Kees H Polderman

University of Pittsburgh, Pittsburgh, Pennsylvania, United States

Are you Kees H Polderman?

Claim your profile

Publications (131)1160.99 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Hypothermia (32-34°C) can mitigate ischemic brain injury, and some evidence suggests that it can reduce infarct size in acute myocardial infarction and acute ischemic stroke. For some indications, speed of cooling may be crucial in determining efficacy. We performed a multicenter prospective intervention study to test an ultrarapid cooling technology, the Velomedix Automated Peritoneal Lavage System using ice-cold fluids continuously circulating through the peritoneal cavity to rapidly induce and maintain hypothermia in comatose patients after cardiac arrest and a small number of awake patients with acute myocardial infarction. Multicenter prospective intervention study. Intensive care- and coronary care units of multiple tertiary referral centers. Access to the peritoneal cavity was gained using a modified blunt dilating instrument, followed by catheter placement. Patients were cooled to a temperature of 32.5°C, maintained for 24 hours (cardiac arrest) or 3 hours (acute myocardial infarction) followed by controlled rewarming. Forty-nine patients were enrolled, and 46 patients completed treatment. One placement was unsuccessful (abdominal wall not breached), two patients were ultimately not cooled, and only safety data are reported. Average catheter insertion time was 2.3 minutes. Mean time to temperature less than 33°C was 10.4 minutes (average cooling rate, 14°C/hr). Median infarct size in patients who had coronary interventions was 16% of LV. No cases of stent thrombosis occurred. Survival in cardiac arrest patients with initial rhythm of ventricular tachycardia/ventricular fibrillation was 56%, of whom 82 had a complete neurologic recovery. This compares favorably to outcomes from previous studies. Automated peritoneal lavage system is a safe and ultrarapid method to induce and maintain hypothermia, which appears feasible in cardiac arrest patients and awake patients with acute myocardial infarction. The shivering response appeared to be delayed and much reduced with this technology, diminishing metabolic disorders associated with cooling and minimizing sedation requirement. Our data suggest that ultrarapid cooling could prevent subtle neurologic damage compared with slower cooling. This will need to be confirmed in direct comparative studies.
    Critical care medicine 07/2015; DOI:10.1097/CCM.0000000000001158 · 6.15 Impact Factor
  • Kees H Polderman
    [Show abstract] [Hide abstract]
    ABSTRACT: Dozens of observational studies published over the past two decades have shown that fever in patients with acute neurologic injury, regardless of its cause, is independently linked to higher mortality, poor neurologic outcome, and increased length of stay in the intensive care unit (ICU) and hospital. This has been demonstrated for traumatic brain injury, acute ischemic stroke (AIS), subarachnoid haemorrhage, intracranial haemorrhage, and cardiac arrest (CA).(1,2) Therefore, therapeutic temperature management (TTM) is a key goal of care in all patients with acute brain injury. In most cases the goal is strict fever control, i.e. controlled normothermia; in patients with post-hypoxic injuries the goals is often to achieve below-normal core temperature, i.e. to induce therapeutic hypothermia (TH).
    Circulation 06/2015; DOI:10.1161/CIRCULATIONAHA.115.017350 · 14.95 Impact Factor
  • Kees H. Polderman, Joseph Varon, Paul E. Marik
    American Journal of Emergency Medicine 05/2015; DOI:10.1016/j.ajem.2015.05.015 · 1.15 Impact Factor
  • Kees H Polderman
    Intensive Care Medicine 05/2015; 41(6). DOI:10.1007/s00134-015-3798-x · 7.21 Impact Factor
  • Kees H Polderman
    Intensive Care Medicine 05/2015; DOI:10.1007/s00134-015-3842-x · 7.21 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Neuroprotective strategies that limit secondary tissue loss and/or improve functional outcomes have been identified in multiple animal models of ischemic, hemorrhagic, traumatic and nontraumatic cerebral lesions. However, use of these potential interventions in human randomized controlled studies has generally given disappointing results. In this paper, we summarize the current status in terms of neuroprotective strategies, both in the immediate and later stages of acute brain injury in adults. We also review potential new strategies and highlight areas for future research.
    Critical care (London, England) 04/2015; 19(1):186. DOI:10.1186/s13054-015-0887-8
  • [Show abstract] [Hide abstract]
    ABSTRACT: Dear Editor,We read with interest the paper by Zhang et al. [1] comparing hemodynamic management guided by transpulmonary thermodilution (PiCCO device) to central venous pressure (CVP) guidance. We congratulate the authors on tackling this issue in a randomized trial. However, in general, monitoring tools can improve outcomes only indirectly, through the therapeutic interventions based on the measurements obtained, while poor therapeutic decisions based on (mis-)interpreted data can cause harm.We have several concerns regarding this study.Patients with septic shock, septic shock with ARDS, and ARDS alone were enrolled. This is illogical; ARDS in non-septic patients requires completely different fluid management strategies.28-day mortality was 49.4 versus 49.5 % [1]. Although this meets APACHE-II score predictions, APACHE-II is 30 years old; actual mortality should be lower, as was the case in all major sepsis/ARDS trials performed since 2000. We have listed a number of trials enrolling ...
    Intensive Care Medicine 03/2015; 41(5). DOI:10.1007/s00134-015-3741-1 · 7.21 Impact Factor
  • Kees H Polderman, Joseph Varon
    [Show abstract] [Hide abstract]
    ABSTRACT: The targeted temperature management (TTM) trial, which found that cooling to 33°C after witnessed cardiac arrest (CA) conferred no benefits compared with 36°C, has led to much debate in the hypothermia community. This article discusses what lessons can be drawn. The TTM trial achieved far better outcomes in controls than any previous randomized controlled trial (RCT) or any nonrandomized study where no fever control was applied. On the other hand, rates of good outcomes in the hypothermia group were somewhat lower than in previous RCTs and most nonrandomized studies. The TTM authors conclude that benefits of temperature management are derived exclusively from fever control and that further lowering of temperature confers no benefit. Indeed, without doubt, the TTM trial demonstrates the crucial importance of strict fever control after CA and that this provides sufficient neuroprotection for some patients. However, we argue that the hypothermia intervention was executed suboptimally (possibly inadvertent selection bias; late start of cooling, up to 4 hours after ROSC; slow cooling rates, 10 hours to target temperature; more rapid rewarming than previous studies; and some other issues). This could explain high rates of good outcomes in controls and lower-than-expected rates in patients cooled to 33°C compared with previous randomized and nonrandomized studies. Outside of two previous RCTs, the use of hypothermia after CA is supported by hundreds of animal experiments, evidence from 46 before-after studies and large registries, and indirect supporting evidence from 7 RCTs in newborns with neonatal asphyxia. In addition, one RCT found improved outcomes with 32°C compared with 34°C. It remains to be explained why the TTM results so completely contradict previous studies in this field. These issues should be thoroughly discussed before changes in guidelines and protocols are made. Ending or modifying hypothermia treatment after CA should require the strongest possible evidence.
    03/2015; 5(2). DOI:10.1089/ther.2014.0031
  • Kees H Polderman, Joseph Varon
    Circulation 02/2015; 131(7):669-75. DOI:10.1161/CIRCULATIONAHA.114.012165 · 14.95 Impact Factor
  • Kees H. Polderman, Joseph Varon
    [Show abstract] [Hide abstract]
    ABSTRACT: Administering intravenous fluids to support the circulation in critically ill patients has been a mainstay of emergency medicine and critical care for decades, especially (but not exclusively) in patients with distributive or hypovolemic shock. However, in recent years, this automatic use of large fluid volumes is beginning to be questioned. Analysis from several large trials in severe sepsis and/or acute respiratory distress syndrome have shown independent links between volumes of fluid administered and outcome; conservative fluid strategies have also been associated with lower mortality in trauma patients. In addition, it is becoming ever more clear that central venous pressure, which is often used to guide fluid administration, is a completely unreliable parameter of volume status or fluid responsiveness. Furthermore, 2 recently published large multicenter trials (ARISE and ProCESS) have discredited the "early goal-directed therapy" approach, which used prespecified targets of central venous pressure and venous saturation to guide fluid and vasopressor administration. This article discusses the risks of "iatrogenic submersion" and strategies to avoid this risk while still giving our patients the fluids they need. The key lies in combining good clinical judgement, awareness of the potential harm from excessive fluid use, restraint in reflexive administration of fluids, and use of data from sophisticated monitoring tools such as echocardiography and transpulmonary thermodilution. Use of smaller volumes to perform fluid challenges, monitoring of extravascular lung water, earlier use of norepinephrine, and other strategies can help further reduce morbidity and mortality from severe sepsis. Copyright © 2015 Elsevier Inc. All rights reserved.
    American Journal of Emergency Medicine 02/2015; 33(3). DOI:10.1016/j.ajem.2015.01.051 · 1.15 Impact Factor
  • Kees H Polderman, Joseph Varon
    Critical Care Medicine 11/2014; 42(11):2452-4. DOI:10.1097/CCM.0000000000000600 · 6.15 Impact Factor
  • Kees H Polderman, Joseph Varon
    Resuscitation 08/2014; 85(8):975-6. DOI:10.1016/j.resuscitation.2014.06.002 · 3.96 Impact Factor
  • Resuscitation 05/2014; 85:S103. DOI:10.1016/j.resuscitation.2014.03.255 · 3.96 Impact Factor
  • Resuscitation 05/2014; 85:S105. DOI:10.1016/j.resuscitation.2014.03.260 · 3.96 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Therapeutic hypothermia (TH) is recommended to reduce ischemic brain injury after cardiac arrest. The variables that predict heat generation by patients receiving TH are uncertain, as is how this heat generation relates to neurologic outcome. We hypothesized that patient characteristics, medication use, inflammation, and organ injury would be associated with heat generation. We further hypothesized that neurologic outcome would be most strongly associated with heat generation. Surface and intravascular cooling devices were used to provide TH in 57 consecutive cardiac arrest patients. Device water temperatures during the maintenance (33°C) phase were collected. Patient heat generation was quantified as the "heat index" (HI), which was the inverse average water temperature over a minimum of 2 hours of maintenance hypothermia. Variables measuring reduced ischemic injury and improved baseline health were significantly associated with HI. After controlling for presenting rhythm, a higher HI was independently associated with favorable disposition (OR=2.2; 95% CI 1.2 to 4.1; P=0.014) and favorable Cerebral Performance Category (OR=1.8; 95% CI 1.0 to 3.1; P=0.035). Higher HI predicted favorable disposition (receiver-operator area under the curve 0.71, P=0.029). HI was linearly correlated with arteriovenous CO2 (r=0.69; P=0.041) but not O2 (r=0.13; P=0.741) gradients. In cardiac arrest patients receiving TH, greater heat generation is associated with better baseline health, reduced ischemic injury, and improved neurologic function, which results in higher metabolism. HI can control for confounding effects of patient heat generation in future clinical trials of rapid TH and offers early prognostic information.
    Journal of the American Heart Association 04/2014; 3(3):e000580. DOI:10.1161/JAHA.113.000580 · 2.88 Impact Factor
  • Source
    Kees H Polderman, Joseph Varon
    Critical care (London, England) 04/2014; 18(2):130. DOI:10.1186/cc13817
  • Joseph Varon, Kees Polderman
    New England Journal of Medicine 04/2014; 370(14):1358-9. DOI:10.1056/NEJMc1401250#SA6 · 54.42 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Amniotic fluid embolism (AFE) is one of the most catastrophic complications that can occur during pregnancy or in the immediate postpartum period, frequently complicated by profound shock and cardiovascular collapse as well as severe respiratory distress. Therapeutic hypothermia (TH) is now commonly used to improve neurological outcomes after various types of hypoxic injury and is widely used in the treatment of postanoxic injury after cardiac arrest (CA). To our knowledge, no studies have evaluated whether TH could be effectively used in AFE, and its use for this indication has not been described previously. We describe the case of a 32-year-old woman, who developed clinical manifestations of AFE and suffered a CA in the 29th week of her pregnancy. She received prolonged CPR (40 minutes until ROSC) and remained comatose. TH was induced and maintained for a total of 60 hours using an endovascular device, followed by controlled rewarming and maintenance of strict normothermia. The patient survived and was neurologically intact (CPC 1) at 6 months of follow up.
    03/2014; DOI:10.1089/ther.2013.0025
  • 03/2014; 4(1):3-7. DOI:10.1089/ther.2014.1502
  • Source
    Kees H Polderman
    [Show abstract] [Hide abstract]
    ABSTRACT: This article discusses the potential of levosimendan to treat calcium-induced myocardial dysfunction associated with deep hypothermia. Moderate hypothermia (30 to 34°C) usually improves myocardial contractility and stabilizes heart rhythm, but deep hypothermia can cause severe myocardial dysfunction, which is mediated by intracellular calcium overload. In experimental studies, levosimendan appears effective in reversing this. Clinical studies are needed to confirm these findings and to determine whether levosimendan could also be used for accidental hypothermia and perhaps to mitigate diastolic dysfunction under moderate hypothermia.
    Critical care (London, England) 12/2013; 17(6):1018. DOI:10.1186/cc13139

Publication Stats

5k Citations
1,160.99 Total Impact Points

Institutions

  • 2009–2015
    • University of Pittsburgh
      • Department of Critical Care Medicine
      Pittsburgh, Pennsylvania, United States
  • 2007–2009
    • Utrecht University
      Utrecht, Utrecht, Netherlands
  • 2006–2009
    • University Medical Center Utrecht
      • Intensive Care Centrum
      Utrecht, Utrecht, Netherlands
  • 1990–2008
    • VU University Amsterdam
      • Department of Adult Intensive Care
      Amsterdamo, North Holland, Netherlands
  • 2002–2007
    • VU University Medical Center
      Amsterdamo, North Holland, Netherlands
  • 2003
    • Academisch Medisch Centrum Universiteit van Amsterdam
      Amsterdamo, North Holland, Netherlands
  • 1999
    • University of Amsterdam
      Amsterdamo, North Holland, Netherlands