.0% (9/29), P<0.002]. Kaplan-Meier survival analysis showed that the 28-day survival rate in the non-EEN group was significantly lower than that in the EEN group, and the risk of death was 2.981 times higher than that in the EEN group ( P<0.001). Conclusions:The energy intake of patients with ECMO above 16.94 kcal/ (kg·d) is a protective factor for prognosis. EEN helps to increase early energy intake and improve prognosis in patients during ECMO.

Objective:To evaluate the prognostic value of serum levels of neuron-specific enolase (NSE) and S-100b in extracorporeal cardiopulmonary resuscitation (ECPR) patients.Methods:Cardiac arrest (CA) patients whose blood samples were collected at 24 h, 48 h and 72 h after establishment of extracorporeal membrane oxygenation between April 2021 and April 2024 in Emergency Department of the First Affiliated Hospital of Nanjing Medical University were enrolled in this single-center study. The serum levels of NSE and S-100b were measured, and their peak values within 72 h were used for further analysis. The neuro-prognostic values of these two indicators in predicting poor outcomes (Cerebral Performance Category 3-5) were analyzed.Results:Among the 110 patients involved, 81 cases(73.6%) were poor outcomes after ECPR treatment. In the poor-outcome group, serum peak levels of NSE and S-100b were significantly increased ( P < 0.05). Furthermore, the poor-outcome group was divided into CPC 3-4 group and CPC 5 group. The levels of NSE and S-100b in CPC 5 group were significantly higher than those in CPC 1-2 and 3-4 groups ( P < 0.05). NSE levels were significantly lower in CPC 1-2 group than in CPC 3-4 group ( P = 0.048), while no significant differences of S-100b levels were found between the two groups ( P = 0.143). Multivariate logistic regression analysis showed that NSE was an independent risk factor for poor outcomes in ECPR patients ( OR = 1.047, 95% CI: 1.018~1.077, P = 0.001). ROC curve showed that peak levels of NSE ( AUC = 0.843, 95% CI: 0.770~0.915, P < 0.001) and S-100b ( AUC =0.822, 95% CI: 0.739~0.905, P < 0.001) within 72 h had predictive value for poor outcomes in ECPR patients, with optimal cut-off values of 60.14 μg/L and 0.195 μg/L, respectively. Conclusions:The serum peak levels of NSE and S-100b within 72 h after ECMO establishment in ECPR patients are correlated with poor neurological outcomes.

Objective:To explore the prognostic value of survival after veno-arterial ECMO (SAVE) score combined with 24-h lactate on the machine in patients with extracorporeal cardiopulmonary resuscitation (ECPR).Methods:Totally 59 patients treated with ECPR in the Emergency Department of the First Affiliated Hospital of Nanjing Medical University from April 2017 to June 2021 were retrospectively analyzed. According to the 28-day prognosis, the patients were divided into the death group ( n=36) and the survival group ( n=23). The differences in baseline data were analyzed, and multivariate logistic regression was performed to identify the influencing factors of 28-day mortality in patients with ECPR. The receiver operating characteristic (ROC) curve was applied to evaluate the predictive value of SAVE score, 24-h lactate and their combined detection for predicting 28-day mortality risk in patients with ECPR. Results:The 28-day survival rate of patients with ECPR was 39% (23/59). SAVE score of the death group was significantly lower than that of the survival group (-11.67±4.60 vs. -2.43±4.77, P<0.001), and the 24-h lactate in the death group was significantly higher than that in the survival group [5.94 (3.37, 12.40) mmol/L vs. 1.65 (1.07, 3.15) mmol/L, P<0.001]. Multivariate logistic regression analysis showed that SAVE score ( OR=0.703, 95% CI: 0.566-0.873, P=0.001) and 24-h lactate ( OR=1.608, 95% CI: 1.025-2.523, P=0.039) were independent influencing factors of 28-day mortality in ECPR patients. ROC curve analysis showed that the best cut-off value of SAVE score was -6, the sensitivity was 78.30% and specificity was 91.70%. The best cutoff value of 24-h lactate was 4.7 mmol/L, the sensitivity was 63.90% and specificity was 100.00%. The sensitivity and specificity of the combined detection of SAVE score and 24-h lactate were 82.60% and 100.00%, respectively. The area under the curve (AUC) of SAVE score combined with 24-h lactate for predicting the 28-day mortality risk in patients with ECPR was larger than that of SAVE score and 24-h lactate alone (0.952 vs. 0.917; 0.952 vs. 0.847). Conclusions:Lower SAVE score and higher 24-h lactate are independently risk factors of 28-day mortality in patients with ECPR, and SAVE score combined with 24-h lactate on the machine has a good predictive value for the prognosis of patients with ECPR.

Objective:To investigate the clinical significance of the acute physiology and chronic health evaluationⅡ (APACHEⅡ) combined with different systematic inflammation markers (SIMs) including neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR)-in adult patients with venous-arterial extracorporeal membrane oxygenation (VA-ECMO).Methods:A total of 89 adult patients with VA-ECMO ( ≥ 3 d) in the Emergency Department of Jiangsu Provincial People's Hospital from January 2017 to June 2020 were retrospectively analyzed. Patients were divided into two groups: survivors ( n=39) and non-survivors ( n=50). The baseline APACHE Ⅱscore and PLR, NLR, LMR before ECMO implantation and at 1, 2, 3 day after ECMO were recorded. Binary logistic regression was used to analyze the risk factors of 28-day mortality in patients with VA-ECMO. The utility of APACHEⅡ score and SIMs alone or combination for predicting clinical prognosis was evaluated using receiver operating characteristic (ROC) curve analysis. The patients were divided into the high risk group and the low risk group according to the best cut-off value, and the difference of ECMO-related complications between the two groups was compared. Results:When combined APACHEⅡ score with SIMs, APACHEⅡ + PLR 48 h + LMR 24 h + LMR 72 h demonstrated the greatest predictive ability with an AUC of 0.833. Compared with the high-risk group, the low-risk group has a lower incidence of acute renal injury, infection, bleeding complications, the use of continuous renal replacement therapy, mechanical ventilation, and a higher hospital survival rate.Conclusions:The combination of APACHEⅡ score and SIMs-PLR, LMR- is better than a single one for death prediction, and it is expected to be a new predictive model for early identification of the risk of death or poor prognosis in patients with VA-ECMO.