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Mhanna M, Al-Abdouh A, Sauer MC, Jabri A, Abusnina W, Safi M, Beran A, Mansour S. Hypothermia as an Adjunctive Therapy in Cardiogenic Shock: A Systematic Review and Meta-Analysis. Ther Hypothermia Temp Manag 2023; 13:160-169. [PMID: 37074118 DOI: 10.1089/ther.2023.0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023] Open
Abstract
In the setting of out-of-hospital cardiac arrest, therapeutic hypothermia (TH) has been shown to improve clinical outcomes. However, trials showing the advantage of TH did not include patients with cardiogenic shock (CS). We performed a comprehensive literature search for studies that evaluated the efficacy and safety of adjunctive TH compared with the standard of care (SOC) in patients with CS. The primary outcome was the mortality rate (in-hospital, short-, and mid-term). The secondary outcomes were the TH-related complications, duration of Intensive Care Unit (ICU) stay, duration of mechanical ventilation (MV-days), and improvement in cardiac function. Relative risk (RR) or the standardized mean difference (SMD) and corresponding 95% confidence intervals (CIs) were calculated using the random-effects model. A total of 7 clinical studies (3 RCTs included), and 712 patients (341 in the TH group and 371 in the SOC group) were included. As compared with the SOC, TH was not associated with a statistically significant improvement in the in-hospital (RR: 0.73%, 95% CI: 0.51-1.03; p = 0.08), short-term (RR: 0.90%, 95% CI: 0.75-1.06; p = 0.21), or mid-term (RR: 0.93%, 95% CI: 0.78-1.10; p = 0.38) mortality rates. Despite the improvement in the cardiac function in the TH group (SMD: 1.08, 95% CI: 0.02-2.1; p = 0.04), the TH strategy did not significantly shorten the MV days, or the ICU stay (p-values >0.05). Finally, there was a trend toward higher risks for infection, major bleeding, and the need for blood transfusion in the TH group. According to our meta-analysis of published clinical studies, TH is not beneficial in patients with CS and has a marginal safety profile. Larger-scale RCTs are needed to further clarify our results.
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Affiliation(s)
- Mohammed Mhanna
- Division of Cardiology, Department of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Ahmad Al-Abdouh
- Department of Internal Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Michael C Sauer
- Department of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Ahmad Jabri
- Department of Cardiology, Case Western Reserve University/MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Waiel Abusnina
- Division of Cardiology, Creighton University, Omaha, Nebraska, USA
| | - Mohammed Safi
- Department of Internal Medicine, The University of Toledo, Toledo, Ohio, USA
| | - Azizullah Beran
- Department of Gastroenterology, Indiana University, Indianapolis, Indiana, USA
| | - Shareef Mansour
- Division of Cardiology, Department of Medicine, University of Iowa, Iowa City, Iowa, USA
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Nielsen N, Friberg H. Changes in Practice of Controlled Hypothermia after Cardiac Arrest in the Past 20 Years: A Critical Care Perspective. Am J Respir Crit Care Med 2023; 207:1558-1564. [PMID: 37104654 DOI: 10.1164/rccm.202211-2142cp] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 04/26/2023] [Indexed: 04/29/2023] Open
Abstract
For 20 years, induced hypothermia and targeted temperature management have been recommended to mitigate brain injury and increase survival after cardiac arrest. On the basis of animal research and small clinical trials, the International Liaison Committee on Resuscitation strongly advocated hypothermia at 32-34 °C for 12-24 hours for comatose patients with out-of-hospital cardiac arrest with initial rhythm of ventricular fibrillation or nonperfusing ventricular tachycardia. The intervention was implemented worldwide. In the past decade, hypothermia and targeted temperature management have been investigated in larger clinical randomized trials focusing on target temperature depth, target temperature duration, prehospital versus in-hospital initiation, nonshockable rhythms, and in-hospital cardiac arrest. Systematic reviews suggest little or no effect of delivering the intervention on the basis of the summary of evidence, and the International Liaison Committee on Resuscitation today recommends only to treat fever and keep body temperature below 37.5 °C (weak recommendation, low-certainty evidence). Here we describe the evolution of temperature management for patients with cardiac arrest during the past 20 years and how the accrued evidence has influenced not only the recommendations but also the guideline process. We also discuss possible paths forward in this field, bringing up both whether fever management is at all beneficial for patients with cardiac arrest and which knowledge gaps future clinical trials in temperature management should address.
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Affiliation(s)
- Niklas Nielsen
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anesthesiology and Intensive Care, Helsingborg Hospital, Helsingborg, Sweden; and
| | - Hans Friberg
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anesthesiology and Intensive Care, Skåne University Hospital, Malmö, Sweden
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Abstract
OBJECTIVE Temperature abnormalities are recognized as a marker of human disease, and the therapeutic value of temperature is an attractive treatment target. The objective of this synthetic review is to summarize and critically appraise evidence for active temperature management in critically ill patients. DATA SOURCES We searched MEDLINE for publications relevant to body temperature management (including targeted temperature management and antipyretic therapy) in cardiac arrest, acute ischemic and hemorrhagic stroke, traumatic brain injury, and sepsis. Bibliographies of included articles were also searched to identify additional relevant studies. STUDY SELECTION English-language systematic reviews, meta-analyses, randomized trials, observational studies, and nonhuman data were reviewed, with a focus on the most recent randomized control trial evidence. DATA EXTRACTION Data regarding study methodology, patient population, temperature management strategy, and clinical outcomes were qualitatively assessed. DATA SYNTHESIS Temperature management is common in critically ill patients, and multiple large trials have been conducted to elucidate temperature targets, management strategies, and timing. The strongest data concerning the use of therapeutic hypothermia exist in comatose survivors of cardiac arrest, and recent trials suggest that appropriate postarrest temperature targets between 33°C and 37.5°C are reasonable. Targeted temperature management in other critical illnesses, including acute stroke, traumatic brain injury, and sepsis, has not shown benefit in large clinical trials. Likewise, trials of pharmacologic antipyretic therapy have not demonstrated improved outcomes, although national guidelines do recommend treatment of fever in patients with stroke and traumatic brain injury based on observational evidence associating fever with worse outcomes. CONCLUSIONS Body temperature management in critically ill patients remains an appealing therapy for several illnesses, and additional studies are needed to clarify management strategies and therapeutic pathways.
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Targeted temperature management in cardiac surgery: a systematic review and meta-analysis on postoperative cognitive outcomes. Br J Anaesth 2021; 128:11-25. [PMID: 34862000 DOI: 10.1016/j.bja.2021.09.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 09/20/2021] [Accepted: 09/27/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Postoperative cognitive decline occurs commonly after cardiac surgery. The available literature is inconclusive on the role of intraoperative causal or protective factors. METHODS We systematically reviewed studies evaluating delayed neurocognitive recovery (DNR), postoperative neurocognitive disorder (NCD), stroke, and the mortality rates among patients undergoing hypothermic or normothermic cardiopulmonary bypass (CPB). We further performed a subgroup analysis for age, surgery type (coronary artery bypass grafting [CABG], valve surgery, or combined), and the mean arterial blood pressure (MAP) during CPB, and conducted a proportion meta-analysis after calculation of single proportions and confidence intervals (CIs). RESULTS We included a total of 58 studies with 9609 patients in our analysis. Among these, 1906 of 4010 patients (47.5%) had DNR, and 2071 of 7160 (28.9%) had postoperative NCD. Ninety of 4625 patients (2.0%) had a stroke, and 174 of 7589 (2.3%) died. There was no statistically significant relationship between the considered variables and DNR, NCD, stroke, and mortality. In the subgroup analysis comparing hypothermic with normothermic CPB, we found higher NCD rates after combined surgery; for normothermic CPB cases only, the rates of DNR and NCD were lower after combined surgery compared with CABG surgery. A MAP >70 mm Hg compared with MAP=50-70 mm Hg during CPB was associated with a lower rate of DNR. CONCLUSIONS Temperature, MAP during cardiopulmonary bypass age, and surgery type were not associated with neurocognitive disorders, stroke, and mortality in cardiac surgery. Normothermic cardiopulmonary bypass, particularly when performed with MAP >70 mm Hg, may reduce the risk of postoperative neurocognitive decline after cardiac surgery. PROSPERO REGISTRATION NUMBER CRD42019140844.
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Kim SE, Shin HY, Lee EY, Yoo YJ, Kim RH, Cho JH, Lee TK, Ahn D, Park BY, Yoon JC, Hong S, Kim IS, Tae HJ, Won MH. Effect of therapeutic hypothermia against renal injury in a rat model of asphyxial cardiac arrest: Α focus on the survival rate, pathophysiology and antioxidant enzymes. Mol Med Rep 2021; 25:19. [PMID: 34796906 PMCID: PMC8628291 DOI: 10.3892/mmr.2021.12535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 10/27/2021] [Indexed: 11/21/2022] Open
Abstract
Although multi-organ dysfunction is associated with the survival rate following cardiac arrest (CA), the majority of studies to date have focused on hearts and brains, and few studies have considered renal failure. The objective of the present study, therefore, was to examine the effects of therapeutic hypothermia on the survival rate, pathophysiology and antioxidant enzymes in rat kidneys following asphyxial CA. Rats were sacrificed one day following CA. The survival rate, which was estimated using Kaplan-Meier analysis, was 42.9% one day following CA. However, hypothermia, which was induced following CA, significantly increased the survival rate (71.4%). In normothermia rats with CA, the serum blood urea nitrogen level was significantly increased one day post-CA. In addition, the serum creatinine level was significantly increased one day post-CA. However, in CA rats exposed to hypothermia, the levels of urea nitrogen and creatinine significantly decreased following CA. Histochemical staining revealed a significant temporal increase in renal injury after the normothermia group was subjected to CA. However, renal injury was significantly decreased in the hypothermia group. Immunohistochemical analysis of the kidney revealed a significant decrease in antioxidant enzymes (copper-zinc superoxide dismutase, manganese superoxide dismutase, glutathione peroxidase and catalase) with time in the normothermia group. However, in the hypothermia group, these enzymes were significantly elevated following CA. Collectively, the results revealed that renal dysfunction following asphyxial CA was strongly associated with the early survival rate and therapeutic hypothermia reduced renal injury via effective antioxidant mechanisms.
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Affiliation(s)
- So Eun Kim
- Department of Emergency Medicine, Research Institute of Clinical Medicine of Jeonbuk National University, Jeonju, Jeollabuk‑do 54907, Republic of Korea
| | - Ha-Young Shin
- College of Veterinary Medicine and Biosafety Research Institute, Jeonbuk National University, Iksan, Jeollabuk‑do 54596, Republic of Korea
| | - Eui-Yong Lee
- College of Veterinary Medicine and Biosafety Research Institute, Jeonbuk National University, Iksan, Jeollabuk‑do 54596, Republic of Korea
| | - Yeo-Jin Yoo
- College of Veterinary Medicine and Biosafety Research Institute, Jeonbuk National University, Iksan, Jeollabuk‑do 54596, Republic of Korea
| | - Ryun-Hee Kim
- College of Veterinary Medicine and Biosafety Research Institute, Jeonbuk National University, Iksan, Jeollabuk‑do 54596, Republic of Korea
| | - Jeong-Hwi Cho
- College of Veterinary Medicine and Biosafety Research Institute, Jeonbuk National University, Iksan, Jeollabuk‑do 54596, Republic of Korea
| | - Tae-Kyeong Lee
- Department of Biomedical Science and Research Institute for Bioscience and Biotechnology, Hallym University, Chuncheon, Gangwon‑do 24252, Republic of Korea
| | - Dongchoon Ahn
- College of Veterinary Medicine and Biosafety Research Institute, Jeonbuk National University, Iksan, Jeollabuk‑do 54596, Republic of Korea
| | - Byung-Yong Park
- College of Veterinary Medicine and Biosafety Research Institute, Jeonbuk National University, Iksan, Jeollabuk‑do 54596, Republic of Korea
| | - Jae Chol Yoon
- Department of Emergency Medicine, Research Institute of Clinical Medicine of Jeonbuk National University, Jeonju, Jeollabuk‑do 54907, Republic of Korea
| | - Seongkweon Hong
- Department of Surgery, Kangwon National University Hospital, School of Medicine, Kangwon National University, Chuncheon, Gangwon‑do 24289, Republic of Korea
| | - In-Shik Kim
- College of Veterinary Medicine and Biosafety Research Institute, Jeonbuk National University, Iksan, Jeollabuk‑do 54596, Republic of Korea
| | - Hyun-Jin Tae
- College of Veterinary Medicine and Biosafety Research Institute, Jeonbuk National University, Iksan, Jeollabuk‑do 54596, Republic of Korea
| | - Moo-Ho Won
- Department of Neurobiology, School of Medicine, Kangwon National University, Chuncheon, Gangwon‑do 24341, Republic of Korea
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6
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Mohyuddin R, Dietrichs ES, Sundaram P, Kondratiev T, Figenschou MF, Sieck GC, Tveita T. Cardiovascular Effects of Epinephrine During Experimental Hypothermia (32°C) With Spontaneous Circulation in an Intact Porcine Model. Front Physiol 2021; 12:718667. [PMID: 34552506 PMCID: PMC8450451 DOI: 10.3389/fphys.2021.718667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 06/25/2021] [Indexed: 01/05/2023] Open
Abstract
Aims: Rewarming from accidental hypothermia and therapeutic temperature management could be complicated by cardiac dysfunction. Although pharmacologic support is often applied when rewarming these patients, updated treatment recommendations are lacking. There is an underlying deficiency of clinical and experimental data to support such interventions and this prevents the development of clinical guidelines. Accordingly, we explored the clinical effects of epinephrine during hypothermic conditions. Materials and methods: Anesthetized pigs were immersion cooled to 32°C. Predetermined variables were compared at temperature/time-point baseline, after receiving 30 ng/kg/min and 90 ng/kg/min epinephrine infusions: (1) before and during hypothermia at 32°C, and after rewarming to 38°C (n = 7) and (2) a time-matched (5 h) normothermic control group (n = 5). Results: At 32°C, both stroke volume and cardiac output were elevated after 30 ng/kg/min administration, while systemic vascular resistance was reduced after 90 ng/kg/min. Epinephrine infusion did not alter blood flow in observed organs, except small intestine flow, and global O2 extraction rate was significantly reduced in response to 90 ng/kg/min infusion. Electrocardiographic measurements were unaffected by epinephrine infusion. Conclusion: Administration of both 30 ng/kg/min and 90 ng/kg/min at 32°C had a positive inotropic effect and reduced afterload. We found no evidence of increased pro-arrhythmic activity after epinephrine infusion in hypothermic pigs. Our experiment therefore suggests that β₁-receptor stimulation with epinephrine could be a favorable strategy for providing cardiovascular support in hypothermic patients, at core temperatures >32°C.
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Affiliation(s)
- Rizwan Mohyuddin
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, Tromsø, Norway
| | - Erik Sveberg Dietrichs
- Experimental and Clinical Pharmacology Research Group, Department of Medical Biology, UiT, The Arctic University of Norway, Tromsø, Norway.,Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
| | - Predip Sundaram
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, Tromsø, Norway
| | - Timofey Kondratiev
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, Tromsø, Norway
| | - Marie Fjellanger Figenschou
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, Tromsø, Norway.,Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
| | - Gary C Sieck
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MI, United States
| | - Torkjel Tveita
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, Tromsø, Norway.,Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway.,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MI, United States
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7
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Rey-Funes M, Contartese DS, Peláez R, García-Sanmartín J, Narro-Íñiguez J, Soliño M, Fernández JC, Sarotto A, Ciranna NS, López-Costa JJ, Dorfman VB, Larrayoz IM, Loidl CF, Martínez A. Hypothermic Shock Applied After Perinatal Asphyxia Prevents Retinal Damage in Rats. Front Pharmacol 2021; 12:651599. [PMID: 33897437 PMCID: PMC8060653 DOI: 10.3389/fphar.2021.651599] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 02/22/2021] [Indexed: 01/10/2023] Open
Abstract
Perinatal asphyxia (PA) can cause retinopathy and different degrees of visual loss, including total blindness. In a rat model of PA, we have previously shown a protective effect of hypothermia on the retina when applied simultaneously with the hypoxic insult. In the present work, we evaluated the possible protective effect of hypothermia on the retina of PA rats when applied immediately after delivery. Four experimental groups were studied: Rats born naturally as controls (CTL), animals that were exposed to PA for 20 min at 37°C (PA), animals exposed to PA for 20 min at 15°C (HYP), and animals that were exposed to PA for 20 min at 37°C and, immediately after birth, kept for 15 min at 8°C (HYP-PA). To evaluate the integrity of the visual pathway, animals were subjected to electroretinography at 45 days of age. Molecular (real time PCR) and histological (immunohistochemistry, immunofluorescence, TUNEL assay) techniques were applied to the eyes of all experimental groups collected at 6, 12, 24, and 48 h, and 6 days after birth. PA resulted in a significant reduction in the amplitude of the a- and b-wave and oscillatory potentials (OP) of the electroretinogram. All animals treated with hypothermia had a significant correction of the a-wave and OP, but the b-wave was fully corrected in the HYP group but only partially in the HYP-PA group. The number of TUNEL-positive cells increased sharply in the ganglion cell layer of the PA animals and this increase was significantly prevented by both hypothermia treatments. Expression of the cold-shock proteins, cold-inducible RNA binding protein (CIRP) and RNA binding motif protein 3 (RBM3), was undetectable in retinas of the CTL and PA groups, but they were highly expressed in ganglion neurons and cells of the inner nuclear layer of the HYP and HYP-PA groups. In conclusion, our results suggest that a post-partum hypothermic shock could represent a useful and affordable method to prevent asphyxia-related vision disabling sequelae.
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Affiliation(s)
- Manuel Rey-Funes
- Laboratorio de Neuropatología Experimental, Instituto de Biología Celular y Neurociencia "Prof, E. De Robertis" (IBCN), Facultad de Medicina, CONICET - Universidad de Buenos Aires, Buenos Aires, Argentina.,Departamento de Biología Celular, Histología, Embriología y Genética, Instituto de Biología Celular y Neurociencia "Prof, E. De Robertis" (IBCN), Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Daniela S Contartese
- Laboratorio de Neuropatología Experimental, Instituto de Biología Celular y Neurociencia "Prof, E. De Robertis" (IBCN), Facultad de Medicina, CONICET - Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Rafael Peláez
- Biomarkers and Molecular Signaling Group, Center for Biomedical Research of La Rioja, Logroño, Spain
| | - Josune García-Sanmartín
- Angiogenesis Group, Oncology Area, Center for Biomedical Research of La Rioja, Logroño, Spain
| | - Judit Narro-Íñiguez
- Angiogenesis Group, Oncology Area, Center for Biomedical Research of La Rioja, Logroño, Spain
| | - Manuel Soliño
- Laboratorio de Neuropatología Experimental, Instituto de Biología Celular y Neurociencia "Prof, E. De Robertis" (IBCN), Facultad de Medicina, CONICET - Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Juan Carlos Fernández
- Laboratorio de Neuropatología Experimental, Instituto de Biología Celular y Neurociencia "Prof, E. De Robertis" (IBCN), Facultad de Medicina, CONICET - Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Aníbal Sarotto
- Laboratorio de Neuropatología Experimental, Instituto de Biología Celular y Neurociencia "Prof, E. De Robertis" (IBCN), Facultad de Medicina, CONICET - Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Nicolás S Ciranna
- Laboratorio de Neuropatología Experimental, Instituto de Biología Celular y Neurociencia "Prof, E. De Robertis" (IBCN), Facultad de Medicina, CONICET - Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Juan José López-Costa
- Laboratorio de Neuropatología Experimental, Instituto de Biología Celular y Neurociencia "Prof, E. De Robertis" (IBCN), Facultad de Medicina, CONICET - Universidad de Buenos Aires, Buenos Aires, Argentina.,Departamento de Biología Celular, Histología, Embriología y Genética, Instituto de Biología Celular y Neurociencia "Prof, E. De Robertis" (IBCN), Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Verónica B Dorfman
- Centro de Estudios Biomédicos Básicos, Aplicados y Desarrollo, Universidad Maimónides, Buenos Aires, Argentina
| | - Ignacio M Larrayoz
- Biomarkers and Molecular Signaling Group, Center for Biomedical Research of La Rioja, Logroño, Spain
| | - C Fabián Loidl
- Laboratorio de Neuropatología Experimental, Instituto de Biología Celular y Neurociencia "Prof, E. De Robertis" (IBCN), Facultad de Medicina, CONICET - Universidad de Buenos Aires, Buenos Aires, Argentina.,Departamento de Biología Celular, Histología, Embriología y Genética, Instituto de Biología Celular y Neurociencia "Prof, E. De Robertis" (IBCN), Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Alfredo Martínez
- Angiogenesis Group, Oncology Area, Center for Biomedical Research of La Rioja, Logroño, Spain
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8
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Danladi J, Sabir H. Perinatal Infection: A Major Contributor to Efficacy of Cooling in Newborns Following Birth Asphyxia. Int J Mol Sci 2021; 22:ijms22020707. [PMID: 33445791 PMCID: PMC7828225 DOI: 10.3390/ijms22020707] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 01/05/2021] [Accepted: 01/09/2021] [Indexed: 12/19/2022] Open
Abstract
Neonatal encephalopathy (NE) is a global burden, as more than 90% of NE occurs in low- and middle-income countries (LMICs). Perinatal infection seems to limit the neuroprotective efficacy of therapeutic hypothermia. Efforts made to use therapeutic hypothermia in LMICs treating NE has led to increased neonatal mortality rates. The heat shock and cold shock protein responses are essential for survival against a wide range of stressors during which organisms raise their core body temperature and temporarily subject themselves to thermal and cold stress in the face of infection. The characteristic increase and decrease in core body temperature activates and utilizes elements of the heat shock and cold shock response pathways to modify cytokine and chemokine gene expression, cellular signaling, and immune cell mobilization to sites of inflammation, infection, and injury. Hypothermia stimulates microglia to secret cold-inducible RNA-binding protein (CIRP), which triggers NF-κB, controlling multiple inflammatory pathways, including nod-like receptor family pyrin domain containing 3 (NLRP3) inflammasomes and cyclooxygenase-2 (COX-2) signaling. Brain responses through changes in heat shock protein and cold shock protein transcription and gene-expression following fever range and hyperthermia may be new promising potential therapeutic targets.
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Affiliation(s)
- Jibrin Danladi
- Department of Neonatology and Pediatric Intensive Care, Children’s Hospital University of Bonn, 53127 Bonn, Germany;
- German Center for Neurodegenerative Diseases (DZNE), 53127 Bonn, Germany
- Correspondence:
| | - Hemmen Sabir
- Department of Neonatology and Pediatric Intensive Care, Children’s Hospital University of Bonn, 53127 Bonn, Germany;
- German Center for Neurodegenerative Diseases (DZNE), 53127 Bonn, Germany
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9
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Jandu S, Sefa N, Sawyer KN, Swor R. Electrocardiographic changes in patients undergoing targeted temperature management. J Am Coll Emerg Physicians Open 2020; 1:327-332. [PMID: 33000055 PMCID: PMC7493533 DOI: 10.1002/emp2.12104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 04/28/2020] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES Targeted temperature management is the recommended therapy for comatose patients after an out-of-hospital cardiac arrest resuscitation due to the reduction in neurological damage and improved outcomes. However, there may result in electrocardiographic instability depending on the degree of targeted temperature management, including minor or life-threatening dysrhythmias or conduction delays. This project aims to describe the frequency of ECG interval changes and clinically relevant dysrhythmias in targeted temperature management patients. METHODS This is a retrospective observational study from January 2009 to December 2015. Patients who qualified for the study had a non-traumatic cardiac arrest with a return of spontaneous circulation, received targeted temperature management at 33.5°C for 24 hours followed by 16 hours of rewarming. ECG interval changes and dysrhythmias were recorded immediately after return of spontaneous circulation, and at 24 and 48 hours post return of spontaneous circulation. RESULTS A total of 322 patients (age 61.0 ± 16.9 years) had targeted temperature management initiated during the study period, of which 169 had complete data and 13 died prior to completing 24 hours of hypothermia. There were statistically significant changes during targeted temperature management in heart rate (96.7 ± 26.0/min before targeted temperature management; 69.5 ± 19.1/min during, P < 0.001), QRS duration (115.1 ± 32.6 ms before targeted temperature management; 107.8 ± 27.9 ms during targeted temperature management, P < 0.001), and QTc (486.3 ± 52.8 ms before targeted temperature management; 526.9 ± 61.7 ms during targeted temperature management, P < 0.001). There were cardiac dysrhythmias that received treatment during cooling and rewarming. CONCLUSION During the period of targeted temperature management and rewarming, we observed few self-limiting ECG interval changes and no clinically significant dysrhythmias in this population during the period of targeted temperature management.
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Affiliation(s)
- Simi Jandu
- Department of Emergency MedicineWilliam Beaumont HospitalRoyal OakMichiganUSA
| | - Nana Sefa
- Department of Emergency MedicineMichigan MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Kelly N. Sawyer
- Department of Emergency MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Robert Swor
- Department of Emergency MedicineWilliam Beaumont HospitalRoyal OakMichiganUSA
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10
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Albrecht M, Zitta K, Groenendaal F, van Bel F, Peeters-Scholte C. Neuroprotective strategies following perinatal hypoxia-ischemia: Taking aim at NOS. Free Radic Biol Med 2019; 142:123-131. [PMID: 30818057 DOI: 10.1016/j.freeradbiomed.2019.02.025] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 02/07/2019] [Accepted: 02/19/2019] [Indexed: 12/13/2022]
Abstract
Perinatal asphyxia is characterized by oxygen deprivation and lack of perfusion in the perinatal period, leading to hypoxic-ischemic encephalopathy and sequelae such as cerebral palsy, mental retardation, cerebral visual impairment, epilepsy and learning disabilities. On cellular level PA is associated with a decrease in oxygen and glucose leading to ATP depletion and a compromised mitochondrial function. Upon reoxygenation and reperfusion, the renewed availability of oxygen gives rise to not only restoration of cell function, but also to the activation of multiple detrimental biochemical pathways, leading to secondary energy failure and ultimately, cell death. The formation of reactive oxygen species, nitric oxide and peroxynitrite plays a central role in the development of subsequent neurological damage. In this review we give insight into the pathophysiology of perinatal asphyxia, discuss its clinical relevance and summarize current neuroprotective strategies related to therapeutic hypothermia, ischemic postconditioning and pharmacological interventions. The review will also focus on the possible neuroprotective actions and molecular mechanisms of the selective neuronal and inducible nitric oxide synthase inhibitor 2-iminobiotin that may represent a novel therapeutic agent for the treatment of hypoxic-ischemic encephalopathy, both in combination with therapeutic hypothermia in middle- and high-income countries, as well as stand-alone treatment in low-income countries.
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Affiliation(s)
- Martin Albrecht
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Karina Zitta
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands; Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Frank van Bel
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands; Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Cacha Peeters-Scholte
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Neurophyxia BV, 's Hertogenbosch, the Netherlands.
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11
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Randhawa VK, Grunau BE, Debicki DB, Zhou J, Hegazy AF, McPherson T, Nagpal AD. Cardiac Intensive Care Unit Management of Patients After Cardiac Arrest: Now the Real Work Begins. Can J Cardiol 2018; 34:156-167. [PMID: 29407008 DOI: 10.1016/j.cjca.2017.11.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 11/22/2017] [Accepted: 11/22/2017] [Indexed: 11/18/2022] Open
Abstract
Survival with a good quality of life after cardiac arrest continues to be abysmal. Coordinated resuscitative care does not end with the effective return of spontaneous circulation (ROSC)-in fact, quite the contrary is true. Along with identifying and appropriately treating the precipitating cause, various components of the post-cardiac arrest syndrome also require diligent observation and management, including post-cardiac arrest neurologic injury and myocardial dysfunction, systemic ischemia-reperfusion phenomenon with potential consequent multiorgan failure, and the various sequelae of critical illness. There is growing evidence that an early invasive approach to coronary reperfusion with percutaneous coronary intervention, together with active targeted temperature management and optimization of hemodynamic, ventilator, and metabolic parameters, may improve survival and neurologic outcomes in cardiac arrest survivors. Neuroprognostication is complex, as are survivorship issues and long-term rehabilitation. Our paramedics, emergency physicians, and resuscitation specialists are all to be congratulated for ever-increasing success with ROSC… but now the real work begins.
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Affiliation(s)
- Varinder K Randhawa
- Division of Cardiology, University of Toronto/University Health Network, Toronto, Ontario, Canada
| | - Brian E Grunau
- Department of Emergency Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Derek B Debicki
- Department of Clinical Neurologic Sciences, Western University/London Health Sciences Centre, London, Ontario, Canada
| | - Jian Zhou
- Department of Anesthesia and Perioperative Medicine, Western University/London Health Sciences Centre, London, Ontario, Canada
| | - Ahmed F Hegazy
- Critical Care Western, Western University/London Health Sciences Centre, London, Ontario, Canada; Department of Anesthesia and Perioperative Medicine, Western University/London Health Sciences Centre, London, Ontario, Canada
| | - Terry McPherson
- Division of Cardiology, Western University/London Health Sciences Centre, London, Ontario, Canada
| | - A Dave Nagpal
- Division of Cardiac Surgery, Western University/London Health Sciences Centre, London, Ontario, Canada; Critical Care Western, Western University/London Health Sciences Centre, London, Ontario, Canada.
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12
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Mędrzycka-Dąbrowska WA, Czyż-Szybenbejl K, Kwiecień-Jaguś K, Lewandowska K. Prediction of cognitive dysfunction after resuscitation - a systematic review. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2018; 14:225-232. [PMID: 30302097 PMCID: PMC6173101 DOI: 10.5114/aic.2018.78324] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 06/17/2018] [Indexed: 12/15/2022] Open
Abstract
Cardiac arrest (CA) due to cardiovascular disease is the leading cause of death in developed countries. It is estimated that over 350,000 people in Europe suffer from out-of-hospital cardiac arrest. According to the literature, the longer the episode of cardiac arrest, the greater the risk of cognitive impairment, especially short-term memory, as well as immediate and delayed recall. Other common dysfunctions include attention deficits and executive function disorders. The aim of this systematic review was to summarize current research on cognitive impairment in patients after sudden cardiac arrest. The electronic databases PubMed/MEDLINE, OVID, Web of Science, and EBSCO were searched using the following key words: 'sudden cardiac arrest', 'out-of-hospital cardiac arrest', 'cognitive function', 'cognitive impairment', 'functional outcome', 'cardiopulmonary resuscitation'. The most recent studies from the last 7 years (2011-2018) were included. Cognitive disorders occurred in a broad range of cases: from 13% to even 100%. In one study, cognitive deficits did not occur at all. Amongst the reviewed articles only two studies were carried out on a large group of patients. The remaining studies were conducted on a small group of respondents; therefore there was no possibility to generalize the results to the entire population. The areas in which the most cognitive impairment occurred were memory, executive functions and visual-motor skills. One of the conclusions derived from the reviewed literature is the importance of continuous training of cognitive functions, especially for people with cardiovascular risk.
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Affiliation(s)
| | - Katarzyna Czyż-Szybenbejl
- Department of Anaesthesiology Nursing and Intensive Care, Medical University of Gdansk, Gdansk, Poland
| | - Katarzyna Kwiecień-Jaguś
- Department of Anaesthesiology Nursing and Intensive Care, Medical University of Gdansk, Gdansk, Poland
| | - Katarzyna Lewandowska
- Department of Anaesthesiology Nursing and Intensive Care, Medical University of Gdansk, Gdansk, Poland
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13
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Kim DH, Kang HH, Kim M, Yang TW, Kwon OY, Yeom JS, Kang BS, Kim YH, Kim YS. Successful Use of Therapeutic Hypothermia for Refractory Nonconvulsive Status Epilepticus. J Epilepsy Res 2017; 7:109-114. [PMID: 29344469 PMCID: PMC5767487 DOI: 10.14581/jer.17017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 11/08/2017] [Indexed: 11/16/2022] Open
Abstract
Therapeutic hypothermia (TH) has rarely been utilized as an adjunct to anticonvulsants in treating patients with refractory convulsive status epilepticus (CSE). However, determining the effectiveness of TH in CSE is difficult due to the unavoidable use of sedative drugs to manage hypothermia. Additionally, the effectiveness of TH has not been studied in patients with refractory non-convulsive status epilepticus (NCSE). Here, we report the successful use of TH without additional sedative drugs in a patient with temporal lobe epilepsy and refractory NCSE. A 46-year-old man was referred to the neurology department because of recurrent seizure attacks. Electroencephalography (EEG) after first-line status treatment showed continuous periodic discharges consistent with NCSE. He was started simultaneously on continuous EEG monitoring and TH, but was not administered any benzodiazepines to control shivering or maintain TH. During TH, EEG abnormalities gradually improved, and the patient regained consciousness in accordance with the improvement in EEG. The patient was alert and his EEG had normalized a few days after starting TH. To the best of our knowledge, this is the first report describing the successful treatment of refractory NCSE with TH. As no sedative drugs were used during the maintenance of hypothermia, NCSE control may have been achieved by TH alone.
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Affiliation(s)
- Do-Hyung Kim
- Department of Neurology, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Hye-Hoon Kang
- Department of Neurology, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Minjung Kim
- Department of Neurology, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Tae-Won Yang
- Department of Neurology, Changwon Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Changwon, Korea
| | - Oh-Young Kwon
- Department of Neurology, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Jung Sook Yeom
- Department of Pediatrics, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Bong Su Kang
- Department of Neurology, Yangpyeong Hospital, Yangpyeong, Korea
| | - Yong Hwan Kim
- Department of Emergency Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Young-Soo Kim
- Department of Neurology, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
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14
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Look X, Li H, Ng M, Lim ETS, Pothiawala S, Tan KBK, Sewa DW, Shahidah N, Pek PP, Ong MEH. Randomized controlled trial of internal and external targeted temperature management methods in post- cardiac arrest patients. Am J Emerg Med 2017; 36:66-72. [PMID: 28698133 DOI: 10.1016/j.ajem.2017.07.017] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 07/04/2017] [Accepted: 07/04/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Targeted temperature management post-cardiac arrest is currently implemented using various methods, broadly categorized as internal and external. This study aimed to evaluate survival-to-hospital discharge and neurological outcomes (Glasgow-Pittsburgh Score) of post-cardiac arrest patients undergoing internal cooling verses external cooling. METHODOLOGY A randomized controlled trial of post-resuscitation cardiac arrest patients was conducted from October 2008-September 2014. Patients were randomized to either internal or external cooling methods. Historical controls were selected matched by age and gender. Analysis using SPSS version 21.0 presented descriptive statistics and frequencies while univariate logistic regression was done using R 3.1.3. RESULTS 23 patients were randomized to internal cooling and 22 patients to external cooling and 42 matched controls were selected. No significant difference was seen between internal and external cooling in terms of survival, neurological outcomes and complications. However in the internal cooling arm, there was lower risk of developing overcooling (p=0.01) and rebound hyperthermia (p=0.02). Compared to normothermia, internal cooling had higher survival (OR=3.36, 95% CI=(1.130, 10.412), and lower risk of developing cardiac arrhythmias (OR=0.18, 95% CI=(0.04, 0.63)). Subgroup analysis showed those with cardiac cause of arrest (OR=4.29, 95% CI=(1.26, 15.80)) and sustained ROSC (OR=5.50, 95% CI=(1.64, 20.39)) had better survival with internal cooling compared to normothermia. Cooling curves showed tighter temperature control for internal compared to external cooling. CONCLUSION Internal cooling showed tighter temperature control compared to external cooling. Internal cooling can potentially provide better survival-to-hospital discharge outcomes and reduce cardiac arrhythmia complications in carefully selected patients as compared to normothermia.
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Affiliation(s)
| | - Huihua Li
- Division of Research, Singapore General Hospital, Singapore
| | - Mingwei Ng
- Emergency Medicine Residency, Singapore Health Services, Singapore
| | | | - Sohil Pothiawala
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | | | - Duu Wen Sewa
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Nur Shahidah
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - Pin Pin Pek
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore; Health Services and Systems Research, Duke-NUS Medical School, Singapore.
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15
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The role of cold‐inducibleRNAbinding protein in cell stress response. Int J Cancer 2017; 141:2164-2173. [DOI: 10.1002/ijc.30833] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 06/01/2017] [Indexed: 12/24/2022]
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16
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Prabakaran S, Subburayulu AS, Ravikumar PT. Surgical Excision of Carotid Body Tumor Through Modified Approach-A Case Report. J Maxillofac Oral Surg 2016; 15:251-5. [PMID: 27298550 PMCID: PMC4871837 DOI: 10.1007/s12663-015-0832-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 07/30/2015] [Indexed: 11/27/2022] Open
Abstract
Paragangliomas arising from the carotid body in the carotid bifurcation are termed as carotid body tumors. They are usually slow growing and asymptomatic. Considering the anatomical location, invasion or pressure on the adjacent vascular and neural tissues, the importance of early diagnosis and management is critical. In this article a case of carotid body tumor excised through transverse neck skin crease incision is presented along with literature review on the diagnosis, grading and different surgical approaches.
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Affiliation(s)
| | | | - P. T. Ravikumar
- />Department of Oral Medicine and Radiology, Vinayaka Missions Sankarachariyar Dental College, Salem, India
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17
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Tang M, Zhao XG, He Y, Gu JY, Mei J. Aggressive re-warming at 38.5 °C following deep hypothermia at 21 °C increases neutrophil membrane bound elastase activity and pro-inflammatory factor release. SPRINGERPLUS 2016; 5:495. [PMID: 27186459 PMCID: PMC4839026 DOI: 10.1186/s40064-016-2084-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 03/31/2016] [Indexed: 11/10/2022]
Abstract
Background Cardiopulmonary bypass (CPB) is often performed under hypothermic condition. The effects of hypothermia and re-warming on neutrophil activity are unclear. This study aimed to compare the effects of different hypothermia and re-warming regimens on neutrophil membrane bound elastase (MBE) activity and the release of pro-inflammatory factors from neutrophils. Methods Human neutrophils were exposed to different hypothermia and re-warming regimens. MBE activity and the release of interleukin (IL)-β1, IL-6, IL-8, and tumor necrosis factor (TNF)-α were measured. Results Neutrophil MBE activity was significantly reduced after 60-min moderate (28 °C) or deep (21 °C) hypothermic treatment. Compared with normothermic (37 °C) re-warming, aggressive re-warming (38.5°) for 120 min following deep hypothermia (21 °C) dramatically increased neutrophil MBE activity (P < 0.05). Co-incubation of neutrophils with platelet-rich plasma further increased MBE activity significantly under all the tested temperature regimens. IL-β1 release from neutrophils was significantly higher after deep hypothermia (21 °C) followed by normothermic (37 °C) re-warming than after moderate hypothermia (28 °C) followed by normothermic re-warming (P < 0.05). Aggressive re-warming (38.5°) following deep hypothermia significantly increased the release of IL-β1, IL-8, and TNF-α from neutrophil compared with moderate re-warming (37 °C) (all P < 0.05). Conclusion Aggressive re-warming following deep hypothermia may contribute to CPB-associated tissue injury by increasing neutrophil MBE activity and stimulating pro-inflammatory factor release, thus, should be avoided. The optimal hypothermic temperature of CPB should be determined based on patient clinical characteristics and surgery type.
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Affiliation(s)
- Min Tang
- Department of Cardiothoracic Surgery, Shanghai Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiao-Gang Zhao
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital Affiliated to Tongji University, Shanghai, China
| | - Yi He
- Department of Cardiothoracic Surgery, Shanghai Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - John Yan Gu
- Department of Biomedical Engineering, University Medical Centre Groningen, Groningen, The Netherlands
| | - Ju Mei
- Department of Cardiothoracic Surgery, Shanghai Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
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18
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Kim EY, Suh HJ, Seo GJ, Choi SH, Huh JW, Hong SB, Koh Y, Lim CM. Clinical outcomes of cardiac arrest patients according to opioid use history. J Crit Care 2016; 35:1-6. [PMID: 27481728 DOI: 10.1016/j.jcrc.2016.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 03/15/2016] [Accepted: 03/17/2016] [Indexed: 10/22/2022]
Abstract
PURPOSE Opioid analgesics are potent respiratory depressants. The purpose of this study was to describe the effects of opioids administered within 24hours before cardiac arrest on clinical outcomes. MATERIALS AND METHODS We retrospectively collected the cardiac arrest data of noncancer patients who were admitted to the general ward of Asan Medical Center from January 2008 to August 2012. We investigated the proportion of these patients who received opioids within 24hours of a cardiac arrest event, as well as the cardiac arrest characteristics, survival rates, and opioid administration patterns. RESULTS Of the 193 patients identified, 58 (30%) had been administered opioids within the previous 24hours (the opioid group), whereas the remaining 135 (70%) had not been administered opioids (the nonopioid group). The survival rate did not differ significantly between these 2 groups. In the opioid group, as-needed opioid administration was associated with a lower 24-hour survival rate than regular opioid administration (9 [33.3%] of 27 patients vs 20 [64.5%] of 31 patients; P=.030). In multivariate logistic regression analysis, as-needed opioid administration was negatively associated with 24-hour survival. CONCLUSIONS Opioid administration within 24hours before cardiac arrest per se was not associated with adverse outcomes. However, administration of opioid analgesics on an as-needed basis was associated with poorer survival outcomes than regular dosing. Greater attention should be paid to patients who receive as-needed opioid administration in the general ward.
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Affiliation(s)
- Eun Young Kim
- Respiratory Care Services, Asan Medical Center, 88 Olympic-ro 43 gil, Songpa-gu, Seoul 05505, South Korea.
| | - Hee Jung Suh
- Respiratory Care Services, Asan Medical Center, 88 Olympic-ro 43 gil, Songpa-gu, Seoul 05505, South Korea.
| | - Ga Jin Seo
- Respiratory Care Services, Asan Medical Center, 88 Olympic-ro 43 gil, Songpa-gu, Seoul 05505, South Korea.
| | - Sun Hui Choi
- Medical Emergency Team, Asan Medical Center, 88 Olympic-ro 43 gil, Songpa-gu, Seoul 05505, South Korea.
| | - Jin Won Huh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro 43 gil, Songpa-gu, Seoul 05505, South Korea.
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro 43 gil, Songpa-gu, Seoul 05505, South Korea.
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro 43 gil, Songpa-gu, Seoul 05505, South Korea.
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro 43 gil, Songpa-gu, Seoul 05505, South Korea.
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Induced Hypothermia Does Not Harm Hemodynamics after Polytrauma: A Porcine Model. Mediators Inflamm 2015; 2015:829195. [PMID: 26170533 PMCID: PMC4481088 DOI: 10.1155/2015/829195] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 05/05/2015] [Accepted: 05/05/2015] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The deterioration of hemodynamics instantly endangers the patients' life after polytrauma. As accidental hypothermia frequently occurs in polytrauma, therapeutic hypothermia still displays an ambivalent role as the impact on the cardiopulmonary function is not yet fully understood. METHODS We have previously established a porcine polytrauma model including blunt chest trauma, penetrating abdominal trauma, and hemorrhagic shock. Therapeutic hypothermia (34°C) was induced for 3 hours. We documented cardiovascular parameters and basic respiratory parameters. Pigs were euthanized after 15.5 hours. RESULTS Our polytrauma porcine model displayed sufficient trauma impact. Resuscitation showed adequate restoration of hemodynamics. Induced hypothermia had neither harmful nor major positive effects on the animals' hemodynamics. Though heart rate significantly decreased and mixed venous oxygen saturation significantly increased during therapeutic hypothermia. Mean arterial blood pressure, central venous pressure, pulmonary arterial pressure, and wedge pressure showed no significant differences comparing normothermic trauma and hypothermic trauma pigs during hypothermia. CONCLUSIONS Induced hypothermia after polytrauma is feasible. No major harmful effects on hemodynamics were observed. Therapeutic hypothermia revealed hints for tissue protective impact. But the chosen length for therapeutic hypothermia was too short. Nevertheless, therapeutic hypothermia might be a useful tool for intensive care after polytrauma. Future studies should extend therapeutic hypothermia.
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Lopez-de-Sa E. ¿Qué hacer con los supervivientes a una parada cardiaca? ¿Inducir hipotermia o basta evitar la hipertermia? Rev Esp Cardiol 2015. [DOI: 10.1016/j.recesp.2015.02.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Lopez-de-Sa E. What Should Be Done With Survivors of a Cardiac Arrest? Induce Hypothermia or Just Avoid Hyperthermia? ACTA ACUST UNITED AC 2015; 68:369-72. [PMID: 25818352 DOI: 10.1016/j.rec.2015.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 02/05/2015] [Indexed: 11/17/2022]
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Xu B, Jacquir S, Laurent G, Binczak S, Pont O, Yahia H. In vitroarrhythmia generation by mild hypothermia: a pitchfork bifurcation type process. Physiol Meas 2015; 36:579-94. [DOI: 10.1088/0967-3334/36/3/579] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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23
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Kim CY, Bae MH, Kim NK, Yang YA, Kim KY, Lee JH, Eun JS, Cho Y. Case of Recurrent Ventricular Fibrillations with Osborn Wave Developed during Therapeutic Hypothermia. Korean Circ J 2015; 45:81-4. [PMID: 25653709 PMCID: PMC4310985 DOI: 10.4070/kcj.2015.45.1.81] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 07/10/2014] [Accepted: 07/14/2014] [Indexed: 01/09/2023] Open
Abstract
Therapeutic hypothermia (TH) has been used to protect neurological functions in cardiac arrest patient. Although Osborn wave is not pathognomonic of hypothermia, it is a well-known electrocardiogram finding of hypothermic patients. The cellular and ionic mechanisms of the Osborn wave have been suggested, and its relationship to tachyarrhythmias, such as ventricular tachycardia and ventricular fibrillation, is being explored. This case highlights the arrhythmogenic potential of Osborn wave and individual difference in response of TH.
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Affiliation(s)
- Chang-Yeon Kim
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Myung Hwan Bae
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Nam Kyun Kim
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Young Ae Yang
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Kyu Yeun Kim
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Jang Hoon Lee
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Jung Su Eun
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Yongkeun Cho
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
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25
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Rothstein TL. Therapeutic hypothermia does not diminish the vital and necessary role of SSEP in predicting unfavorable outcome in anoxic-ischemic coma. Clin Neurol Neurosurg 2014; 126:205-9. [DOI: 10.1016/j.clineuro.2014.08.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 08/20/2014] [Accepted: 08/26/2014] [Indexed: 10/24/2022]
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Soleimanpour H, Rahmani F, Safari S, EJ Golzari S. Hypothermia after cardiac arrest as a novel approach to increase survival in cardiopulmonary cerebral resuscitation: a review. IRANIAN RED CRESCENT MEDICAL JOURNAL 2014; 16:e17497. [PMID: 25237582 PMCID: PMC4166101 DOI: 10.5812/ircmj.17497] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Revised: 03/13/2014] [Accepted: 03/16/2014] [Indexed: 12/12/2022]
Abstract
Context: The aim of this review study was to evaluate therapeutic mild hypothermia, its complications and various methods for induced mild hypothermia in patients following resuscitation after out-of-hospital cardiac arrest. Evidence Acquisition: Studies conducted on post-cardiac arrest cares, history of induced hypothermia, and therapeutic hypothermia for patients with cardiac arrest were included in this study. We used the valid databases (PubMed and Cochrane library) to collect relevant articles. Results: According to the studies reviewed, induction of mild hypothermia in patients after cardiopulmonary resuscitation would lead to increased survival and better neurological outcome; however, studies on the complications of hypothermia or different methods of inducing hypothermia were limited and needed to be studied further. Conclusions: This study provides strategic issues concerning the induction of mild hypothermia, its complications, and different ways of performing it on patients; using this method helps to increase patients’ neurological survival rate.
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Affiliation(s)
- Hassan Soleimanpour
- Medical Education Research Center, Tabriz University of Medical Sciences, Tabriz, IR Iran
- Corresponding Author: Hassan Soleimanpour, Medical Education Research Center, Tabriz University of Medical Sciences, Tabriz, IR Iran. Tel: +98-9141164134, Fax: +98-4113352078, E-mail:
| | - Farzad Rahmani
- Department of Emergency Medicine, Tabriz University of Medical Sciences, Tabriz, IR Iran
| | - Saeid Safari
- Department of Anesthesiology and Critical Care, Iran University of Medical Sciences, Tehran, IR Iran
| | - Samad EJ Golzari
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, IR Iran
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Use of Therapeutic Hypothermia After In-Hospital Cardiac Arrest. Crit Care Med 2014; 42:e545-6. [DOI: 10.1097/ccm.0000000000000294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Soleimanpour H, Rahmani F, Golzari SE, Safari S. Main complications of mild induced hypothermia after cardiac arrest: a review article. J Cardiovasc Thorac Res 2014; 6:1-8. [PMID: 24753824 PMCID: PMC3992725 DOI: 10.5681/jcvtr.2014.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 01/20/2014] [Indexed: 11/22/2022] Open
Abstract
The aim of the present study is to assess the complications of mild induced hypothermia (MIH) in patients with cardiac arrest. Presently, based on the guidelines of the American heart Association, MIH following successful cardiopulmonary resuscitation (CPR) in unconscious adult patients due to ventricular fibrillation (VF) with out-of-hospital cardiac arrest (OOHCA) is essential and required. However, MIH could be associated with complications in Patients with cardiac arrest. Studies conducted on the precautions and care following cardiac arrest and MIH were included. Valid scientific data bases were used for data collection. The obtained results from different studies revealed that mild MIH could be associated with numerous complications and the knowledge and awareness of the medical staff from the complications is required to guarantee successful therapeutic approaches in MIH following cardiac arrest which is a novel medical facility with different styles and complications. Overall, further future studies are required to improve the quality of MIH, to increase survival and to decrease complications rates.
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Affiliation(s)
- Hassan Soleimanpour
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Farzad Rahmani
- Emergency Medicine Department, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Samad Ej Golzari
- Liver and Gastrointestinal Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Saeid Safari
- Anesthesiology and Critical Care Department, Iran University of Medical Sciences, Tehran, Iran
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Prolonged exposure to isoflurane ameliorates infarction severity in the rat pup model of neonatal hypoxia-ischemia. Transl Stroke Res 2013; 2:382-90. [PMID: 21892364 DOI: 10.1007/s12975-011-0081-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The neonatal hypoxia-ischemia rat model referred to as the Rice-Vannucci model is extensively used to study perinatal hypoxia-ischemia and child brain injury. One of the major weaknesses of this model is its inconsistency of brain infarction among animals. We hypothesize that the inconsistency of infarction is caused by prolonged operation time and therefore isoflurane exposure. Neonatal hypoxia-ischemia was induced in postnatal days 7 and 10 rat pups by unilateral right common carotid ligation followed by 2.5 h of hypoxia (8% oxygen). The incision-to-ligation (ITL) was defined as the amount of time from initial incision (4 min after 2% isoflurane exposure) to completion of carotid ligation (at which point isoflurane exposure was also terminated). In the first part of the study, the ITL of each group was designated to be 5, 13, and 21 min. In the second part of the study, the ITL is designated to 4 min; however, continued isoflurane was used to make 5, 13, and 21 min isoflurane exposure for each group. Percentages of brain infarction were assessed at 48 h following surgery. Motor deficits were accessed by Rotarod test. Marked brain infarction was observed in the 5-min ITL group and a decrease of brain infarction observed in the 13-and 21-min groups (P<0.05). In the second part of the study, marked brain infarction was observed in the 5-min isoflurane exposure group, and a decrease of brain infarction was observed in each of the 13- and 21-min isoflurane exposure groups (P<0.05). Similar tendencies were observed in Rotarod tests than 5-min ITL and 5-min isoflurane groups showed more marked deficits (P<0.05). This study demonstrated that brain infarction inconsistency of the neonatal hypoxia-ischemia rat pup model is related to the operation time. The observed time-dependent decrease of brain infarction is correlated to the isoflurane exposure time. Shorter operation and isoflurane exposure improves this model consistency of brain infarction and motor deficits.
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Deng G, Yonchek JC, Quillinan N, Strnad FA, Exo J, Herson PS, Traystman RJ. A novel mouse model of pediatric cardiac arrest and cardiopulmonary resuscitation reveals age-dependent neuronal sensitivities to ischemic injury. J Neurosci Methods 2013; 222:34-41. [PMID: 24192226 DOI: 10.1016/j.jneumeth.2013.10.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 10/21/2013] [Accepted: 10/26/2013] [Indexed: 01/28/2023]
Abstract
BACKGROUND Pediatric sudden cardiac arrest (CA) is an unfortunate and devastating condition, often leading to poor neurologic outcomes. However, little experimental data on the pathophysiology of pediatric CA is currently available due to the scarcity of animal models. NEW METHOD We developed a novel experimental model of pediatric cardiac arrest and cardiopulmonary resuscitation (CA/CPR) using postnatal day 20-25 mice. Adult (8-12 weeks) and pediatric (P20-25) mice were subjected to 6min CA/CPR. Hippocampal CA1 and striatal neuronal injury were quantified 3 days after resuscitation by hematoxylin and eosin (H&E) and Fluoro-Jade B staining, respectively. RESULTS Pediatric mice exhibited less neuronal injury in both CA1 hippocampal and striatal neurons compared to adult mice. Increasing ischemia time to 8 min CA/CPR resulted in an increase in hippocampal injury in pediatric mice, resulting in similar damage in adult and pediatric brains. In contrast, striatal injury in the pediatric brain following 6 or 8 min CA/CPR remained extremely low. As observed in adult mice, cardiac arrest causes delayed neuronal death in pediatric mice, with hippocampal CA1 neuronal damage maturing at 72 h after insult. Finally, mild therapeutic hypothermia reduced hippocampal CA1 neuronal injury after pediatric CA/CPR. COMPARISON WITH EXISTING METHOD This is the first report of a cardiac arrest and CPR model of global cerebral ischemia in mice. CONCLUSIONS Therefore, the mouse pediatric CA/CPR model we developed is unique and will provide an important new tool to the research community for the study of pediatric brain injury.
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Affiliation(s)
- G Deng
- Department of Pharmacology, University of Colorado Denver, Anschutz Medical Campus, 12800 E. 19th Ave., Aurora, CO 80045, United States
| | - J C Yonchek
- Department of Anesthesiology, University of Colorado Denver, Anschutz Medical Campus, 12800 E. 19th Ave., Aurora, CO 80045, United States
| | - N Quillinan
- Department of Anesthesiology, University of Colorado Denver, Anschutz Medical Campus, 12800 E. 19th Ave., Aurora, CO 80045, United States
| | - F A Strnad
- Department of Anesthesiology, University of Colorado Denver, Anschutz Medical Campus, 12800 E. 19th Ave., Aurora, CO 80045, United States
| | - J Exo
- Department of Pediatrics, University of Colorado Denver, Anschutz Medical Campus, 12800 E. 19th Ave., Aurora, CO 80045, United States
| | - P S Herson
- Department of Pharmacology, University of Colorado Denver, Anschutz Medical Campus, 12800 E. 19th Ave., Aurora, CO 80045, United States; Department of Anesthesiology, University of Colorado Denver, Anschutz Medical Campus, 12800 E. 19th Ave., Aurora, CO 80045, United States
| | - R J Traystman
- Department of Pharmacology, University of Colorado Denver, Anschutz Medical Campus, 12800 E. 19th Ave., Aurora, CO 80045, United States; Department of Anesthesiology, University of Colorado Denver, Anschutz Medical Campus, 12800 E. 19th Ave., Aurora, CO 80045, United States.
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Saad H, Aladawy M. Temperature management in cardiac surgery. Glob Cardiol Sci Pract 2013; 2013:44-62. [PMID: 24689001 PMCID: PMC3963732 DOI: 10.5339/gcsp.2013.7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Accepted: 03/06/2013] [Indexed: 01/06/2023] Open
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Gasparetto N, Cacciavillani L, Valente S. The accuracy of PiCCO® measurements in hypothermic post-cardiac arrest patients. Anaesthesia 2012; 67:1050-1. [PMID: 22861517 DOI: 10.1111/j.1365-2044.2012.07281.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Tveita T, Sieck GC. Effects of milrinone on left ventricular cardiac function during cooling in an intact animal model. Cryobiology 2012; 65:27-32. [DOI: 10.1016/j.cryobiol.2012.03.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Revised: 03/21/2012] [Accepted: 03/21/2012] [Indexed: 11/29/2022]
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Susantitaphong P, Alfayez M, Bucay AC, Balk EM, Jaber BL. Therapeutic hypothermia and prevention of acute kidney injury: a meta-analysis of randomized controlled trials. Resuscitation 2012; 83:159-67. [PMID: 21983123 PMCID: PMC3273643 DOI: 10.1016/j.resuscitation.2011.09.023] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Revised: 09/09/2011] [Accepted: 09/24/2011] [Indexed: 01/28/2023]
Abstract
BACKGROUND Therapeutic hypothermia has been shown to reduce neurological morbidity and mortality in the setting of out-of-hospital cardiac arrest and may be beneficial following brain injury and cardiopulmonary bypass. We conducted a systematic review to ascertain the effect of therapeutic hypothermia on development of acute kidney injury (AKI) and mortality. METHODS We searched for randomized controlled trials in MEDLINE through February 2011. We included trials comparing hypothermia to normothermia that reported kidney-related outcomes including, development of AKI, dialysis requirement, changes in serum creatinine, and mortality. We performed Peto fixed-effect and random-effects model meta-analyses, and meta-regressions. RESULTS Nineteen trials reporting on 2218 patients were included; in the normothermia group, the weighted rate of AKI was 4.2%, dialysis requirement 3.7%, and mortality 10.8%. By meta-analysis, hypothermia was not associated with a lower odds of AKI (odds ratio [OR] 1.01, 95% confidence interval [CI] 0.68, 1.51; P=0.95) or dialysis requirement (OR 0.81; 95% CI 0.30, 2.19; P=0.68); however, by meta-regression, a lower target cooling temperature was associated with a lower odds of AKI (P=0.01). Hypothermia was associated with lower mortality (OR 0.69; 95% CI 0.51, 0.92; P=0.01). CONCLUSIONS In trials that ascertained kidney endpoints, therapeutic hypothermia prevented neither the development of AKI nor dialysis requirement, but was associated with lower mortality. Different definitions and rates of AKI, differences in mortality rates, and concerns about the optimal target cooling temperature preclude definitive conclusions.
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Affiliation(s)
- Paweena Susantitaphong
- Division of Nephrology, Department of Medicine, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
- Extracorporeal Multiorgan Support Dialysis Center, Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | - Mansour Alfayez
- Division of Nephrology, Department of Medicine, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Abraham Cohen Bucay
- Division of Nephrology, Department of Medicine, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Ethan M. Balk
- Center for Clinical Evidence Synthesis, Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts, USA
| | - Bertrand L. Jaber
- Division of Nephrology, Department of Medicine, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
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Sugimori H, Kanna T, Yamashita K, Kuwashiro T, Yoshiura T, Zaitsu A, Hashizume M. Early findings on brain computed tomography and the prognosis of post-cardiac arrest syndrome: application of the score for stroke patients. Resuscitation 2012; 83:848-54. [PMID: 22227499 DOI: 10.1016/j.resuscitation.2011.12.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2011] [Revised: 12/05/2011] [Accepted: 12/09/2011] [Indexed: 10/14/2022]
Abstract
AIM To examine whether early findings of the brain computed tomography (CT) evaluated by the modified Alberta stroke programme early CT (m-ASPECT) score is useful for determining the prognosis of post-cardiac arrest syndrome (PCAS) patients or not. MATERIALS From 2003 through 2010, 149 consecutive PCAS patients: (1) with various aetiologies but neither from haemorrhagic stroke nor trauma, (2) who were 15 years old or older and (3) whose brain CT was available were admitted to our intensive care unit. Early findings on all of their CT images were rated with the m-ASPECT scoring system by three raters, and an inter-rater comparison was conducted. Next, the images within 24 h from arrest were collected from 133 patients (89 males, age 60.2±17.6 years), and a relation of the scores with outcome at day 30 of the patients was analysed. RESULTS According to the inter-rater comparison based on a linear regression analysis, agreement between the raters was good (correlation coefficient 0.76-0.88). A receiver operating curve analysis revealed that the m-ASPECT scores within 24 h were a good predictor of poor outcome (dead or vegetative state) with an area under the curve of 0.905. An m-ASPECT score ≤13 was 100% predictive of a poor outcome, with a negative predictive value of 0.57. The m-ASPECT score was the best predictor of poor outcome (odds ratio 45.62) among various factors including cause or duration of arrest. CONCLUSION The m-APSECT score evaluated within 24 h from arrest was found to be the most predictive factor for outcome at day 30.
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Affiliation(s)
- Hiroshi Sugimori
- Emergency and Critical Care Center, Kyushu University Hospital, Fukuoka, Japan.
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Allen D, Nakayama S, Kuroiwa M, Nakano T, Palmateer J, Kosaka Y, Ballesteros C, Watanabe M, Bond CT, Luján R, Maylie J, Adelman JP, Herson PS. SK2 channels are neuroprotective for ischemia-induced neuronal cell death. J Cereb Blood Flow Metab 2011; 31:2302-12. [PMID: 21712833 PMCID: PMC3323193 DOI: 10.1038/jcbfm.2011.90] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
In mouse hippocampal CA1 pyramidal neurons, the activity of synaptic small-conductance Ca(2+)-activated K(+) channels type 2 (SK2 channels) provides a negative feedback on N-methyl-D-aspartate receptors (NMDARs), reestablishing Mg(2+) block that reduces Ca(2+) influx. The well-established role of NMDARs in ischemia-induced excitotoxicity led us to test the neuroprotective effect of modulating SK2 channel activity following cerebral ischemia induced by cardiac arrest and cardiopulmonary resuscitation (CA/CPR). Administration of the SK channel positive modulator, 1-ethyl-benzimidazolinone (1-EBIO), significantly reduced CA1 neuron cell death and improved CA/CPR-induced cognitive outcome. Electrophysiological recordings showed that CA/CPR-induced ischemia caused delayed and sustained reduction of synaptic SK channel activity, and immunoelectron microscopy showed that this is associated with internalization of synaptic SK2 channels, which was prevented by 1-EBIO treatment. These results suggest that increasing SK2 channel activity, or preventing ischemia-induced loss of synaptic SK2 channels, are promising and novel approaches to neuroprotection following cerebral ischemia.
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Affiliation(s)
- Duane Allen
- Vollum Institute, Oregon Health and Science University, Portland, Oregon 97201, USA
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Tveita T, Sieck GC. The physiologic responses to epinephrine during cooling and after rewarming in vivo. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R225. [PMID: 21943089 PMCID: PMC3334771 DOI: 10.1186/cc10465] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Revised: 08/12/2011] [Accepted: 09/23/2011] [Indexed: 11/12/2022]
Abstract
Introduction The purpose of our study was to determine whether hypothermia has any effects on physiological hemodynamic responses to epinephrine (Epi), and whether rewarming reverses these effects. Methods Sprague-Dawley rats were instrumented to measure mean arterial pressure (MAP), and left ventricular (LV) pressure-volume changes were recorded by using a Millar pressure-volume conductance catheter. Core temperature was reduced from 37°C to 28°C and returned to 37°C by using both internal and external heat exchangers. Two groups of rats were infused with either saline (n = 7), or Epi 0.125 μg/min continuously (n = 7). At 33°C, 30°C, and 28°C, the Epi infusion was temporarily increased from 0.125 to 1.25 μg/min. Results Before cooling, Epi infusion in both groups resulted in a significant, dose-dependent increase in heart rate (HR), stroke volume (SV), cardiac output (CO), LV dP/dtmax (maximum derivative of systolic pressure over time), but only Epi infusion at 1.25 μg/min caused elevation of MAP. During cooling to 30°C, Epi infusion at 0.125 μg/min caused a significant elevation of central hemodynamic variables, whereas MAP remained unchanged. In contrast, Epi infusions at 1.25 μg/min caused a significant elevation of MAP during cooling to 28°C but no increases in central hemodynamics. After rewarming, all hemodynamic variables returned to baseline in both groups, but only the saline-treated animals displayed the prehypothermic hemodynamic dose responses to Epi infusions. Conclusions This study shows that hypothermia causes a change in the physiological hemodynamic response to Epi, which is not reversed by rewarming.
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Affiliation(s)
- Torkjel Tveita
- Department of Physiology & Biomedical Engineering, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA
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Weant KA, Martin JE, Humphries RL, Cook AM. Pharmacologic options for reducing the shivering response to therapeutic hypothermia. Pharmacotherapy 2011; 30:830-41. [PMID: 20653360 DOI: 10.1592/phco.30.8.830] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Recent literature has demonstrated significant improvements in neurologic outcomes in patients who have received induced hypothermia in the setting of out-of-hospital cardiac arrest. Through multiple metabolic mechanisms, the induction of hypothermia slows the progression and devastation of transient cerebral hypoxia. Despite these benefits, the desired reduction in core temperature is often a challenging venture as the body attempts to maintain homeostasis through the induction of thermoregulatory processes aimed at elevating body temperature. Shivering is an involuntary muscular activity that enhances heat production in an attempt to restore homeostasis. For successful induction and maintenance of induced hypothermia, shivering, as well as other thermoregulatory responses, must be overcome. Several pharmacologic options are available, either used alone or in combination, that safely and effectively prevent or treat shivering after the induction of hypothermia. We conducted a PubMed search (1966-March 2009) to identify all human investigations published in English that discussed pharmacologic mechanisms for the control of shivering. Among these options, clonidine, dexmedetomidine, and meperidine have demonstrated the greatest and most clinically relevant impact on depression of the shivering threshold. More research in this area is needed, however, and the role of the clinical pharmacist in the development and implementation of this therapy needs to be defined.
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Affiliation(s)
- Kyle A Weant
- Pharmacy Services, University of Kentucky HealthCare, University of Kentucky, Lexington, KY 40536-0293, USA.
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Therapeutic hypothermia after cardiac arrest - cerebral perfusion and metabolism during upper and lower threshold normocapnia. Resuscitation 2011; 82:1174-9. [PMID: 21636200 DOI: 10.1016/j.resuscitation.2011.04.022] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Revised: 03/23/2011] [Accepted: 04/25/2011] [Indexed: 11/22/2022]
Abstract
BACKGROUND During cardiac arrest and after successful resuscitation a continuum of ischaemia-reperfusion injury develops. Mild hypothermia exerts protective effects in the postresuscitation phase but also alters CO₂ production and solubility, which may lead to deleterious effects if overlooked when adjusting the ventilation of the resuscitated patient. Using a multimodality approach, the effects of different carbaemic states on cerebral perfusion and metabolism were evaluated during therapeutic hypothermia. METHODS Eight comatose survivors of prehospital cardiac arrest were cooled to 33°C for 24 h and underwent a 60 min phase of interventional lower threshold normocapnia according to temperature non-corrected pCO₂ (4.2 kPa) and higher threshold normocapnia according to corrected pCO₂ (6.0 kPa) in a random order. Prior to, during and after each phase, cerebral perfusion and metabolites via a microdialysis catheter were measured. RESULTS During upper-threshold pCO₂, an increase in middle cerebral artery mean flow velocity (MFV) and jugular bulb oxygen saturation (jSvO₂) were observed with a concomitant decrease in cerebral lactate concentration. Lower threshold normocapnia was associated with a decrease in MFV in most patients. In all patients jSvO₂ decreased but no change in cerebral lactate was observed. In seven patients jSvO₂ decreased below 55%. These changes were not reflected to intracranial pressure or cerebral oximetry. CONCLUSIONS During induced hypothermia, lower threshold normocapnia was associated with decreased cerebral perfusion/oxygenation but not reflected to interstitial metabolites. Upper threshold pCO₂ increased cerebral perfusion and reduced cerebral lactate. Vigilance over the ventilatory and CO₂ analysis regimen is mandatory during mild hypothermia.
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Sorrell VL, Paleru V, Altbach MI, Hilwig RW, Kern KB, Gaballa M, Ewy GA, Berg RA. Mild hypothermia delays the development of stone heart from untreated sustained ventricular fibrillation--a cardiovascular magnetic resonance study. J Cardiovasc Magn Reson 2011; 13:17. [PMID: 21375776 PMCID: PMC3060150 DOI: 10.1186/1532-429x-13-17] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Accepted: 03/06/2011] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND 'Stone heart' resulting from ischemic contracture of the myocardium, precludes successful resuscitation from ventricular fibrillation (VF). We hypothesized that mild hypothermia might slow the progression to stone heart. METHODS Fourteen swine (27 ± 1 kg) were randomized to normothermia (group I; n=6) or hypothermia groups (group II; n=8). Mild hypothermia (34 ± 2 °C) was induced with ice packs prior to VF induction. The LV and right ventricular (RV) cross-sectional areas were followed by cardiovascular magnetic resonance until the development of stone heart. A commercial 1.5T GE Signa NV-CV/i scanner was used. Complete anatomic coverage of the heart was acquired using a steady-state free precession (SSFP) pulse sequence gated at baseline prior to VF onset. Un-gated SSFP images were obtained serially after VF induction. The ventricular endocardium was manually traced and LV and RV volumes were calculated at each time point. RESULTS In group I, the LV was dilated compared to baseline at 5 minutes after VF and this remained for 20 minutes. Stone heart, arbitrarily defined as LV volume <1/3 of baseline at the onset of VF, occurred at 29 ± 3 minutes. In group II, there was less early dilation of the LV (p<0.05) and the development of stone heart was delayed to 52 ± 4 minutes after onset of VF (P<0.001). CONCLUSIONS In this closed-chest swine model of prolonged untreated VF, hypothermia reduced the early LV dilatation and importantly, delayed the onset of stone heart thereby extending a known, morphologic limit of resuscitability.
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Affiliation(s)
- Vincent L Sorrell
- Department of Medicine, Sarver Heart Center, University of Arizona College of Medicine, Tucson, Arizona, USA
- Department of Radiology, University of Arizona College of Medicine, Tucson, Arizona, USA
- Department of Pediatrics, Steel Memorial Children Research Center, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Vijayasree Paleru
- Department of Medicine, Sarver Heart Center, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Maria I Altbach
- Department of Radiology, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Ronald W Hilwig
- Department of Medicine, Sarver Heart Center, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Karl B Kern
- Department of Medicine, Sarver Heart Center, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Mohamed Gaballa
- Department of Medicine, Sarver Heart Center, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Gordon A Ewy
- Department of Medicine, Sarver Heart Center, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Robert A Berg
- Department of Pediatrics, Steel Memorial Children Research Center, University of Arizona College of Medicine, Tucson, Arizona, USA
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Abstract
The use of induced hypothermia has been considered for treatment of head injuries since the 1900s. However, it was not until 2 landmark studies were published in 2002 that induced hypothermia was considered best practice for patients after cardiac arrest. In 2005, the American Heart Association included recommendations in the postresuscitation support guidelines recommending consideration of mild hypothermia for unconscious adult patients with return of spontaneous circulation following out-of-hospital cardiac arrest due to ventricular fibrillation. This article provides an overview on the history and supportive research for inducing mild hypothermia after cardiac arrest, the pathophysiology associated with cerebral ischemia occurring with hypothermia, nursing management for this patient population, and the development of a protocol for induced hypothermia after cardiac arrest.
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Abstract
Introduction/Aim. The most important clinically relevant cause of global
cerebral ischemia is cardiac arrest. Clinical studies showed a marked
neuroprotective effect of mild hypothermia in resuscitation. The aim of this
study was to evaluate the impact of mild hypothermia on neurological outcome
and survival of the patients in coma, after cardiac arrest and return of
spontaneous circulation. Methods. The prospective study was conducted on
consecutive comatose patients admitted to our clinic after cardiac arrest and
return of spontaneous circulation, between February 2005 and May 2009. The
patients were divided into two groups: the patients treated with mild
hypothermia and the patients treated conservatively. The intravascular in
combination with external method of cooling or only external cooling was used
during the first 24 hours, after which spontaneous rewarming started. The
endpoints were survival rate and neurological outcome. The neurological
outcome was observed with Cerebral Performance Category Scale (CPC).
Follow-up was 30 days. Results. The study was conducted on 82 patients: 45
patients (age 57.93 ? 14.08 years, 77.8% male) were treated with hypothermia,
and 37 patients (age 62.00 ? 9.60 years, 67.6% male) were treated
conservatively. In the group treated with therapeutic hypothermia protocol,
21 (46.7%) patients had full neurological restitution (CPC 1), 3 (6.7%)
patients had good neurologic outcome (CPC 2), 1 (2.2%) patient remained in
coma and 20 (44.4%) patients finally died (CPC 5). In the normothermic group
7 (18.9%) patients had full neurological restitution (CPC 1), and 30 (81.1%)
patients remained in coma and finally died (CPC 5). Between the two
therapeutic groups there was statistically significant difference in
frequencies of different neurologic outcome (p = 0.006), specially between
the patients with CPC 1 and CPC 5 outcome (p = 0.003). In the group treated
with mild hypothermia 23 (51.1%) patients survived, and in the normothermic
group 30 (81.1%) patients died, while in the group of survived patients 23
(76.7%) were treated with mild hypothermia (p = 0.003). Conclusion. Mild
therapeutic hypothermia applied after cardiac arrest improved neurological
outcome and reduced mortality in the studied group of comatose survivors.
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Sonna LA, Kuhlmeier MM, Khatri P, Chen D, Lilly CM. A microarray analysis of the effects of moderate hypothermia and rewarming on gene expression by human hepatocytes (HepG2). Cell Stress Chaperones 2010; 15:687-702. [PMID: 20526826 PMCID: PMC3006613 DOI: 10.1007/s12192-010-0181-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2008] [Revised: 02/19/2010] [Accepted: 02/22/2010] [Indexed: 11/30/2022] Open
Abstract
The gene expression changes produced by moderate hypothermia are not fully known, but appear to differ in important ways from those produced by heat shock. We examined the gene expression changes produced by moderate hypothermia and tested the hypothesis that rewarming after hypothermia approximates a heat-shock response. Six sets of human HepG2 hepatocytes were subjected to moderate hypothermia (31 degrees C for 16 h), a conventional in vitro heat shock (43 degrees C for 30 min) or control conditions (37 degrees C), then harvested immediately or allowed to recover for 3 h at 37 degrees C. Expression analysis was performed with Affymetrix U133A gene chips, using analysis of variance-based techniques. Moderate hypothermia led to distinct time-dependent expression changes, as did heat shock. Hypothermia initially caused statistically significant, greater than or equal to twofold changes in expression (relative to controls) of 409 sequences (143 increased and 266 decreased), whereas heat shock affected 71 (35 increased and 36 decreased). After 3 h of recovery, 192 sequences (83 increased, 109 decreased) were affected by hypothermia and 231 (146 increased, 85 decreased) by heat shock. Expression of many heat shock proteins was decreased by hypothermia but significantly increased after rewarming. A comparison of sequences affected by thermal stress without regard to the magnitude of change revealed that the overlap between heat and cold stress was greater after 3 h of recovery than immediately following thermal stress. Thus, while some overlap occurs (particularly after rewarming), moderate hypothermia produces extensive, time-dependent gene expression changes in HepG2 cells that differ in important ways from those induced by heat shock.
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Affiliation(s)
- Larry A Sonna
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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Green RS, Howes D. Hypothermic modulation of anoxic brain injury in adult survivors of cardiac arrest: a review of the literature and an algorithm for emergency physicians. CAN J EMERG MED 2010; 7:42-7. [PMID: 17355653 DOI: 10.1017/s1481803500012926] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Anoxic brain injury is a common outcome after cardiac arrest. Despite substantial research into the pathophysiology and management of this injury, a beneficial treatment modality has not been previously identified. Recent studies show that induced hypothermia reduces mortality and improves neurological outcomes in patients resuscitated from ventricular fibrillation. This article reviews the literature on induced hypothermia for anoxic brain injury and summarizes a treatment algorithm proposed by the Canadian Association of Emergency Physicians Critical Care Committee for hypothermia induction in cardiac arrest survivors.
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Affiliation(s)
- Robert S Green
- Division of Critical Care Medicine, Dalhousie University, Halifax, NS, Canada.
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Suresh MS, LaToya Mason C, Munnur U. Cardiopulmonary resuscitation and the parturient. Best Pract Res Clin Obstet Gynaecol 2010; 24:383-400. [DOI: 10.1016/j.bpobgyn.2010.01.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2010] [Accepted: 01/12/2010] [Indexed: 10/19/2022]
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Mechem CC, Goodloe JM, Richmond NJ, Kaufman BJ, Pepe PE. Resuscitation center designation: recommendations for emergency medical services practices. PREHOSP EMERG CARE 2010; 14:51-61. [PMID: 19947868 DOI: 10.3109/10903120903349804] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Regionalization of medical resources by designating specialty receiving centers, such as trauma and stroke centers, within emergency medical services (EMS) systems is intended to ensure the highest-quality patient care in the most efficient and fiscally responsible fashion. Significant advances in the past decade such as induction of therapeutic hypothermia following resuscitation from cardiac arrest and a time-driven, algorithmic approach to management of septic patients have created compelling arguments for similar designation for specialized resuscitative interventions. Resuscitation of critically ill patients is both labor- and resource-intensive. It can significantly interrupt emergency department (ED) patient throughput. In addition, clinical progress in developing resuscitation techniques is often dependent on the presence of a strong research infrastructure to generate and validate new therapies. It is not feasible for many hospitals to make the commitment to care for large numbers of critically ill patients and the accompanying investigational activities, whether in the prehospital, ED, or inpatient arena. Because of this, the question of whether EMS systems should designate specific hospitals as "resuscitation centers" has now come center stage. Just as EMS systems currently delineate criteria and monitor compliance for trauma, ST-elevation myocardial infarction (STEMI), and stroke centers, strong logic now exists to develop similar standards for resuscitation facilities. Accordingly, this discussion reviews the current applicable trends in resuscitation science and presents a rationale for resuscitation center designation within EMS systems. Potential barriers to the establishment of such centers are discussed and strategies to overcome them are proposed.
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Affiliation(s)
- C Crawford Mechem
- Department of Emergency Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
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Abstract
The use of therapeutic hypothermia (TH) in acute care medicine has evolved over the past 2 centuries, and its use over the past decade has increased in emergency departments, intensive care units, and operating rooms. Therapeutic hypothermia has several potential clinical applications based on its putative mechanisms of action. It appears to improve oxygen supply to ischemic areas of the brain and decreases intracranial pressure. Mild-to-moderate TH (33 degrees C +/- 1 degrees C) after resuscitation from cardiac arrest is neuroprotective, and also acts on the cardiovascular system with evidence of a decrease in heart rate and increase in systemic vascular resistance. Therapeutic hypothermia decreases cardiac output by 7% for each 1 degrees C decrease in core body temperature, but maintains the stroke volume and the mean arterial pressure. Despite a growing amount of data, this life-saving technique is underutilized in hospitals worldwide. The purpose of this comprehensive review is to show the evolution and the clinical use of TH as it pertains to acute care practitioners.
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Affiliation(s)
- Joseph Varon
- The University of Texas Health Science Center at Houston, 2219 Dorrington St., Houston, TX 77030, USA.
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Kelly FE, Nolan JP. The effects of mild induced hypothermia on the myocardium: a systematic review. Anaesthesia 2010; 65:505-15. [DOI: 10.1111/j.1365-2044.2009.06237.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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