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The zoll catheter was not returned for investigation.Therefore, a physical investigation could not be performed.A supplemental report will be filed if the product is returned and investigation has been completed.Medical safety assessments: the use of endovascular cooling catheters was associated with a higher risk of venous catheter-related thrombosis compared with standard central venous catheters, with potential severe complications, including death.Given the lack of survival benefit provided by this device, the risk-benefit ratio and costs of using systematic endovascular cooling catheters instead of other methods should therefore be carefully appraised.Additionally, endovascular cooling catheters should be promptly removed at the end of the ttm period, and a new standard central venous catheter inserted if central venous access is still required, ideally in the subclavian vein.Whether the risk of thrombosis depends only on the catheter device or on the biological changes induced by hypothermia and cardiac arrest remains to be investigated.Cardiac arrest and thrombotic complication.This was a resuscitated post cardiac arrest (ca) patient.It is known that in such patient population blood flow is compromised and inflammatory status is high, which may lead to development of thrombotic complications.Disseminated vascular endothelium damages explain that this phenomenon of ischemia-reperfusion evolves toward systemic inflammation: production of cytokines (il-1, il-6, il-8, tnf-[?]), complement activation, synthesis of metabolites of arachidonic acid, expression of leukocyte adhesion molecules by endothelial cells are all stimuli for activation, and chemotaxis of polymorphonuclear neutrophils at the origin of the inflammatory response.Sequestration of activated neutrophils in the lungs and other organs is a major engine for development of multiple organ failure.It is plausible that infectious lesions of digestive origin are involved, in relation to bacterial translocation from altered gastrointestinal mucosa.It would explain the high levels of plasma endotoxin observed in the most critically ill patients.This activation of the systemic inflammatory response associates with changes in coagulation, generating secondary endothelial damage, in turn responsible for thrombosis and increased capillary permeability [adrie c, adib-conquy m, laurent i, monchi m, vinsonneau c, fitting c, fraisse f, dinh-xuan at, carli p, spaulding c, dhainaut jf, cavaillon jm.Successful cardiopulmonary resuscitation after cardiac arrest as a "sepsis-like" syndrome.Circulation.2002;106:562-568.} nicolas mongardon et all described that the prognosis for postcardiac arrest patients remains very bleak, not only because of anoxic-ischemic neurological damage, but also because of the "postcardiac arrest syndrome," a phenomenon often severe enough to cause death before any neurological evaluation.This syndrome includes all clinical and biological manifestations related to the phenomenon of global ischemia-reperfusion triggered by cardiac arrest and return of spontaneous circulation.The main component of the postcardiac arrest syndrome is an early but severe cardiocirculatory dysfunction that may lead to multiple organ failure and death.[postcardiac arrest syndrome: from immediate resuscitation to long-term outcome in ann intensive care.2011; 1: 45].Cardiovascular support relies on conventional medical and mechanical treatment of circulatory failure.Hemodynamic stabilization is a major objective to limit secondary brain insult.When the cause of cardiac arrest is related to myocardial infarction, percutaneous coronary revascularization is associated with improved prognosis; early angiographic exploration should then be discussed when there is no obvious extracardiac cause.Therapeutic hypothermia is now the cornerstone of postanoxic cerebral protection.Its widespread use is clearly recommended, with a favorable risk-benefit ratio in selected population.Neuroprotection also is based on the prevention of secondary cerebral damages, pending the results of ongoing therapeutic evaluations regarding the potential efficiency of new therapeutic drugs.The postcardiac arrest shock, initially described by negovsky in 1975, is a mixed shock, with cardiogenic and vasodilatory components [2] and is characterized by a severe but reversible systolic dysfunction.Left ventricular dysfunction usually begins early, within minutes after rosc, and is completely reversible within 48 to 72 hours.It takes the form of myocardial systolic and diastolic dysfunctions, even in the absence of coronary cause.Obviously, this has to be distinguished from the focal hypocontractility caused by a coronary thrombosis, which evolves on its own.The circulatory failure might also be favored by the occurrence of relative adrenal insufficiency, as observed during septic shock: clinical data show that approximately half of patients have relative adrenal insufficiency similar to what can be observed in septic shock.Among these patients, shock-related deaths seem to be more frequent in the group of those with adrenal insufficiency [12].[laurent i, monchi m, chiche jd, joly lm, spaulding c, bourgeois b, cariou a, rozenberg a, carli p, weber s, dhainaut jf.Reversible myocardial dysfunction in survivors of out-of-hospital cardiac arrest.J am coll cardiol.2002;40:2110-2116.[pubmed]; pene f, hyvernat h, mallet v, cariou a, carli p, spaulding c, dugue ma, mira jp.Prognostic value of relative adrenal insufficiency after out-of-hospital cardiac arrest.Intensive care med.2005;31:627-633.[pubmed].Asymptomatic thrombi in vein in studied post cardiac arrest patients, presence of which was reported in this article, could potentially lead to pe in such patient population.It is known that in turn, that in rare cases pe can lead to acute respiratory distress.Event assessed as possibly related to the catheter even in this predisposed patient.Cerebral hemorrhage secondary to intravenous thrombolysis.Thrombolysis (thrombolytic therapy), is a treatment to dissolve dangerous clots in blood vessels using medication to improve blood flow, and prevent damage to tissues and organs.It is used in st elevation myocardial infarction, stroke, massive pulmonary embolisms, severe deep vein thrombosis, and acute limb ischemia.Article does not specify indication to administration of thrombolytic therapy in this patient as well as underlying clinical condition that led to cardiac arrest.It is known that the patient was resuscitated after cardiac arrest and admitted to the hospital for further treatment.Thrombolysis is not without risks, which physician should carefully considered.An absolute contraindication is in itself enough to avoid thrombolysis, while a relative contraindication needs to be considered in relation to the overall clinical situation.Contraindications for thrombolysis include: traumatic cardiopulmonary resuscitation within 3 weeks.Major surgery, trauma, or bleeding within 2 weeks.Any previous history of hemorrhagic stroke, ischemic stroke within 3 months.Transient ischemic attack within 6 months.History of stroke, dementia, or central nervous system damage within 1 year.Head trauma within 3 weeks or brain surgery within 6 months.Suspected aortic dissection.Internal bleeding within 6 weeks.Active bleeding or known bleeding disorder.Oral anticoagulant therapy.Intracardiac thrombi.Coma or severe obtundation with fixed eye deviation and complete hemiplegia.Patient having received a heparin medication within the last 48 hours and has an elevated activated prothrombin time (aptt) or has a known hereditary or acquired haemorrhagic diathesis.Age >80 years.Major surgery within the last 14 days (consider intra-arterial thrombolysis).Patient has a known history of intracranial haemorrhage, subarachnoid haemorrhage, known intracranial arteriovenous malformation or previously known intracranial neoplasm etc.There are also side-effects of thrombolytic therapy.The main complication is bleeding (which can be dangerous), and in some situations thrombolysis may therefore be unsuitable.Thrombolysis can also play an important part in reperfusion therapy that deals specifically with blocked arteries.Hemorrhagic stroke is a rare but serious complication of thrombolytic therapy, which this patient experienced.It was not specified in the article, what was a reason for administration of intravenous thrombolysis, how late after occurrence of pe the patient was treated with intravenous thrombolysis, if pe was resolved or not before that time.It is also not specified when pe occurred in relation to cooling procedure and if this patient had defined by ultrasonography-confirmed thrombosis at the catheter insertion site.With that, based on available information, event of cerebral hemorrhage secondary to intravenous thrombolysis is assessed as possibly related to pe in case it was administrated to treat condition of pe.Pe in term assessed as possibly related to asymptomatic thrombus i the patient's vein.At the same time, this patient was admitted after resuscitated cardiac arrest.Mortality rate is this population is high and it is possible was related to the patient's underling clinical condition.
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