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Lee HY, Jung YH, Mamadjonov N, Jeung KW, Lee BK, Kim T, Kim HJ, Gumucio JA, Salcido DD. Assessment of the Effects of Sodium Nitroprusside Administered Via Intracranial Subdural Catheters on the Cerebral Blood Flow and Lactate Using Dynamic Susceptibility Contrast Magnetic Resonance Imaging and Proton Magnetic Resonance Spectroscopy in a Pig Cardiac Arrest Model. J Am Heart Assoc 2023; 12:e029774. [PMID: 37776216 PMCID: PMC10727238 DOI: 10.1161/jaha.123.029774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 08/29/2023] [Indexed: 10/02/2023]
Abstract
Background Cerebral blood flow (CBF) is impaired in the early phase after return of spontaneous circulation. Sodium nitroprusside (SNP) administration via intracranial subdural catheters improves cerebral cortical microcirculation. We determined whether the SNP treatment improves CBF in the subcortical tissue and evaluated the effects of this treatment on cerebral lactate. Methods and Results Sixty minutes after return of spontaneous circulation following 14 minutes of untreated cardiac arrest, 14 minipigs randomly received 4 mg SNP or saline via intracranial subdural catheters. CBF was measured in regions of interest within the cerebrum and thalamus using dynamic susceptibility contrast-magnetic resonance imaging. After return of spontaneous circulation, CBF was expressed as a percentage of the baseline value. In the saline group, the %CBF in the regions of interest within the cerebrum remained at approximately 50% until 3.5 hours after return of spontaneous circulation, whereas %CBF in the thalamic regions of interest recovered to approximately 73% at this time point. The percentages of the baseline values in the cortical gray matter and subcortical white matter were higher in the SNP group (group effect P=0.026 and 0.025, respectively) but not in the thalamus. The cerebral lactate/creatine ratio measured using magnetic resonance spectroscopy increased over time in the saline group but not in the SNP group (group-time interaction P=0.035). The thalamic lactate/creatine ratio was similar in the 2 groups. Conclusions SNP administered via intracranial subdural catheters improved CBF not only in the cortical gray matter but also in the subcortical white matter. The CBF improvement by SNP was accompanied by a decrease in cerebral lactate.
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Affiliation(s)
- Hyoung Youn Lee
- Trauma CenterChonnam National University HospitalGwangjuRepublic of Korea
| | - Yong Hun Jung
- Department of Emergency MedicineChonnam National University HospitalGwangjuRepublic of Korea
- Department of Emergency MedicineChonnam National University Medical SchoolGwangjuRepublic of Korea
| | - Najmiddin Mamadjonov
- Department of Medical ScienceChonnam National University Graduate SchoolGwangjuRepublic of Korea
| | - Kyung Woon Jeung
- Department of Emergency MedicineChonnam National University HospitalGwangjuRepublic of Korea
- Department of Emergency MedicineChonnam National University Medical SchoolGwangjuRepublic of Korea
| | - Byung Kook Lee
- Department of Emergency MedicineChonnam National University HospitalGwangjuRepublic of Korea
- Department of Emergency MedicineChonnam National University Medical SchoolGwangjuRepublic of Korea
| | - Tae‐Hoon Kim
- Medical Convergence Research CenterWonkwang UniversityIksanRepublic of Korea
| | - Hyung Joong Kim
- Medical Science Research InstituteKyung Hee University HospitalSeoulRepublic of Korea
| | - Jorge Antonio Gumucio
- Department of Emergency MedicineSchool of Medicine University of PittsburghPittsburghPAUSA
| | - David D. Salcido
- Department of Emergency MedicineSchool of Medicine University of PittsburghPittsburghPAUSA
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Schoenthal T, Hoiland R, Griesdale DE, Sekhon MS. Cerebral hemodynamics after cardiac arrest: implications for clinical management. Minerva Anestesiol 2023; 89:824-833. [PMID: 37676177 DOI: 10.23736/s0375-9393.23.17268-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
Following resuscitation from cardiac arrest, hypoxic ischemic brain injury (HIBI) ensues, which is the primary determinant of adverse outcome. The pathophysiology of HIBI can be compartmentalized into primary and secondary injury, resulting from cerebral ischemia during cardiac arrest and reperfusion following successful resuscitation, respectively. During the secondary injury phase, increased attention has been directed towards the optimization of cerebral oxygen delivery to prevent additive injury to the brain. During this phase, cerebral hemodynamics are characterized by early hyperemia following resuscitation and then a protracted phase of cerebral hypoperfusion termed "no-reflow" during which additional hypoxic-ischemic injury can occur. As such, identification of therapeutic strategies to optimize cerebral delivery of oxygen is at the forefront of HIBI research. Unfortunately, randomized control trials investigating the manipulation of arterial carbon dioxide tension and mean arterial pressure augmentation as methods to potentially improve cerebral oxygen delivery have shown no impact on clinical outcomes. Emerging literature suggests differential patient-specific phenotypes may exist in patients with HIBI. The potential to personalize therapeutic strategies in the critical care setting based upon patient-specific pathophysiology presents an attractive strategy to improve HIBI outcomes. Herein, we review the cerebral hemodynamic pathophysiology of HIBI, discuss patient phenotypes as it pertains to personalizing care, as well as suggest future directions.
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Affiliation(s)
- Tison Schoenthal
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Ryan Hoiland
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Department of Cellular and Physiological Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Center for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, Faculty of Health and Social Development, University of British Columbia Okanagan, Kelowna, BC, Canada
- International Collaboration on Repair Discoveries, Vancouver, BC, Canada
| | - Donald E Griesdale
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Center for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada -
- International Collaboration on Repair Discoveries, Vancouver, BC, Canada
- Djavad Mowafaghian Center for Brain Health, University of British Columbia, Vancouver, BC, Canada
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Alcock S, Singh S, Wiens EJ, Singh N, Ande SR, Lampron K, Huang B, Kirkpatrick I, Trivedi A, Schaffer SA, Shankar JS. CT perfusion for Assessment of poor Neurological outcome in Comatose Cardiac Arrest Patients (CANCCAP): protocol for a prospective study. BMJ Open 2023; 13:e071166. [PMID: 37270194 DOI: 10.1136/bmjopen-2022-071166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2023] Open
Abstract
INTRODUCTION Cardiac arrest remains one of the most common causes of death with the majority occurring outside of hospitals (out of hospital cardiac arrest). Despite advancements in resuscitation management, approximately 50% of comatose cardiac arrest patients (CCAP) will suffer a severe unsurvivable brain injury. To assess brain injury, a neurological examination is conducted, however, its reliability in predicting outcomes in the first days following cardiac arrest is limited. Non-contrast CT is the most employed scan to assess hypoxic changes, even though it is not sensitive to early hypoxic-ischaemic changes in the brain. CT perfusion (CTP) has shown high sensitivity and specificity in brain death patients, although its use in predicting poor neurological outcome in CCAP has not yet been explored. The purpose of this study is to validate CTP for predicting poor neurological outcome (modified Rankin scale, mRS≥4) at hospital discharge in CCAP. METHODS AND ANALYSIS The CT Perfusion for Assessment of poor Neurological outcome in Comatose Cardiac Arrest Patients study is a prospective cohort study funded by the Manitoba Medical Research Foundation. Newly admitted CCAP receiving standard Targeted Temperature Management are eligible. Patients undergo a CTP at the same time as the admission standard of care head CT. Admission CTP findings will be compared with the reference standard of an accepted bedside clinical assessment at the time of admission. Deferred consent will be used. The primary outcome is a binary outcome of good neurological status, defined as mRs<4 or poor neurological status (mRs≥4) at hospital discharge. A total of 90 patients will be enrolled. ETHICS AND DISSEMINATION This study has been approved by the University of Manitoba Health Research Ethics Board. The findings from our study will be disseminated through peer-reviewed journals and presentations at local rounds, national and international conferences. The public will be informed at the end of the study. TRIAL REGISTRATION NUMBER NCT04323020.
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Affiliation(s)
- Susan Alcock
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sarbjeet Singh
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Evan J Wiens
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Navjit Singh
- University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Sudharsana Rao Ande
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kristen Lampron
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Beili Huang
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Iain Kirkpatrick
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Anurag Trivedi
- Section of Neurology, Department of Internal Medicine, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| | - Stephen Allan Schaffer
- Sections of Cardiology and Critical Care Medicine, Department of Internal Medicine, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Jai Shiva Shankar
- Department of Radiology, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
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Jha RM, Elmer J. Transcranial dopplers after cardiac arrest: Should we ride this wave? Resuscitation 2019; 141:204-206. [PMID: 31260711 DOI: 10.1016/j.resuscitation.2019.06.281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 06/19/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Ruchira M Jha
- Departments of Critical Care Medicine, Neurology and Neurosurgery, University of Pittsburgh, Pittsburgh, USA
| | - Jonathan Elmer
- Departments of Emergency Medicine, Critical Care Medicine and Neurology, University of Pittsburgh, Pittsburgh, USA.
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Elmer J, Flickinger KL, Anderson MW, Koller AC, Sundermann ML, Dezfulian C, Okonkwo DO, Shutter LA, Salcido DD, Callaway CW, Menegazzi JJ. Effect of neuromonitor-guided titrated care on brain tissue hypoxia after opioid overdose cardiac arrest. Resuscitation 2018; 129:121-126. [PMID: 29679696 PMCID: PMC6054552 DOI: 10.1016/j.resuscitation.2018.04.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 03/23/2018] [Accepted: 04/13/2018] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Brain tissue hypoxia may contribute to preventable secondary brain injury after cardiac arrest. We developed a porcine model of opioid overdose cardiac arrest and post-arrest care including invasive, multimodal neurological monitoring of regional brain physiology. We hypothesized brain tissue hypoxia is common with usual post-arrest care and can be prevented by modifying mean arterial pressure (MAP) and arterial oxygen concentration (PaO2). METHODS We induced opioid overdose and cardiac arrest in sixteen swine, attempted resuscitation after 9 min of apnea, and randomized resuscitated animals to three alternating 6-h blocks of standard or titrated care. We invasively monitored physiological parameters including brain tissue oxygen (PbtO2). During standard care blocks, we maintained MAP > 65 mmHg and oxygen saturation 94-98%. During titrated care, we targeted PbtO2 > 20 mmHg. RESULTS Overall, 10 animals (63%) achieved ROSC after a median of 12.4 min (range 10.8-21.5 min). PbtO2 was higher during titrated care than standard care blocks (unadjusted β = 0.60, 95% confidence interval (CI) 0.42-0.78, P < 0.001). In an adjusted model controlling for MAP, vasopressors, sedation, and block sequence, PbtO2 remained higher during titrated care (adjusted β = 0.75, 95%CI 0.43-1.06, P < 0.001). At three predetermined thresholds, brain tissue hypoxia was significantly less common during titrated care blocks (44 vs 2% of the block duration spent below 20 mmHg, P < 0.001; 21 vs 0% below 15 mmHg, P < 0.001; and, 7 vs 0% below 10 mmHg, P = .01). CONCLUSIONS In this model of opioid overdose cardiac arrest, brain tissue hypoxia is common and treatable. Further work will elucidate best strategies and impact of titrated care on functional outcomes.
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Affiliation(s)
- Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA.
| | - Katharyn L Flickinger
- Department of Emergency Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA
| | - Maighdlin W Anderson
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA
| | - Allison C Koller
- Department of Emergency Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA
| | - Matthew L Sundermann
- Department of Emergency Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA
| | - Cameron Dezfulian
- Department of Critical Care Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA
| | - Lori A Shutter
- Department of Critical Care Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA; Department of Neurological Surgery, University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA
| | - David D Salcido
- Department of Emergency Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA
| | - James J Menegazzi
- Department of Emergency Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA
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Abstract
Cardiac arrest is common and deadly. Most patients who are treated in the hospital after achieving return of spontaneous circulation still go on to die from the sequelae of anoxic brain injury. In this review, the authors provide an overview of the mechanisms and consequences of postarrest brain injury. Special attention is paid to potentially modifiable mechanisms of secondary brain injury including seizures, hyperpyrexia, cerebral hypoxia and hypoperfusion, oxidative injury, and the development of cerebral edema. Finally, the authors discuss the outcomes of cardiac arrest survivors with a focus on commonly observed patterns of injury as well as the scales used to measure patient outcome and their limitations.
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Affiliation(s)
- Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Abstract
Suboptimal neurodevelopmental outcome is common in children who have congenital heart disease. Its aetiology is often multifactorial. This review focuses on the role of cardiopulmonary bypass. Hypothermia is the mainstay of cerebral protection. Low flow and regional low flow are preferred to deep hypothermic circulatory arrest in many situations. Cooling and rewarming, aortopulmonary collaterals, pH, air emboli, the systemic inflammatory response, haematocrit, oxygenation, glucose and ultrafiltration can influence neurodevelopmental outcome. Although no pharmacological agents have been shown to have a beneficial effect on neurodevelopmental outcome in clinical practice in children, animal work on the use of steroids several hours before surgery is encouraging.
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Aging Effect on Post-recovery Hypofusion and Mortality Following Cardiac Arrest and Resuscitation in Rats. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016. [PMID: 26782221 DOI: 10.1007/978-1-4939-3023-4_33] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
In this study we investigated the effect of aging on brain blood flow following transient global ischemia. Male Fisher rats (6 and 24 months old) underwent cardiac arrest (15 min) and resuscitation. Regional brain (cortex, hippocampus, brainstem and cerebellum) blood flow was measured in non-arrested rats and 1-h recovery rats using [14C] iodoantipyrene (IAP) autoradiography; the 4-day survival rate was determined in the two age groups. The pre-arrest baseline blood flows were similar in cortex, brainstem and cerebellum between the 6-month and the 24-month old rats; however, the baseline blood flow in hippocampus was significantly lower in the 24-month old group. At 1 h following cardiac arrest and resuscitation, both 6-month and 24-month groups had significantly lower blood flows in all regions than the pre-arrest baseline values; compared to the 6-month old group, the blood flow was significantly lower (about 40% lower) in all regions in the 24-month old group. The 4-day survival rate for the 6-month old rats was 50% (3/6) whereas none of the 24-month old rats (0/10) survived for 4 days. The data suggest that there is an increased vulnerability to brain ischemic-reperfusion injury in the aged rats; the degree of post-recovery hypoperfusion may contribute to the high mortality in the aged rats following cardiac arrest and resuscitation.
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Deng R, Koenig MA, Young LM, Jia X. Early Quantitative Gamma-Band EEG Marker is Associated with Outcomes After Cardiac Arrest and Targeted Temperature Management. Neurocrit Care 2015; 23:262-73. [PMID: 26130405 PMCID: PMC4560606 DOI: 10.1007/s12028-015-0157-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Brain recovery after cardiac arrest (CA) is sensitive to temperature. Yet the effect of temperature management on different EEG frequency bands has not been elucidated. A novel quantitative EEG algorithm, sub-band information quantity (SIQ), was applied to evaluate EEG recovery and outcomes after CA. METHODS Twenty-four Wistar rats undergoing 7-min CA were randomly assigned to immediate hypothermia (32-34 °C), normothermia (36.5-37.5 °C), or hyperthermia (38.5-39.5 °C) (n = 8). EEG was recorded continuously for the first 8 h and then for serial 30-min epochs daily. The neurologic deficit score (NDS) at 72-h was the primary functional outcome. Another four rats without brain injury were added as a control. RESULTS Better recovery of gamma-band SIQ was found in the hypothermia group (0.60 ± 0.03) compared with the normothermia group (0.40 ± 0.03) (p < 0.01) and in the normothermia group compared with the hyperthermia group (0.34 ± 0.03) (p < 0.05). The NDS was also improved in the lower temperature groups: hypothermia [median (25th, 75th), 74 (61, 74)] versus normothermia [49 (47, 61)] versus hyperthermia [43 (0, 50)] (p < 0.01). Throughout the 72-h experiment, the gamma-band SIQ showed the strongest correlation at every time point (ranging 0.520-0.788 from 30-min to 72-h post-resuscitation, all p < 0.05) whereas the delta-band SIQ had poor correlation with the 72-h NDS. No significant difference of sub-band EEG was found with temperature manipulation alone. CONCLUSIONS Recovery of gamma-band SIQ-qEEG was strongly associated with functional outcomes after CA. Induced hypothermia was associated with faster recovery of gamma-band SIQ and improved functional outcomes. Targeted temperature management primarily affected gamma frequency oscillations but not delta rhythm.
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Affiliation(s)
- Ruoxian Deng
- Department of Biomedical Engineering, The Johns Hopkins University School of Medicine, Baltimore, MD 21205
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201
| | - Matthew A. Koenig
- Department of Medicine, The University of Hawaii John A. Burns School of Medicine, Honolulu, HI 96813
- Neuroscience Institute, The Queen’s Medical Center, Honolulu, HI 96813
| | - Leanne Moon Young
- Department of Biomedical Engineering, The Johns Hopkins University School of Medicine, Baltimore, MD 21205
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201
| | - Xiaofeng Jia
- Department of Biomedical Engineering, The Johns Hopkins University School of Medicine, Baltimore, MD 21205
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD 21205
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD 21201
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Abstract
Full cerebral recovery after cardiopulmonary resuscitation is still a rare event. Unfortunately, up to now, no specific and outcome-improving therapy was available after such events. From several cases it is known that low body and brain temperature during a cardiocirculatory arrest improves the neurological outcome following these events. As it is not possible in acute events to induce hypothermia beforehand, whether cooling after the insult could also be protective was evaluated. After animal studies in the 1990s and first clinical pilot trials of mild therapeutic and induced hypothermia, two randomized trials of hypothermic therapy after successful resuscitation after cardiac arrest were conducted. These studies demonstrated that hypothermia after cardiac arrest could improve neurological outcome as well as overall mortality.
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Affiliation(s)
- Michael Holzer
- Department of Emergency Medicine, University of Vienna, Universitätsklinik für Notfallmedizin, AKH--Wien, Austria.
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Abstract
BACKGROUND Ischemia depletes antioxidant reserves and impairs mitochondrial electron transport. Oxygen within blood reperfusing ischemic tissue can form free radicals, worsen oxidative stress, and exacerbate tissue injury (reperfusion injury). One strategy for limiting reperfusion injury is to limit delivery of "luxuriant" oxygen during or after reperfusion. Resuscitation guidelines for children with cardiac arrest recommend early weaning of supplemental oxygen as tolerated. There are currently no studies demonstrating the frequency and outcomes of hyperoxia and hypoxia after pediatric cardiac arrest. OBJECTIVE To determine the frequency and outcomes of hyperoxia and hypoxia in patients following resuscitation from pediatric cardiac arrest admitted to a tertiary care center. DESIGN AND METHODS This is a retrospective observational cohort study. Charts of children resuscitated from cardiac arrest and admitted to our hospital from 2004 to 2008 were reviewed. Partial pressures of oxygen (PaO2) obtained within the first 24 hours following return of spontaneous circulation and mortality at 6 months was recorded. Children who did not survive the initial 48 hours, patients having undergone extracorporeal oxygenation or had congenital heart disease, and those in whom arterial blood gases were not obtained were excluded. RESULTS Seventy-four patients met inclusion criteria. Of these, 38 (51%) had at least one arterial blood gases with a PaO2 > 300 mm Hg and 10 (14%) had a PaO2 < 60 mm Hg in the first 24 hours. Neither hyperoxia nor hypoxia on initial arterial blood gases (p = 0.912 and p = 0.384) nor any arterial blood gases within the first 24 hours after cardiac arrest (p = 0.325 and p = 0.553) was associated with 6-month mortality. CONCLUSIONS Hyperoxia occurs commonly within the first 24 hours of management in children resuscitated from cardiac arrest.
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Infusion of 4°C normal saline can improve the neurological outcome in a porcine model of cardiac arrest. J Trauma Acute Care Surg 2012; 72:1213-9; discussion 1219. [PMID: 22673247 DOI: 10.1097/ta.0b013e318246ed36] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study sought to investigate induction of therapeutic hypothermia using ice-cold intravenous fluid after cardiopulmonary resuscitation (CPR). The effects on temperature, hemodynamics, cognitive performance and the accompanying neurohistopathological changes, and apoptosis were assessed. METHODS Fourteen piglets had 4 minutes of untreated ventricular fibrillation, followed by CPR. The animals in which spontaneous circulation was restored were randomly assigned to two groups: the hypothermia group (n = 7) was given an infusion of 4°C cold normal saline solution 30 mL/kg at an infusion rate of 1.33 mL/kg/min, followed by 10 mL/kg/h to 4 hours after restoration of spontaneous circulation; the control group (n = 7) was given the same infusion at room temperature. Variables were measured repeatedly until 4 hours after restoration of spontaneous circulation. Neurocognitive performance was evaluated 24 hours after CPR. Then animals were killed and the brains were removed for histopathology at 24 hours after restoration of spontaneous circulation. Terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling method was used for apoptosis evaluation. RESULTS Compared with the control group, the core temperature of the hypothermia group was significantly decreased (p < 0.01). The cerebral performance categories at 24 hours after restoration of spontaneous circulation in the hypothermia group were better than that in the control group (p < 0.05). The percentage of terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling-positive cells in the cortex and dentate gyrus of the hippocampus were significantly reduced in the hypothermia group compared with the control group at 24 hours after restoration of spontaneous circulation. By observation of transmission electron microscopy, the neuron damages were significantly reduced in hypothermia group. CONCLUSION 4°C normal saline solution is a safe and effective method to reduce brain damages and prevent apoptotic cell death after cardiac arrest.
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van den Boogaard M, Wijers-Holys P, Wijnen N, Gielen S, Verschuur E. Decubitus op de ic na gecontroleerde milde hypothermie. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012. [DOI: 10.1007/s12426-010-0107-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Lebiedz P, Meiners J, Samol A, Wasmer K, Reinecke H, Waltenberger J, Eckardt L. Electrocardiographic changes during therapeutic hypothermia. Resuscitation 2012; 83:602-6. [DOI: 10.1016/j.resuscitation.2011.11.016] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2011] [Revised: 11/01/2011] [Accepted: 11/10/2011] [Indexed: 10/15/2022]
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Chill therapy in the patients with resuscitated cardiac arrest: A new weapon in the battle against anoxic brain injury. Int J Cardiol 2010; 138:300-2. [DOI: 10.1016/j.ijcard.2008.06.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2008] [Accepted: 06/28/2008] [Indexed: 11/17/2022]
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Nolan JP, Neumar RW, Adrie C, Aibiki M, Berg RA, Bbttiger BW, Callaway C, Clark RS, Geocadin RG, Jauch EC, Kern KB, Laurent I, Longstreth W, Merchant RM, Morley P, Morrison LJ, Nadkarni V, Peberdy MA, Rivers EP, Rodriguez-Nunez A, Sellke FW, Spaulding C, Sunde K, Hoek TV. Post-cardiac arrest syndrome: Epidemiology, pathophysiology, treatment, and prognostication: A Scientific Statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke (Part II). Int Emerg Nurs 2010; 18:8-28. [DOI: 10.1016/j.ienj.2009.07.001] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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17
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Nolan JP, Neumar RW, Adrie C, Aibiki M, Berg RA, Bbttiger BW, Callaway C, Clark RSB, Geocadin RG, Jauch EC, Kern KB, Laurent I, Longstreth WT, Merchant RM, Morley P, Morrison LJ, Nadkarni V, Peberdy MA, Rivers EP, Rodriguez-Nunez A, Sellke FW, Spaulding C, Sunde K, Hoek TV. Post-cardiac arrest syndrome: Epidemiology, pathophysiology, treatment, and prognostication: A scientific statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke (Part 1). Int Emerg Nurs 2009; 17:203-25. [PMID: 19782333 DOI: 10.1016/j.ienj.2009.01.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
AIM OF THE REVIEW To review the epidemiology, pathophysiology, treatment and prognostication in relation to the post-cardiac arrest syndrome. METHODS Relevant articles were identified using PubMed, EMBASE and an American Heart Association EndNote master resuscitation reference library, supplemented by hand searches of key papers. Writing groups comprising international experts were assigned to each section. Drafts of the document were circulated to all authors for comment and amendment. RESULTS The 4 key components of post-cardiac arrest syndrome were identified as (1) post-cardiac arrest brain injury, (2) post-cardiac arrest myocardial dysfunction, (3) systemic ischaemia/reperfusion response, and (4) persistent precipitating pathology. CONCLUSIONS A growing body of knowledge suggests that the individual components of the postcardiac arrest syndrome are potentially treatable.
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Affiliation(s)
- Jerry P Nolan
- Consultant in Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, United Kingdom.
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Abstract
BACKGROUND Mild to moderate hypothermia (32-35 degrees C) is the first treatment with proven efficacy for postischemic neurological injury. In recent years important insights have been gained into the mechanisms underlying hypothermia's protective effects; in addition, physiological and pathophysiological changes associated with cooling have become better understood. OBJECTIVE To discuss hypothermia's mechanisms of action, to review (patho)physiological changes associated with cooling, and to discuss potential side effects. DESIGN Review article. INTERVENTIONS None. MAIN RESULTS A myriad of destructive processes unfold in injured tissue following ischemia-reperfusion. These include excitotoxicty, neuroinflammation, apoptosis, free radical production, seizure activity, blood-brain barrier disruption, blood vessel leakage, cerebral thermopooling, and numerous others. The severity of this destructive cascade determines whether injured cells will survive or die. Hypothermia can inhibit or mitigate all of these mechanisms, while stimulating protective systems such as early gene activation. Hypothermia is also effective in mitigating intracranial hypertension and reducing brain edema. Side effects include immunosuppression with increased infection risk, cold diuresis and hypovolemia, electrolyte disorders, insulin resistance, impaired drug clearance, and mild coagulopathy. Targeted interventions are required to effectively manage these side effects. Hypothermia does not decrease myocardial contractility or induce hypotension if hypovolemia is corrected, and preliminary evidence suggests that it can be safely used in patients with cardiac shock. Cardiac output will decrease due to hypothermia-induced bradycardia, but given that metabolic rate also decreases the balance between supply and demand, is usually maintained or improved. In contrast to deep hypothermia (<or=30 degrees C), moderate hypothermia does not induce arrhythmias; indeed, the evidence suggests that arrhythmias can be prevented and/or more easily treated under hypothermic conditions. CONCLUSIONS Therapeutic hypothermia is a highly promising treatment, but the potential side effects need to be properly managed particularly if prolonged treatment periods are required. Understanding the underlying mechanisms, awareness of physiological changes associated with cooling, and prevention of potential side effects are all key factors for its effective clinical usage.
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Neumar RW, Nolan JP, Adrie C, Aibiki M, Berg RA, Böttiger BW, Callaway C, Clark RSB, Geocadin RG, Jauch EC, Kern KB, Laurent I, Longstreth WT, Merchant RM, Morley P, Morrison LJ, Nadkarni V, Peberdy MA, Rivers EP, Rodriguez-Nunez A, Sellke FW, Spaulding C, Sunde K, Vanden Hoek T. Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication. A consensus statement from the International Liaison Committee on Resuscitation (American Heart Association, Australian and New Zealand Council on Resuscitation, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Asia, and the Resuscitation Council of Southern Africa); the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; and the Stroke Council. Circulation 2008; 118:2452-83. [PMID: 18948368 DOI: 10.1161/circulationaha.108.190652] [Citation(s) in RCA: 1059] [Impact Index Per Article: 66.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Nolan JP, Neumar RW, Adrie C, Aibiki M, Berg RA, Böttiger BW, Callaway C, Clark RSB, Geocadin RG, Jauch EC, Kern KB, Laurent I, Longstreth WT, Merchant RM, Morley P, Morrison LJ, Nadkarni V, Peberdy MA, Rivers EP, Rodriguez-Nunez A, Sellke FW, Spaulding C, Sunde K, Hoek TV. Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication. A Scientific Statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke. Resuscitation 2008; 79:350-79. [PMID: 18963350 DOI: 10.1016/j.resuscitation.2008.09.017] [Citation(s) in RCA: 697] [Impact Index Per Article: 43.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2008] [Accepted: 09/22/2008] [Indexed: 12/12/2022]
Abstract
AIM OF THE REVIEW To review the epidemiology, pathophysiology, treatment and prognostication in relation to the post-cardiac arrest syndrome. METHODS Relevant articles were identified using PubMed, EMBASE and an American Heart Association EndNote master resuscitation reference library, supplemented by hand searches of key papers. Writing groups comprising international experts were assigned to each section. Drafts of the document were circulated to all authors for comment and amendment. RESULTS The 4 key components of post-cardiac arrest syndrome were identified as (1) post-cardiac arrest brain injury, (2) post-cardiac arrest myocardial dysfunction, (3) systemic ischaemia/reperfusion response, and (4) persistent precipitating pathology. CONCLUSIONS A growing body of knowledge suggests that the individual components of the post-cardiac arrest syndrome are potentially treatable.
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Affiliation(s)
- Jerry P Nolan
- Consultant in Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, United Kingdom.
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21
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Abstract
In industrial countries it is estimated that the incidence of out-of-hospital sudden cardiac arrest lies between 36 and 128 per 100,000 inhabitants per year. Almost 80% of patients who initially survive a cardiac arrest present with coma lasting more than 1 h. Current therapy during cardiac arrest concentrates on the external support of circulation and respiration with additional drug and electrical therapy. Therapeutic hypothermia provides a new and very effective therapy for neuroprotection in patients after cardiac arrest. It is critical that mild hypothermia has to be applied very early after the ischaemic insult to be effective, otherwise the beneficial effects would be diminished or even abrogated. There are numerous methods available for cooling patients after ischaemic states. Surface cooling devices are non-invasive and range from simple ice packs to sophisticated machines with automatic feedback control. Other non-invasive methods include drugs and cold liquid ventilation. The newer devices have cooling rates comparable to invasive catheter techniques. Invasive cooling methods include the administration of ice-cold fluids intravenously, the use of intravascular cooling catheters, body cavity lavage, extra-corporeal circuits and selective brain cooling. Most of these methods are quite invasive and are still in an experimental stage. The optimal timing and technique for the induction of hypothermia after cardiac arrest have not yet been defined, and it is currently a major topic of ongoing research. The induction of hypothermia after cardiac arrest needs to be an integral component of the initial evaluation and stabilization of the patient.
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Abstract
Increasing evidence suggests that induction of mild hypothermia (32-35 degrees C) in the first hours after an ischaemic event can prevent or mitigate permanent injuries. This effect has been shown most clearly for postanoxic brain injury, but could also apply to other organs such as the heart and kidneys. Hypothermia has also been used as a treatment for traumatic brain injury, stroke, hepatic encephalopathy, myocardial infarction, and other indications. Hypothermia is a highly promising treatment in neurocritical care; thus, physicians caring for patients with neurological injuries, both in and outside the intensive care unit, are likely to be confronted with questions about temperature management more frequently. This Review discusses the available evidence for use of controlled hypothermia, and also deals with fever control. Besides discussing the evidence, the aim is to provide information to help guide treatments more effectively with regard to timing, depth, duration, and effective management of side-effects. In particular, the rate of rewarming seems to be an important factor in establishing successful use of hypothermia in the treatment of neurological injuries.
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Affiliation(s)
- Kees H Polderman
- Department of Intensive Care, University Medical Center Utrecht, Utrecht, Netherlands.
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Abstract
Experimental studies have demonstrated the neuroprotective effects of induced hypothermia in prevention of secondary insults following acute brain injury. Therefore, therapeutic hypothermia could be effective in the clinical setting of intensive care therapy. In this paper pathophysiological aspects of induced hypothermia are discussed and clinically relevant study results of hypothermia therapy are given in respect to evidence-based medicine.
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Affiliation(s)
- J Meixensberger
- Klinik und Poliklinik für Neurochirurgie, Universität Leipzig, Johannisallee 34, 04103 Leipzig.
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24
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Polderman KH. Induced Hypothermia for Neuroprotection: Understanding the Underlying Mechanisms. Intensive Care Med 2007. [DOI: 10.1007/0-387-35096-9_31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Feuchtl A, Gockel B, Lawrenz T, Bartelsmeier M, Stellbrink C. Endovascular cooling improves neurological short-term outcome after prehospital cardiac arrest. ACTA ACUST UNITED AC 2007. [DOI: 10.1007/s00390-007-0740-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Arawwawala D, Brett SJ. Clinical review: beyond immediate survival from resuscitation-long-term outcome considerations after cardiac arrest. Crit Care 2007; 11:235. [PMID: 18177512 PMCID: PMC2246198 DOI: 10.1186/cc6139] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
A substantial body of literature concerning resuscitation from cardiac arrest now exists. However, not surprisingly, the greater part concerns the cardiac arrest event itself and optimising survival and outcome at relatively proximal time points. The aim of this review is to present the evidence base for interventions and therapeutic strategies that might be offered to patients surviving the immediate aftermath of a cardiac arrest, excluding components of resuscitation itself that may lead to benefits in long-term survival. In addition, this paper reviews the data on long-term impact, physical and neuropsychological, on patients and their families, revealing a burden that is often underestimated and underappreciated. As greater numbers of patients survive cardiac arrest, outcome measures more sophisticated than simple survival are required.
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Affiliation(s)
- Dilshan Arawwawala
- Department of Anaesthesia and Intensive Care Medicine, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Stephen J Brett
- Department of Anaesthesia and Intensive Care Medicine, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
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Cavus E, Bein B, Dörges V, Stadlbauer KH, Wenzel V, Steinfath M, Hanss R, Scholz J. Brain tissue oxygen pressure and cerebral metabolism in an animal model of cardiac arrest and cardiopulmonary resuscitation. Resuscitation 2006; 71:97-106. [PMID: 16942830 DOI: 10.1016/j.resuscitation.2006.03.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2005] [Revised: 02/28/2006] [Accepted: 03/09/2006] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Direct measurement of brain tissue oxygenation (PbtO2) is established during spontaneous circulation, but values of PbtO2 during and after cardiopulmonary resuscitation (CPR) are unknown. The purpose of this study was to investigate: (1) the time-course of PbtO2 in an established model of CPR, and (2) the changes of cerebral venous lactate and S-100B. METHODS In 12 pigs (12-16 weeks, 35-45 kg), ventricular fibrillation (VF) was induced electrically during general anaesthesia. After 4 min of untreated VF, all animals were subjected to CPR (chest compression rate 100/min, FiO2 1.0) with vasopressor therapy after 7, 12, and 17 min (vasopressin 0.4, 0.4, and 0.8 U/kg, respectively). Defibrillation was performed after 22 min of cardiac arrest. After return of spontaneous circulation (ROSC), the pigs were observed for 1h. RESULTS After initiation of VF, PbtO2 decreased compared to baseline (mean +/- SEM; 22 +/- 6 versus 2 +/- 1 mmHg after 4 min of VF; P < 0.05). During CPR, PbtO2 increased, and reached maximum values 8 min after start of CPR (25 +/- 7 mmHg; P < 0.05 versus no-flow). No further changes were seen until ROSC. Lactate, and S-100B increased during CPR compared to baseline (16 +/- 2 versus 85 +/- 8 mg/dl, and 0.46 +/- 0.05 versus 2.12 +/- 0.40 microg/l after 13 min of CPR, respectively; P < 0.001); lactate remained elevated, while S-100B returned to baseline after ROSC. CONCLUSIONS Though PbtO2 returned to pre-arrest values during CPR, PbtO2 and cerebral lactate were lower than during post-arrest reperfusion with 100% oxygen, which reflected the cerebral low-flow state during CPR. The transient increase of S-100B may indicate a disturbance of the blood-brain-barrier.
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Affiliation(s)
- Erol Cavus
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Schwanenweg 21, 24105 Kiel, Germany.
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Bunch TJ, Hammill SC, White RD. Outcomes after ventricular fibrillation out-of-hospital cardiac arrest: expanding the chain of survival. Mayo Clin Proc 2005; 80:774-82. [PMID: 15945529 DOI: 10.1016/s0025-6196(11)61532-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Coronary heart disease is the most common cause of death in the United States, with ventricular fibrillation (VF) the most common initial rhythm when cardiac disease causes arrest. Survival after VF out-of-hospital cardiac arrest (OHCA) depends on a sequence of events called the chain of survival, which Includes rapid access to emergency medical services, cardiopulmonary resuscitation, defibrillation, and advanced care. Because of widespread implementation of defibrillation programs, more patients survive VF OHCAs, making subsequent care of these patients important. Early hospitalization must focus on potential neurologic injury and therapy targeted at the underlying cardiac disease and antiarrhythmic therapy for long-term secondary prevention of sudden death. Attention to certain cohorts who are at high risk despite their underlying disease, such as women and elderly patients, is necessary. These cohorts may have the greatest response to short-term and long-term therapies for cardiac rehabilitation. With these approaches, long-term survival and quality of life after VF OHCA are favorable. Broadening the focus of the chain of survival to include in-hospital and long-term care will further improve favorable outcomes achieved in an early defibrillation program.
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Affiliation(s)
- T Jared Bunch
- Department of Internal Medicine and Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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Brüx A, Girbes ARJ, Polderman KH. [Controlled mild-to-moderate hypothermia in the intensive care unit]. Anaesthesist 2005; 54:225-44. [PMID: 15742173 DOI: 10.1007/s00101-005-0808-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Controlled hypothermia is used as a therapeutic intervention to provide neuroprotection and (more recently) cardioprotection. The growing insight into the underlying pathophysiology of apoptosis and destructive processes at the cellular level, and the mechanisms underlying the protective effects of hypothermia, have led to improved application and to a widening of the range of potential indications. In many centres hypothermia has now become part of the standard therapy for post-anoxic coma in certain patients, but for other indications its use still remains controversial. The negative findings of some studies may be partly explained by inadequate protocols for the application of hypothermia and insufficient attention to the prevention of potential side effects. This review deals with some of the concepts underlying hypothermia-associated neuroprotection and cardioprotection, and discusses some potential clinical indications as well as reasons why some clinical trials may have produced conflicting results. Practical aspects such as methods to induce hypothermia, as well as the side effects of cooling are also discussed.
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Affiliation(s)
- A Brüx
- Abteilung Intensivmedizin, Freie Universität Medisch Centrum Amsterdam, Niederlande
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Polderman KH. Application of therapeutic hypothermia in the ICU: opportunities and pitfalls of a promising treatment modality. Part 1: Indications and evidence. Intensive Care Med 2004; 30:556-75. [PMID: 14767591 DOI: 10.1007/s00134-003-2152-x] [Citation(s) in RCA: 216] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2003] [Accepted: 12/18/2003] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Hypothermia has been used for medicinal purposes since ancient times. This paper reviews the current potential clinical applications for mild hypothermia (32-35 degrees C). DESIGN AND SETTING Induced hypothermia is used mostly to prevent or attenuate neurological injury, and has been used to provide neuroprotection in traumatic brain injury, cardiopulmonary resuscitation, stroke, and various other disorders. The evidence for each of these applications is discussed, and the mechanisms underlying potential neuroprotective effects are reviewed. Some of this evidence comes from animal models, and a brief overview of these models and their limitations is included in this review. RESULTS The duration of cooling and speed of re-warming appear to be key factors in determining whether hypothermia will be effective in preventing or mitigating neurological injury. Some other potential usages of hypothermia, such as its use in the peri-operative setting and its application to mitigate cardiac injury following ischemia and reperfusion, are also discussed. CONCLUSIONS Although induced hypothermia appears to be a highly promising treatment, it should be emphasized that it is associated with a number of potentially serious side effects, which may negate some or all of its potential benefits. Prevention and/or early treatment of these complications are the key to successful use of hypothermia in clinical practice. These side effects, as well as various physiological changes induced by cooling, are discussed in a separate review.
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Affiliation(s)
- Kees H Polderman
- Department of Intensive Care, VU University Medical Center, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands.
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Rosenthal RE, Silbergleit R, Hof PR, Haywood Y, Fiskum G. Hyperbaric oxygen reduces neuronal death and improves neurological outcome after canine cardiac arrest. Stroke 2003; 34:1311-6. [PMID: 12677019 DOI: 10.1161/01.str.0000066868.95807.91] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Studies suggest that hyperbaric oxygen (HBO) is neuroprotective after experimental cerebral ischemia, but the mechanism is unknown. This study tested the hypotheses that postischemic HBO affords clinical and histopathological neuroprotection after experimental cardiac arrest and resuscitation (A/R) and that this neuroprotection results from improved cerebral oxygen metabolism after A/R. METHODS Anesthetized adult female beagles underwent A/R and randomization to HBO (2.7-atm absolute [ATA] for 60 minutes, 1 hour after A/R) or control (Po2=80 to 100 mm Hg; 1 ATA). Animals underwent neurological deficit scoring (NDS) 23 hours after A/R. After euthanasia at 24 hours, neuronal death (necrotic and apoptotic) in representative animals was determined stereologically in hippocampus and cerebral neocortex. In experiment 2, arterial and sagittal sinus oxygenation and cerebral blood flow (CBF) were measured. Cerebral oxygen extraction ratio (ERc), oxygen delivery (Do2c), and metabolic rate for oxygen (CMRo2) were calculated (baseline and 2, 30, 60, 120, 180, 240, 300, and 360 minutes after restoration of spontaneous circulation). RESULTS NDS improved after A/R in HBO animals (HBO, 35+/-14; controls, 54+/-15; P=0.028). Histopathological examination revealed significantly fewer dying neurons in HBO animals; the magnitude of neuronal injury correlated well with NDS. HBO corrected elevations in ERc (peak, 60+/-14% for controls, 26+/-4% for HBO) but did not increase Do2c or CMRo2, which decreased approximately 50% after A/R in both groups. CONCLUSIONS HBO inhibits neuronal death and improves neurological outcome after A/R; the mechanism of HBO neuroprotection is not due to stimulation of oxidative cerebral energy metabolism.
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Affiliation(s)
- Robert E Rosenthal
- Program in Trauma, Department of Surgery, University of Maryland, Baltimore, USA.
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Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G, Smith K. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 2002; 346:557-63. [PMID: 11856794 DOI: 10.1056/nejmoa003289] [Citation(s) in RCA: 3742] [Impact Index Per Article: 170.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Cardiac arrest outside the hospital is common and has a poor outcome. Studies in laboratory animals suggest that hypothermia induced shortly after the restoration of spontaneous circulation may improve neurologic outcome, but there have been no conclusive studies in humans. In a randomized, controlled trial, we compared the effects of moderate hypothermia and normothermia in patients who remained unconscious after resuscitation from out-of-hospital cardiac arrest. METHODS The study subjects were 77 patients who were randomly assigned to treatment with hypothermia (with the core body temperature reduced to 33 degrees C within 2 hours after the return of spontaneous circulation and maintained at that temperature for 12 hours) or normothermia. The primary outcome measure was survival to hospital discharge with sufficiently good neurologic function to be discharged to home or to a rehabilitation facility. RESULTS The demographic characteristics of the patients were similar in the hypothermia and normothermia groups. Twenty-one of the 43 patients treated with hypothermia (49 percent) survived and had a good outcome--that is, they were discharged home or to a rehabilitation facility--as compared with 9 of the 34 treated with normothermia (26 percent, P=0.046). After adjustment for base-line differences in age and time from collapse to the return of spontaneous circulation, the odds ratio for a good outcome with hypothermia as compared with normothermia was 5.25 (95 percent confidence interval, 1.47 to 18.76; P=0.011). Hypothermia was associated with a lower cardiac index, higher systemic vascular resistance, and hyperglycemia. There was no difference in the frequency of adverse events. CONCLUSIONS Our preliminary observations suggest that treatment with moderate hypothermia appears to improve outcomes in patients with coma after resuscitation from out-of-hospital cardiac arrest.
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Hachimi-Idrissi S, Corne L, Huyghens L. The effect of mild hypothermia and induced hypertension on long term survival rate and neurological outcome after asphyxial cardiac arrest in rats. Resuscitation 2001; 49:73-82. [PMID: 11334694 DOI: 10.1016/s0300-9572(00)00268-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
STUDY OBJECTIVE we studied the long-term effect of a combined treatment with resuscitative mild hypothermia and induced hypertension on survival rate and neurological outcome after asphyxial cardiac arrest (CA) in rats. METHODS 36 male Wistar rats, were randomised into three groups: Group I (n=10): anaesthetised with halothane and N(2)O/O(2) (70/30%) had vessel cannulation but no asphyxial CA; mechanical ventilation was continued to 1 h. Group II (n=13): under the same anaesthetic conditions and vessel cannulation, was subjected to asphyxial CA of 8 min, reversed by brief external heart massage and followed by mechanical ventilation to 1 h post restoration of spontaneous circulation (ROSC). Group III (n=13): received the same insult and resuscitation as described in group II, but in contrast to the previous group, a combination treatment of hypothermia (34 degrees C) and induced hypertension was started immediately after ROSC and maintained for 60 min ROSC. Survival rate and neurological deficit (ND) scores were determined before arrest, at 2 and 24 h, and each 24-h up to 4 weeks after ROSC. RESULTS Baseline variables were the same in the three groups. Comparison of the asphyxial CA groups (groups II and III), showed an increased, although not statistically significant, survival rate at 72 h after ROSC in group III, and it became highly significant at 4 weeks after ROSC. The ND scores were the same in both asphyxial CA groups (groups II and III). CONCLUSIONS Resuscitative mild hypothermia and induced hypertension after asphyxial CA in rats is associated with a better survival rate. This beneficial effect persisted for 4 weeks after ROSC.
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Affiliation(s)
- S Hachimi-Idrissi
- Department of Critical Care Medicine and Cerebral Resuscitation Research Group, Vrije Universiteit Brussel, Laarbeeklaan, 101, B-1090 Brussels, Belgium.
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Nozari A, Rubertsson S, Gedeborg R, Nordgren A, Wiklund L. Maximisation of cerebral blood flow during experimental cardiopulmonary resuscitation does not ameliorate post-resuscitation hypoperfusion. Resuscitation 1999; 40:27-35. [PMID: 10321845 DOI: 10.1016/s0300-9572(99)00003-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Continuous intra-aortic balloon occlusion has been reported to improve cerebral blood flow during cardiopulmonary resuscitation (CPR) but not to ameliorate the impaired blood recirculation occurring after restoration of spontaneous circulation (ROSC). Volume expansion with hypertonic solutions may improve recovery of brain function by enhancing post-resuscitation cerebral blood flow. We hypothesised that the combination of these treatments with open-chest CPR would improve cerebral blood flow during CPR, and attenuate post-resuscitation flow disturbances. In 32 anaesthetised piglets, catheters were placed for haemodynamic and blood gas monitoring. Open-chest CPR was initiated after 9 min of ventricular fibrillation. The piglets were treated either with 3 ml kg(-1) hypertonic saline and dextran (HSD) (n = 10), HSD and balloon occlusion (n = 10) or with normal saline (n = 12). After 7 min of CPR, internal defibrillatory shocks were administered to restore spontaneous circulation. Haemodynamic variables, continuous cerebral cortical blood flow, cerebral tissue pH and pCO2 and blood gas parameters were measured during CPR and up to 210 min after ROSC. Higher cerebral perfusion pressure was found in the balloon-HSD group during CPR. This group exhibited less arterial hypertension immediately after ROSC compared with the other groups. Thereafter, a fairly rapid decrease of the perfusion pressures was observed in all groups reaching a minimum level approximately 30 min after ROSC. Cerebral cortical blood flow was significantly higher and cerebral oxygen extraction ratio significantly lower in the balloon-HSD group during CPR, but not after ROSC. In conclusion, a combination of intra-aortic balloon occlusion and HSD administration improves cerebral blood flow and brain oxygen supply during experimental open-chest CPR. In contrast, cerebral blood flow after ROSC was not shown to be influenced by this treatment.
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Affiliation(s)
- A Nozari
- Department of Anaesthesiology and Intensive Care, Uppsala University Hospital, Sweden.
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Yanagawa Y, Ishihara S, Norio H, Takino M, Kawakami M, Takasu A, Okamoto K, Kaneko N, Terai C, Okada Y. Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest. Resuscitation 1998; 39:61-6. [PMID: 9918449 DOI: 10.1016/s0300-9572(98)00118-x] [Citation(s) in RCA: 147] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The effects of mild hypothermia (MH) were investigated. From 1995 to 1996, 28 adult patients with out-of-hospital cardiopulmonary arrest (CPA) had return of spontaneous circulation and survived for more than two days. Thirteen patients were in the MH group. In the MH group, core temperature was maintained between 33 and 34 degrees C for 48 h, and then re-warmed to a temperature of 37 degrees C, at a rate of no greater than 1 degrees C per day. Fifteen patients, admitted before the MH protocol was instituted, were in the control group. Despite the fact that the number of witnessed arrests in the control group were greater than in the MH group, there were both more survivors (7/13 vs. 5/15) and more fully recovered patients (3/13 vs. 1/15) in the MH vs Control groups. Eleven of 13 MH patients, as compared to 6/15 controls developed pneumonia. Our study, although preliminary, suggests that MH might confer improved outcome, as has been shown in animal models, after CPA. This treatment is associated with an increase in pneumonic complications.
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Affiliation(s)
- Y Yanagawa
- Department of Traumatology and Critical Care Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
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Müllner M, Sterz F, Behringer W, Schörkhuber W, Holzer M, Laggner AN. The influence of chronic prearrest health conditions on mortality and functional neurological recovery in cardiac arrest survivors. Am J Med 1998; 104:369-73. [PMID: 9576411 DOI: 10.1016/s0002-9343(98)00057-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE To study the impact of chronic prearrest health conditions on mortality and neurological recovery in patients after witnessed cardiac arrest and primary successful resuscitation. PATIENTS AND METHODS The study was set in the community of Vienna, Austria. Data concerning cardiopulmonary resuscitation of adult patients who survived a witnessed cardiac arrest were collected according to an internationally recommended protocol (Utstein-Style). Chronic prearrest health conditions and New York Heart Association (NYHA) functional classes were evaluated. All patients were followed up for 6 months after the event or death. Adverse outcome was defined as death or severe neurological impairment. A forward stepwise logistic regression model was applied to assess the impact of pre-arrest morbidity on unfavorable outcome, expressed as odds ratio (OR) with 95% confidence intervals (CI). RESULTS Of 411 patients, 269 (66%) had one or more of the following pre-arrest diseases: coronary heart disease (45%), hypertension (26%), congestive heart failure (20%), diabetes mellitus (14%), chronic pulmonary disease (6%), and cerebrovascular disease (5%). In 22% a NYHA class of III or IV was present before cardiac arrest. At 6-month follow-up, 161 (40%) of the patients were alive with favorable neurological recovery; overall mortality was 57% (n = 233). Increasing NYHA classes (OR 1.4 per NYHA class increase; CI 1.1 to 1.7) and increasing age were independent predictors of adverse outcome (OR 1.03 per 10-year increase; CI 1.01 to 1.05), as were durations of cardiac arrest (OR 1.10 per 5-minute increase; CI 1.07 to 1.12) and the presence of ventricular fibrillation or tachycardia (OR 0.3; CI 0.2 to 0.5). The remaining health conditions, as listed above, were not independently associated with outcome. CONCLUSIONS A large proportion of patients with cardiac arrest had chronic diseases before the event. The presence of impaired functional performance in patients with structural heart disease increased unfavorable outcome within 6 months in primary cardiac arrest survivors. However, the impact of chronic prearrest conditions on outcome seems to be very small, and should not influence decisions whether to withhold or withdraw therapy.
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Affiliation(s)
- M Müllner
- Department of Emergency Medicine, Vienna General Hospital, University of Vienna, Medical School, Austria
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Rumana CS, Gopinath SP, Uzura M, Valadka AB, Robertson CS. Brain temperature exceeds systemic temperature in head-injured patients. Crit Care Med 1998; 26:562-7. [PMID: 9504587 DOI: 10.1097/00003246-199803000-00032] [Citation(s) in RCA: 167] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To identify the temperature differences in readings taken from the brain, jugular bulb, and core body in head-injured patients. DESIGN Prospective, observational study. SETTING Neurosurgical intensive care unit of a university-affiliated county hospital. PATIENTS Thirty patients with severe head injuries had measurements of brain and core body temperatures. Fourteen patients also had measurements of jugular venous blood at the level of the jugular bulb. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Brain temperature was increased an average of 2.0 degrees F (1.1 degrees C) over the core body temperature. In individual patients, the average brain temperature increase over the core body temperature ranged from -0.5 degrees to 3.8 degrees F (-0.30 degrees to 2.1 degrees C). Jugular vein and core body temperatures were similar. The difference in the brain and body temperatures increased when cerebral perfusion pressure decreased to between 20 and 50 mm Hg. The difference in the brain and body temperatures decreased in those patients treated with barbiturate coma. CONCLUSIONS Direct measurement of temperature in head-injured patients is a safe procedure. Temperatures in the brain are typically increased over the core body temperature and the jugular bulb temperatures. Jugular vein temperature measurement is not a good measurement of brain temperature since it reflects body, not brain temperature. These findings support the potential importance of monitoring brain temperature and the importance of controlling fever in severely head-injured patients since brain temperature may be higher than expected.
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Affiliation(s)
- C S Rumana
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX 77030, USA
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Cardiopulmonary and cerebral resuscitation: An update. Acta Anaesthesiol Scand 1997. [DOI: 10.1111/j.1399-6576.1997.tb04885.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Müllner M, Sterz F, Domanovits H, Behringer W, Binder M, Laggner AN. The association between blood lactate concentration on admission, duration of cardiac arrest, and functional neurological recovery in patients resuscitated from ventricular fibrillation. Intensive Care Med 1997; 23:1138-43. [PMID: 9434919 DOI: 10.1007/s001340050470] [Citation(s) in RCA: 71] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To assess the association between arterial lactate concentration on admission and the duration of human ventricular fibrillation cardiac arrest, and to what degree the arterial lactate concentration on admission is an early predictor of functional neurological recovery in human cardiac arrest survivors. DESIGN Cohort study. Arterial lactate concentrations and out-of-hospital data concerning cardiac arrest and cardiopulmonary resuscitation were collected retrospectively according to a standardized protocol. Functional neurological recovery was assessed prospectively at regular intervals for 6 months. SETTING Emergency department of an urban tertiary care hospital. PATIENTS A total of 167 primary survivors of witnessed out-of-hospital ventricular fibrillation cardiac arrest. MEASUREMENTS The association between arterial lactate concentration on admission, the duration of cardiac arrest, and functional neurological recovery was assessed. Further, we assessed whether admission concentrations of arterial lactate and duration of cardiac arrest can predict unfavorable functional neurological recovery. Functional neurological recovery was measured in cerebral performance categories (CPC). No or minimal functional impairment (CPC 1 and 2) was defined as favorable outcome; the remaining categories (CPC 3, 4 and 5) were defined as unfavorable functional neurological recovery. RESULTS In 167 patients, a weak association between total duration of cardiac arrest and admission levels of lactate (r = 0.49, P < 0.001) could be shown. With increasing admission concentrations of arterial lactate functional neurological recovery was more likely to be unfavorable (OR 1.15 per mmol/l increase, 95% CI 1.04-1.27). Nevertheless, only at very high levels of lactate (16.3 mmol/l) could unfavorable neurological recovery be detected with 100% specificity, yielding a very low sensitivity of 16%. CONCLUSIONS The arterial admission lactate concentration after out-of-hospital ventricular fibrillation cardiac arrest is a weak measure of the duration of ischemia. High admission lactate levels are associated with severe neurological impairment. However, this parameter has poor prognostic value for individual estimation of the severity of subsequent functional neurological impairment.
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Affiliation(s)
- M Müllner
- Department of Emergency Medicine, Vienna General Hospital-University of Vienna, Medical School, Austria.
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Bernard SA, Jones BM, Horne MK. Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest. Ann Emerg Med 1997; 30:146-53. [PMID: 9250636 DOI: 10.1016/s0196-0644(97)70133-1] [Citation(s) in RCA: 300] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
STUDY OBJECTIVE To examine the effects of moderate hypothermia (33 degrees C), induced by surface cooling in the ED and maintained for 12 hours in the ICU, on patients with anoxic brain injury after out-of-hospital cardiac arrest. METHODS We conducted the study in a teaching hospital in Melbourne, Victoria, Australia. Participants were 22 adults who remained unconscious after return of spontaneous circulation following out-of-hospital cardiac arrest. This treatment group was studied prospectively, and a control group of 22 similar patients was studied by retrospective chart review. Moderate hypothermia (33 degrees C) was induced in the ED by means of surface cooling and maintained for 12 hours in the ICU with rewarming to normothermia over 6 hours; control patients were maintained at normothermia. RESULTS There were no significant adverse effects of induced hypothermia. Cardiovascular changes included decreased pulse rate, but there were no significant differences in mean arterial blood pressure between the two groups. Small increases in serum potassium and decreases in pH at 18 hours in the hypothermic patients compared with normothermic controls were of no clinical significance. There were no septic complications. There was a significant increase in the number of patients with good outcome (Glasgow Outcome Coma Scale category 1 or 2) with induced hypothermia (11 of 22, versus 3 of 22 for normothermic controls; P<.05), and the mortality rate was significantly lower (10 of 22 versus 17 of 22; P<.05). CONCLUSION Compared with historical normothermic controls, outcome was significantly improved and there was no increase in complications when moderate hypothermia was induced in comatose survivors of out-of-hospital cardiac arrest and maintained for 12 hours. Larger, prospective, randomized, controlled studies of induced moderate hypothermia in comatose survivors of out-of-hospital cardiac arrest are warranted.
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Affiliation(s)
- S A Bernard
- Department of Intensive Care, Dandenong Hospital, Victoria, Australia
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Iida K, Satoh H, Arita K, Nakahara T, Kurisu K, Ohtani M. Delayed hyperemia causing intracranial hypertension after cardiopulmonary resuscitation. Crit Care Med 1997; 25:971-6. [PMID: 9201049 DOI: 10.1097/00003246-199706000-00013] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To clarify whether early or delayed failure of cerebral perfusion after cardiopulmonary resuscitation (CPR) occurs in humans and contributes to secondary brain damage. DESIGN Prospective, repeated-measures study. SETTING Intensive care unit of Hiroshima University School of Medicine. PATIENTS Eight comatose patients who had undergone successful resuscitation from cardiac arrest. INTERVENTIONS All patients underwent transcranial Doppler sonography examination. The intracranial cerebral pressure (ICP) and jugular venous oxygen saturation (SO2) also were continuously monitored in five patients and three patients, respectively. MEASUREMENTS AND MAIN RESULTS In each patient, we measured the mean flow velocity of the middle cerebral artery transcranially and the mean flow velocity of the internal carotid artery, high in the neck, using transcranial Doppler sonography. The pulsatility index for each measurement was also calculated. The first examinations were performed within 4 to 12 hrs of CPR, and repeat examinations were performed approximately every 12 hrs. The initial mean flow velocities of the middle cerebral artery and the initial mean flow velocities of the internal carotid artery were relatively low, with relatively high pulsatility indices. The mean flow velocities of the middle cerebral artery began to increase at 12 to 24 hrs after CPR and peaked 24 to 120 hrs after CPR. A simultaneous increase in mean flow velocities of the internal carotid artery was observed during this period. The pulsatility index in both arteries dropped significantly during peak mean flow velocity of the middle cerebral artery. In six of seven patients with an abnormal increase (> 100 cm/ sec) in peak mean flow velocity of the middle cerebral artery, the ratio of mean flow velocity of the middle cerebral artery to mean flow velocity of the internal carotid artery was < 3. This value tended to be lower in patients with poor outcomes. An increased mean flow velocity of the middle cerebral artery, with a ratio of < 3 for mean flow velocity of the middle cerebral artery to mean flow velocity of the internal carotid artery, was defined as hyperemia. Although the mean flow velocity of the internal carotid artery was not measured, another patient with an abnormal increase in mean flow velocity of the middle cerebral artery revealed a high jugular venous SO2 value of 83.5%, also representing hyperemia. All ICP values were within the normal range 4 to 12 hrs after CPR and tended to increase before peak mean flow velocity of the middle cerebral artery. The two patients with the lowest ratios of mean flow velocity of the middle cerebral artery to mean flow velocity of the internal carotid artery showed significant increases in ICP after the peak mean flow velocity of the middle cerebral artery. These two patients subsequently developed brain death. CONCLUSIONS Delayed hyperemia occurs in humans after resuscitation from cardiac arrest. Our data suggest that this delayed hyperemia can lead to intracranial hypertension and occasionally acute brain swelling, contributing to a poor outcome. A high mean flow velocity of the middle cerebral artery with a low ratio of mean flow velocity of the middle cerebral artery to mean flow velocity of the internal carotid artery may be predictive of critical hyperemia. As an indirect method of measuring cerebral blood flow transcranial Doppler sonography can be used to adjust treatment for failure of cerebral perfusion after resuscitation.
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Affiliation(s)
- K Iida
- Department of Neurosurgery, Hiroshima University School of Medicine, Japan
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Takasu A, Matsushima S, Takino M, Okada Y. Effect of an endothelin-1 antagonist, BQ-485, on cerebral oxygen metabolism after complete global cerebral ischemia in dogs. Resuscitation 1997; 34:65-9. [PMID: 9051826 DOI: 10.1016/s0300-9572(96)01056-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Endothelin-1 (ET-1) plays an important role in the physiologic or pathophysiologic regulation of cerebral circulation. To evaluate the effects of the newly synthesized ETA receptor-selective antagonist, BQ-485 (N-perhydroazepin-l-ylcarbonyl-Leu-D-Trp-D-Trp-OH), on the cerebral metabolism of oxygen during the delayed cerebral hypoperfusion that follows global cerebral ischemia, we occluded the ascending aorta and caval veins of 10 beagle dogs for 12.5 min. The animals were randomized into two groups. BQ-485 was given directly into the carotid artery at 0.03 mg/kg per min for 30 min, starting 15 min after reperfusion in the treatment group (n = 5). Isotonic saline was infused in the control group (n = 5). A fiberoptic catheter was inserted into the superior sagittal sinus to monitor its oxygen saturation (SssO2) continuously. Arterial O2 content (CaO2), and sagittal sinus O2 content (CssO2) were monitored before and at 0.5, 1, 2, 4, 6 and 8 h after the ischemic insult. BQ-485 significantly prevented the expected decrease in SssO2 and increase in the cerebral O2 utilization coefficient at 4, 6 and 8 h after the ischemic insult (P < 0.05). Thus, BQ-485 ameliorated the mismatch between O2 supply and demand in the delayed hypoperfusion phase. We conclude that ET may be involved in the pathogenesis of delayed cerebral hypoperfusion after cardiac arrest.
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Affiliation(s)
- A Takasu
- Department of Traumatology and Critical Care Medicine, National Defense Medical College, Saitama, Japan
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Abstract
Induced hypothermia as adjunctive therapy has been the subject of considerable research interest and debate for over fifty years. Recently the first prospective randomized controlled trials were undertaken in humans with severe traumatic brain injury, with supportive results. Another prospective controlled study of induced hypothermia in severe septic adult respiratory distress syndrome also suggested improved outcome. Other studies in patients with anoxic brain injury have been suggested following promising findings in animal models. There have been anecdotal reports of the use of induced hypothermia in a wide range of other neurological injuries. There are significant physiological changes during induced hypothermia, particularly affecting the cardiovascular system. In addition, hypokalaemia, prolonged clotting times and neutropenia may occur. The evidence that induced hypothermia may be hazardous is mostly drawn from the literature on accidental hypothermia occurring in trauma, or patients with sepsis. It is likely that further trials will be conducted and if benefit is confirmed, induced hypothermia may become more widely used in selected patients in the intensive care unit.
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Affiliation(s)
- S Bernard
- Intensive Care Unit, Dandenong Hospital, Victoria
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