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Surman TL, Abrahams JM, Manavis J, Finnie J, Christou C, Williams GK, Walls A, Frantzis P, Adams M, Edwards J, Worthington MG, Beltrame J. The susceptibility of the aortic root: porcine aortic rupture testing under cardiopulmonary bypass. J Cardiothorac Surg 2021; 16:283. [PMID: 34602088 PMCID: PMC8489069 DOI: 10.1186/s13019-021-01667-9] [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: 03/08/2021] [Accepted: 09/20/2021] [Indexed: 11/30/2022] Open
Abstract
Background In our earlier study on the functional limits of the aneurysmal aortic root we determined the pig root is susceptible to failure at high aortic pressures levels. We established a pig rupture model using cardiopulmonary bypass to determine the most susceptible region of the aortic root under the highest pressures achievable using continuous flow, and what changes occur in these regions on a macroscopic and histological level. This information may help guide clinical management of aortic root and ascending aorta pathology.
Methods Five pigs underwent 4D flow MRI imaging pre surgery to determine vasopressor induced wall sheer stress and flow parameters. All pigs were then placed on cardiopulmonary bypass (CPB) via median sternotomy, and maximal aortic root and ascending aorta flows were initiated until rupture or failure, to determine the most susceptible region of the aorta. The heart was explanted and analysed histologically to determine if histological changes mirror the macroscopic observations.
Results The magnetic resonance imaging (MRI) aortic flow and wall sheer stress (WSS) increased significantly in all regions of the aorta, and the median maximal pressures obtained during cardiopulmonary bypass was 497 mmHg and median maximal flows was 3.96 L/m. The area of failure in all experiments was the non-coronary cusp of the aortic valve. Collagen and elastin composition (%) was greatest in the proximal regions of the aorta. Collagen I and III showed greatest content in the inner aortic root and ascending aorta regions. Conclusions This unique porcine model shows that the aortic root is most susceptible to failure at high continuous aortic pressures, supported histologically by different changes in collagen content and subtypes in the aortic root. With further analysis, this information could guide management of the aortic root in disease. Supplementary Information The online version contains supplementary material available at 10.1186/s13019-021-01667-9.
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Affiliation(s)
- Timothy Luke Surman
- D'Arcy Sutherland Cardiothoracic Surgical Unit, Royal Adelaide Hospital, Adelaide, SA, Australia.
| | - John Matthew Abrahams
- D'Arcy Sutherland Cardiothoracic Surgical Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Jim Manavis
- Department of Medical and Health Sciences, University of Adelaide Health Sciences, Adelaide, SA, Australia
| | - John Finnie
- Department of Medical and Health Sciences, University of Adelaide Health Sciences, Adelaide, SA, Australia
| | - Chris Christou
- Preclinical, Imaging, and Research Laboratories, South Australian Health and Medical Research Institute, Gilles Plains, Adelaide, SA, Australia
| | - Georgia Kate Williams
- Preclinical, Imaging, and Research Laboratories, South Australian Health and Medical Research Institute, Gilles Plains, Adelaide, SA, Australia.,National Imaging Facility, Brisbane, Australia
| | - Angela Walls
- Dr Jones and Partners, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Peter Frantzis
- D'Arcy Sutherland Cardiothoracic Surgical Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Mark Adams
- D'Arcy Sutherland Cardiothoracic Surgical Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - James Edwards
- D'Arcy Sutherland Cardiothoracic Surgical Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
| | | | - John Beltrame
- D'Arcy Sutherland Cardiothoracic Surgical Unit, Royal Adelaide Hospital, Adelaide, SA, Australia.,Cardiology Department, The Queen Elizabeth Hospital, Adelaide, SA, Australia
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Postreanimationsbehandlung. Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0331-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Ventricular Fibrillation Waveform Changes during Controlled Coronary Perfusion Using Extracorporeal Circulation in a Swine Model. PLoS One 2016; 11:e0161166. [PMID: 27536996 PMCID: PMC4990236 DOI: 10.1371/journal.pone.0161166] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 08/01/2016] [Indexed: 11/19/2022] Open
Abstract
Background Several characteristics of the ventricular fibrillation (VF) waveform have been found predictive of successful defibrillation and hypothesized to reflect the myocardial energy state. In an open-chest swine model of VF, we modeled “average CPR” using extracorporeal circulation (ECC) and assessed the time course of coronary blood flow, myocardial metabolism, and myocardial structure in relation to the amplitude spectral area (AMSA) of the VF waveform without artifacts related to chest compression. Methods VF was induced and left untreated for 8 minutes in 16 swine. ECC was then started adjusting its flow to maintain a coronary perfusion pressure of 10 mmHg for 10 minutes. AMSA was calculated in the frequency domain and analyzed continuously with a 2.1 s timeframe and a Tukey window that moved ahead every 0.5 s. Results AMSA progressively declined during untreated VF. With ECC, AMSA increased from 7.0 ± 1.9 mV·Hz (at minute 8) to 12.8 ± 3.3 mV·Hz (at minute 14) (p < 0.05) without subsequent increase and showing a modest correlation with coronary blood flow of borderline statistical significance (r = 0.489, p = 0.0547). Myocardial energy measurements showed marked reduction in phosphocreatine and moderate reduction in ATP with increases in ADP, AMP, and adenosine along with myocardial lactate, all indicative of ischemia. Yet, ischemia did not resolve during ECC despite a coronary blood flow of ~ 30% of baseline. Conclusion AMSA increased upon return of coronary blood flow during ECC. However, the maximal level was reached after ~ 6 minutes without further change. The significance of the findings for determining the optimal timing for delivering an electrical shock during resuscitation from VF remains to be further explored.
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Nolan JP, Soar J, Cariou A, Cronberg T, Moulaert VRM, Deakin CD, Bottiger BW, Friberg H, Sunde K, Sandroni C. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines for Post-resuscitation Care 2015: Section 5 of the European Resuscitation Council Guidelines for Resuscitation 2015. Resuscitation 2016; 95:202-22. [PMID: 26477702 DOI: 10.1016/j.resuscitation.2015.07.018] [Citation(s) in RCA: 749] [Impact Index Per Article: 93.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jerry P Nolan
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, UK.
| | - Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK
| | - Alain Cariou
- Cochin University Hospital (APHP) and Paris Descartes University, Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Division of Neurology, Lund University, Lund, Sweden
| | - Véronique R M Moulaert
- Adelante, Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands
| | - Charles D Deakin
- Cardiac Anaesthesia and Cardiac Intensive Care and NIHR Southampton Respiratory Biomedical Research Unit, University Hospital, Southampton, UK
| | - Bernd W Bottiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Hans Friberg
- Department of Clinical Sciences, Division of Anesthesia and Intensive Care Medicine, Lund University, Lund, Sweden
| | - Kjetil Sunde
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
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Monsieurs K, Nolan J, Bossaert L, Greif R, Maconochie I, Nikolaou N, Perkins G, Soar J, Truhlář A, Wyllie J, Zideman D. Kurzdarstellung. Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0097-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Monsieurs KG, Nolan JP, Bossaert LL, Greif R, Maconochie IK, Nikolaou NI, Perkins GD, Soar J, Truhlář A, Wyllie J, Zideman DA, Alfonzo A, Arntz HR, Askitopoulou H, Bellou A, Beygui F, Biarent D, Bingham R, Bierens JJ, Böttiger BW, Bossaert LL, Brattebø G, Brugger H, Bruinenberg J, Cariou A, Carli P, Cassan P, Castrén M, Chalkias AF, Conaghan P, Deakin CD, De Buck ED, Dunning J, De Vries W, Evans TR, Eich C, Gräsner JT, Greif R, Hafner CM, Handley AJ, Haywood KL, Hunyadi-Antičević S, Koster RW, Lippert A, Lockey DJ, Lockey AS, López-Herce J, Lott C, Maconochie IK, Mentzelopoulos SD, Meyran D, Monsieurs KG, Nikolaou NI, Nolan JP, Olasveengen T, Paal P, Pellis T, Perkins GD, Rajka T, Raffay VI, Ristagno G, Rodríguez-Núñez A, Roehr CC, Rüdiger M, Sandroni C, Schunder-Tatzber S, Singletary EM, Skrifvars MB, Smith GB, Smyth MA, Soar J, Thies KC, Trevisanuto D, Truhlář A, Vandekerckhove PG, de Voorde PV, Sunde K, Urlesberger B, Wenzel V, Wyllie J, Xanthos TT, Zideman DA. European Resuscitation Council Guidelines for Resuscitation 2015: Section 1. Executive summary. Resuscitation 2015; 95:1-80. [PMID: 26477410 DOI: 10.1016/j.resuscitation.2015.07.038] [Citation(s) in RCA: 568] [Impact Index Per Article: 63.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Koenraad G Monsieurs
- Emergency Medicine, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium.
| | - Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, Bristol, UK
| | | | - Robert Greif
- Department of Anaesthesiology and Pain Medicine, University Hospital Bern, Bern, Switzerland; University of Bern, Bern, Switzerland
| | - Ian K Maconochie
- Paediatric Emergency Medicine Department, Imperial College Healthcare NHS Trust and BRC Imperial NIHR, Imperial College, London, UK
| | | | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Heart of England NHS Foundation Trust, Birmingham, UK
| | - Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Jonathan Wyllie
- Department of Neonatology, The James Cook University Hospital, Middlesbrough, UK
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European Resuscitation Council Guidelines for Resuscitation 2010 Section 4. Adult advanced life support. Resuscitation 2011; 81:1305-52. [PMID: 20956049 DOI: 10.1016/j.resuscitation.2010.08.017] [Citation(s) in RCA: 752] [Impact Index Per Article: 57.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Nolan JP, Deakin CD, Soar J, Böttiger BW, Smith G, Baubin M, Dirks B, Wenzel V. Erweiterte Reanimationsmaßnahmen für Erwachsene (ALS). Notf Rett Med 2006; 9:38-80. [PMID: 32834772 PMCID: PMC7371819 DOI: 10.1007/s10049-006-0796-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- J. P. Nolan
- Sektion Notfallmedizin, Universitätsklinik für Anästhesiologie, Ulm
| | - C. D. Deakin
- Sektion Notfallmedizin, Universitätsklinik für Anästhesiologie, Ulm
| | - J. Soar
- Sektion Notfallmedizin, Universitätsklinik für Anästhesiologie, Ulm
| | - B. W. Böttiger
- Sektion Notfallmedizin, Universitätsklinik für Anästhesiologie, Ulm
| | - G. Smith
- Sektion Notfallmedizin, Universitätsklinik für Anästhesiologie, Ulm
| | - M. Baubin
- Klinik für Anästhesie und allgemeine Intensivmedizin, Universität, Innsbruck, Österreich
| | - B. Dirks
- Sektion Notfallmedizin, Universitätsklinik für Anästhesiologie, Ulm
- Sektion Notfallmedizin, Universitätsklinik für Anästhesiologie, Prittwitzstraße 43, 89075 Ulm
| | - V. Wenzel
- Klinik für Anästhesie und allgemeine Intensivmedizin, Universität, Innsbruck, Österreich
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Nolan JP, Deakin CD, Soar J, Böttiger BW, Smith G. European Resuscitation Council Guidelines for Resuscitation 2005. Resuscitation 2005; 67 Suppl 1:S39-86. [PMID: 16321716 DOI: 10.1016/j.resuscitation.2005.10.009] [Citation(s) in RCA: 606] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Montie HL, Haezebrouck AJ, Gutwald JC, DeGracia DJ. PERK is activated differentially in peripheral organs following cardiac arrest and resuscitation. Resuscitation 2005; 66:379-89. [PMID: 16029920 DOI: 10.1016/j.resuscitation.2005.03.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2005] [Revised: 03/14/2005] [Accepted: 03/14/2005] [Indexed: 11/16/2022]
Abstract
Visceral organs display differential sensitivity to ischemia and reperfusion injury, but the cellular mechanisms underlying these differential responses are not completely understood. A significant response to ischemia identified in brain is stress to the endoplasmic reticulum (ER), as indicated by PKR-like endoplasmic reticulum eIF2alpha kinase (PERK)-mediated phosphorylation of eIF2alpha. To determine the generality of this response, we evaluated the PERK pathway in brain, GI tract, heart, liver, lung, kidney, pancreas and skeletal muscle following a clinically relevant, 10 min cardiac arrest-induced whole body ischemia and either 10 or 90 min reperfusion. The potential role of nitric oxide (NO) on PERK activation was investigated by conducting ischemia and reperfusion in the presence and absence of the NO synthase inhibitor nitro-L-arginine methyl ester (L-NAME). Organ stress could be ranked with respect to the degree of eIF2alpha phosphorylation at 10 min reperfusion. Brain, kidney and GI tract were reactive organs, showing 15 to 20-fold increases in eIF2alpha(P) compared to controls. Moderately reactive organs included liver and heart, showing <10-fold increases in eIF2alpha(P). Pancreas, lung and skeletal muscle were nonreactive. Although treatment of cultured neuroblastoma 104 cells with the NO-donor S-nitroso-N-acetyl-penicillamine (SNAP) activated PERK, administration of L-NAME had no effect on PERK activation or eIF2alpha phosphorylation in organs following ischemia and reperfusion. Thus, PERK is activated differentially in reperfused organs independent of NO. These results suggest that ER stress may play a role in differential responses of viscera to ischemia and reperfusion. ER stress in viscera may contribute to the pathophysiology of resuscitation from cardiac arrest and during organ transplantation procedures.
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Affiliation(s)
- Heather L Montie
- Department of Physiology, Wayne State University, School of Medicine, 3125 Scott Hall, 540 East Canfield Avenue, Detroit, MI 48201, USA
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Little CM, Angelos MG, Paradis NA. Compared to angiotensin II, epinephrine is associated with high myocardial blood flow following return of spontaneous circulation after cardiac arrest. Resuscitation 2003; 59:353-9. [PMID: 14659605 DOI: 10.1016/s0300-9572(03)00239-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Epinephrine (adrenaline) and vasopressin are used currently to improve myocardial blood flow (MBF) during cardiac arrest. Angiotensin II has also been shown to improve MBF during CPR. We explored the effects of angiotensin II or epinephrine alone, and the combination of angiotensin with epinephrine, on myocardial and cerebral blood flows in a swine model of cardiac arrest. METHODS Swine were instrumented for regional blood flow measurements. Ventricular fibrillation was induced and CPR begun. Angiotensin II 50 mcg/kg (ANG), epinephrine 0.02 mg/kg (EPI) or the combination (ANG+EPI) was administered. Blood flow was measured during baseline normal sinus rhythm (NSR), before (CPR) and after drug administration (CPR+DRUG), and post reperfusion return of spontaneous circulation (ROSC). RESULTS All groups had a significant increase in MBF during CPR following drug administration (P<0.05). [table: see text] There was a trend toward higher flows in the EPI groups. The group receiving both EPI and ANG did not have higher blood flows than the EPI or ANG alone groups. Both groups that received EPI had markedly elevated MBF following ROSC compared with angiotensin II (P<0.05). CONCLUSIONS The combination of ANG and EPI did not improve MBF during cardiac arrest. Epinephrine may increase MBF compared with angiotensin II post-reperfusion.
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Affiliation(s)
- Charles M Little
- Division of Emergency Medicine, Department of Surgery, Health Sciences Center, University of Colorado, 4200 E. Ninth Avenue, Denver, CO 80262, USA
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Abstract
The effects of periodic Gz acceleration (pGz) on cardiovascular function and hemodynamics were determined in a pig model of acute cardiopulmonary resuscitation (CPR). The application of pGz (horizontal head-to-foot oscillations) at 2 Hz increased cardiac output in fibrillated animals proportional to the amplitude of the applied acceleration force that plateaued at 0.7 G. Cardiac output in fibrillating animals was restored to 20% of the values obtained before fibrillation with pGz-CPR and arterial blood gas values were normal during this period. The central vascular pressure gradient driving blood flow was only about 6 mmHg, suggesting low vascular resistance during pGz-CPR. In another study, capillary blood flow was determined before and after pGz-CPR using colored microspheres. Capillary perfusion was detected in all tissue beds studied during pGz-CPR. Significant capillary blood flow was detected in the endocardium and brain stem during pGz-CPR that represented 39 and 197% of control values before fibrillation, respectively. Thus, the cardiac output during pGz-CPR was preferentially distributed to the myocardial and brain tissues. In a final group, animals were successfully resuscitated with return of spontaneous circulation (ROSC) after pGz-CPR for 15 min following cardiac fibrillation with a 3-min non-intervention period. Following ROSC, blood pressure was maintained at pre-arrest values for 2 h without any pharmacological or mechanical support. Arterial blood gases during the pGz-CPR and the ROSC periods were normal and not different from values obtained before fibrillation. None of the control animals (18 min of fibrillation without pGz-CPR) survived the experimental protocol and only two of these six animals briefly returned to spontaneous circulation (<20 min). In conclusion, experimental pGz-CPR produces cardiac output, capillary blood flow, and ventilation sufficient to maintain fibrillating animals for 18 min with ROSC for 2 h without support.
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Affiliation(s)
- J A Adams
- Department of Research, Division of Neonatology, Mount Sinai Medical Center, and Miami Heart Research Institute, 4300 Alton Road, 3 Blum, Miami Beach, FL 33140, USA.
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Angelos MG, DeBehnke DJ. Epinephrine and high-flow reperfusion after cardiac arrest in a canine model. Ann Emerg Med 1995; 26:208-15. [PMID: 7618785 DOI: 10.1016/s0196-0644(95)70153-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
STUDY OBJECTIVES Epinephrine has been used in cardiac arrest to increase the low blood flow generated by standard CPR methods. Reperfusion with high flow such as that obtained with cardiopulmonary bypass (CPB) may obviate the need for or alter the dose of epinephrine after cardiac arrest. The objective of this study was to evaluate the effect of high-flow reperfusion after cardiac arrest with and without epinephrine on coronary perfusion pressure, defibrillation energy, restoration of spontaneous circulation (ROSC), and 2-hour survival after prolonged cardiac arrest. DESIGN Prospective, randomized, double-blind, placebo-controlled study using a canine model. INTERVENTIONS Thirty mongrel dogs were randomized to receive, after ventricular fibrillation cardiac arrest of 12 minutes' duration without CPR, placebo (n = 10), standard-dose epinephrine (.02 mg/kg) (n = 10), or high-dose epinephrine (.2 mg/kg) (n = 10) during reperfusion with CPB. Epinephrine or placebo was given with the start of CPB and then every 5 minutes, followed by countershock until ROSC or crossover at the fourth dose to high-dose epinephrine. RESULTS ROSC was achieved in the first 15 minutes of bypass in 10 of 10 dogs given high-dose epinephrine, in 9 of 10 given standard-dose epinephrine, and in 1 of 10 given placebo. After the crossover to high-dose epinephrine, ROSC was achieved in 8 of 10 dogs originally given placebo and the remaining animal given the standard dose of epinephrine. During early reperfusion, the high-dose group had a higher mean coronary perfusion pressure (high dose, 153 + 62 mm Hg; standard dose, 81 +/- 18 mm Hg; placebo, 51 +/- 15 mm Hg; P < .002) and a shorter mean ROSC time (high dose, 16.2 +/- 8 minutes; standard dose, 20.3 +/- 3.6 minutes; placebo, 27.9 +/- 3.2; P < .02) and required less defibrillation energy. CPB flow during ventricular fibrillation was 63% of baseline cardiac output in all three groups. Two-hour survival was 5 of 10 in the high-dose group, 8 of 10 in the standard-dose group, and 5 of 10 in the placebo group. CONCLUSION Restoration of high blood flow alone is insufficient to restore spontaneous circulation after prolonged cardiac arrest. Epinephrine, when administered early under high-flow conditions, increases coronary perfusion pressure, decreases defibrillation energy, and decreases time elapsed before ROSC. Higher doses of epinephrine under conditions of high-flow reperfusion do not improve 2-hour survival compared with standard-dose epinephrine.
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Affiliation(s)
- M G Angelos
- Department of Emergency Medicine, Ohio State University, Columbus, USA
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