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Singh A, Jefferson J. Post-Cardiac Arrest Care. Emerg Med Clin North Am 2023; 41:617-632. [PMID: 37391254 DOI: 10.1016/j.emc.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
A structured approach to postcardiac arrest care is needed. Although immediate goals include obtaining a blood pressure reading and ECG immediately after return of spontaneous circulation, other more advanced goals include minimizing CNS injury, managing cardiovascular dysfunction, reducing systemic ischemic/reperfusion injury, and identifying and treating the underlying cause to the arrest. This article summarizes the current understanding of the hemodynamic, neurologic, and metabolic abnormalities encountered in postarrest patients.
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Affiliation(s)
- Amandeep Singh
- Department of Emergency Medicine, Highland Hospital, 1411 East 31st Street, Oakland, CA 94602, USA.
| | - Jamal Jefferson
- Department of Emergency Medicine, Highland Hospital, 1411 East 31st Street, Oakland, CA 94602, USA
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2
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Lutz J, Levenbrown Y, Hossain MJ, Hesek A, Massa KE, Keith JP, Shaffer TH. Impact of intravenous fluid administration on cardiac output and oxygenation during cardiopulmonary resuscitation. Intensive Care Med Exp 2023; 11:13. [PMID: 36959337 PMCID: PMC10036707 DOI: 10.1186/s40635-023-00497-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/07/2023] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND The effect of intravenous fluid (IVF) administration during cardiopulmonary resuscitation (CPR) is an unexplored factor that may improve cardiac output (CO) during CPR. The aim of this study was to determine the effect of IVF administration on CO and oxygenation during CPR. METHODS This experimental animal study was performed in a critical care animal laboratory. Twenty-two Landrace-Yorkshire female piglets weighing 27-37 kg were anesthetized, intubated, and placed on positive pressure ventilation. Irreversible cardiac arrest was induced with bupivacaine. CPR was performed with a LUCAS 3 mechanical compression device. Pigs were randomized into IVF or no-IVF groups. Pigs in the IVF group were given 20 mL/kg of Plasma-Lyte (Baxter International, Deerfield, IL USA), infused from 15 to 35 min of CPR. CPR was maintained for 50 min with serial measurements of CO obtained using ultrasound dilution technology and partial pressure of oxygen (PaO2). RESULTS A mixed-effects repeated measures analysis of variance was used to compare within-group, and between-group mean changes in CO and PaO2 over time. CO and PaO2 for the piglets were measured at 10-min intervals during the 50 min of CPR. CO was greater in the IVF compared with the control group at all time points during and after the infusion of the IVF. Mean PaO2 decreased with time; however, at no time was there a significant difference in PaO2 between the IVF and control groups. CONCLUSIONS Administration of IVF during CPR resulted in a significant increase in CO during CPR both during and after the IVF infusion. There was no statistically significant decrease in PaO2 between the IVF and control groups.
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Affiliation(s)
- Jennifer Lutz
- Division of Pediatric Critical Care, Nemours Children's Health, 1600 Rockland Road, Wilmington, DE, 19803, USA
- Department of Pediatrics, Sidney Kimmel Medical School of Thomas Jefferson University, Philadelphia, PA, USA
| | - Yosef Levenbrown
- Division of Pediatric Critical Care, Nemours Children's Health, 1600 Rockland Road, Wilmington, DE, 19803, USA.
- Department of Pediatrics, Sidney Kimmel Medical School of Thomas Jefferson University, Philadelphia, PA, USA.
| | - Md Jobayer Hossain
- Nemours Biomedical Research, Nemours Children's Health, Wilmington, DE, USA
- Department of Applied Economics and Statistics, University of Delaware, Newark, DE, USA
| | - Anne Hesek
- Nemours Biomedical Research, Nemours Children's Health, Wilmington, DE, USA
| | - Kelly E Massa
- Department of Respiratory Care, Nemours Children's Health, Wilmington, DE, USA
| | - James P Keith
- Department of Respiratory Care, Nemours Children's Health, Wilmington, DE, USA
| | - Thomas H Shaffer
- Department of Pediatrics, Sidney Kimmel Medical School of Thomas Jefferson University, Philadelphia, PA, USA
- Nemours Biomedical Research/Research Lung Center, Nemours Children's Health, Wilmington, DE, USA
- Department of Pediatrics, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
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Abstract
PURPOSE OF REVIEW Most patients who are successfully resuscitated after cardiac arrest are initially comatose and require mechanical ventilation and other organ support in an ICU. Best practice has been to cool these patients and control their temperature at a constant value in the range of 32-36 oC for at least 24 h. But the certainty of the evidence for this practice is increasingly being challenged. This review will summarize the evidence on key aspects of temperature control in comatose postcardiac arrest patients. RECENT FINDINGS The Targeted Temperature Management 2 (TTM-2) trial documented no difference in 6-month mortality among comatose postcardiac arrest patients managed at 33 oC vs. targeted normothermia. A systematic review and meta-analysis completed by the Advanced Life Support (ALS) Task Force of the International Liaison Committee on Resuscitation (ILCOR) concluded that temperature control with a target of 32-34 °C did not improve survival or favourable functional outcome after cardiac arrest. Two observational studies have documented an association between predicted moderate hypoxic-ischaemic brain injury and better outcome with temperature control at 33-34 oC compared with 35-36 oC. SUMMARY We suggest actively preventing fever by targeting a temperature 37.5 oC or less for those patients who remain comatose following return of spontaneous circulation (ROSC) after cardiac arrest.
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Affiliation(s)
- Jerry P Nolan
- Warwick Clinical Trials Unit, University of Warwick, Coventry
- Royal United Hospital, Bath
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, UK
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Soar J, Böttiger BW, Carli P, Couper K, Deakin CD, Djärv T, Lott C, Olasveengen T, Paal P, Pellis T, Perkins GD, Sandroni C, Nolan JP. [Adult advanced life support]. Notf Rett Med 2021; 24:406-446. [PMID: 34121923 PMCID: PMC8185697 DOI: 10.1007/s10049-021-00893-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2021] [Indexed: 12/19/2022]
Abstract
These European Resuscitation Council Advanced Life Support guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the prevention of and ALS treatments for both in-hospital cardiac arrest and out-of-hospital cardiac arrest.
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Affiliation(s)
- Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, Großbritannien
| | - Bernd W. Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, Universitätsklinikum Köln, Köln, Deutschland
| | - Pierre Carli
- SAMU de Paris, Center Hospitalier Universitaire Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, and Université Paris Descartes, Paris, Frankreich
| | - Keith Couper
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
- Warwick Medical School, University of Warwick, Coventry, Großbritannien
| | - Charles D. Deakin
- University Hospital Southampton NHS Foundation Trust, Southampton, Großbritannien
- South Central Ambulance Service NHS Foundation Trust, Otterbourne, Großbritannien
| | - Therese Djärv
- Dept of Acute and Reparative Medicine, Karolinska University Hospital, Stockholm, Schweden
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Schweden
| | - Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - Theresa Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norwegen
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Österreich
| | - Tommaso Pellis
- Department of Anaesthesia and Intensive Care, Azienda Sanitaria Friuli Occidentale, Pordenone, Italien
| | - Gavin D. Perkins
- Warwick Medical School and University Hospitals Birmingham NHS Foundation Trust, University of Warwick, Coventry, Großbritannien
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rom, Italien
- Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rom, Italien
| | - Jerry P. Nolan
- Warwick Medical School, Coventry, Großbritannien, Consultant in Anaesthesia and Intensive Care Medicine Royal United Hospital, University of Warwick, Bath, Großbritannien
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5
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Soar J, Böttiger BW, Carli P, Couper K, Deakin CD, Djärv T, Lott C, Olasveengen T, Paal P, Pellis T, Perkins GD, Sandroni C, Nolan JP. European Resuscitation Council Guidelines 2021: Adult advanced life support. Resuscitation 2021; 161:115-151. [PMID: 33773825 DOI: 10.1016/j.resuscitation.2021.02.010] [Citation(s) in RCA: 479] [Impact Index Per Article: 159.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
These European Resuscitation Council Advanced Life Support guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the prevention of and ALS treatments for both in-hospital cardiac arrest and out-of-hospital cardiac arrest.
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Affiliation(s)
- Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
| | - Bernd W Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Pierre Carli
- SAMU de Paris, Centre Hospitalier Universitaire Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, and Université Paris Descartes, Paris, France
| | - Keith Couper
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Warwick Medical School, University of Warwick, Coventry,UK
| | - Charles D Deakin
- University Hospital Southampton NHS Foundation Trust, Southampton, UK; South Central Ambulance Service NHS Foundation Trust, Otterbourne,UK
| | - Therese Djärv
- Dept of Acute and Reparative Medicine, Karolinska University Hospital, Stockholm, Sweden, Department of Medicine Solna, Karolinska Institutet,Stockholm, Sweden
| | - Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-Universitaet Mainz, Germany
| | - Theresa Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Tommaso Pellis
- Department of Anaesthesia and Intensive Care, Azienda Sanitaria Friuli Occidentale, Italy
| | - Gavin D Perkins
- University of Warwick, Warwick Medical School and University Hospitals Birmingham NHS Foundation Trust, Coventry, UK
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy; Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jerry P Nolan
- University of Warwick, Warwick Medical School, Coventry, CV4 7AL; Royal United Hospital, Bath, UK
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Grace J, Nagel S, Zeiler G. Successful prolonged cardiopulmonary resuscitation in a Siamese cat: A case of post‐cardiac arrest concerns. VETERINARY RECORD CASE REPORTS 2021. [DOI: 10.1002/vrc2.32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Justin Grace
- Department of Companion Animal Studies Faculty of Veterinary Science University of Pretoria Pretoria Republic of South Africa
| | - Salome Nagel
- Anaesthesia and Critical Care Service Valley Farm Animal Hospital Pretoria Republic of South Africa
| | - Gareth Zeiler
- Department of Companion Animal Studies Faculty of Veterinary Science University of Pretoria Pretoria Republic of South Africa
- Anaesthesia and Critical Care Service Valley Farm Animal Hospital Pretoria Republic of South Africa
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Nongchang P, Wong WL, Pitaksanurat S, Amchai PB. Intravenous Fluid Administration and the Survival of Pre hospital Resuscitated out of Hospital Cardiac Arrest Patients in Thailand. J Clin Diagn Res 2017; 11:OC29-OC32. [PMID: 29207756 DOI: 10.7860/jcdr/2017/29603.10656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 08/16/2017] [Indexed: 11/24/2022]
Abstract
Introduction Out of Hospital Cardiac Arrest (OHCA) is a leading cause of death worldwide. The Emergency Medical Service (EMS) provides early care to critical OHCA patients. Pre hospital intervention has been improving OHCA survival rate, however it is still unclear for the recommendation of routine infusion of Intravenous (IV) fluids during cardiac arrest resuscitation. Aim This study aimed to determine whether IV fluid administration was associated with increasing survival of resuscitated OHCA patients and to assess the survival rate of resuscitated OHCA patients. Materials and Methods This cross-sectional analytical study was conducted among 33,006 resuscitated OHCA patients who received emergency medical service in Thailand. Data set from the EMS Registry of the OHCA patients who received Advanced Life Support (ALS) and Cardiopulmonary Resuscitation (CPR) during January 2011 to December 2015 was enrolled as per inclusion criteria. Data were analysed by using both descriptive statistic and multiple logistic regression. Results The result indicated that 27,270 OHCA patients (82.62%:95%CI=82.121-83.030%) survived until they reached hospital. In addition, after adjusting for effect modifiers and covariates, it was found that adult (≥18 years) with IV fluid administration were more likely to survive (adjusted OR=4.389; 95% CI: 3.911-4.744) when compared to children (<18 years) with IV fluid administration (adjusted OR =2.952; 95% CI: 2.040-4.273). Other factors associated with OHCA patients' survival were female gender (adjusted OR =1.151; 95% CI: 1.067-1.241), response time per minutes (adjusted OR =0.993; 95% CI: 0.989-0.997), scene time per minutes (adjusted OR=0.948; 95% CI: 0.944-0.952) and transport time per minutes (adjusted OR=0.973, 95%CI: 0.968-0.978). Conclusion This study revealed that IV fluid administration was significantly associated with survival of OHCA patients while controlled other covariates including female gender, response time, scene time and transport time. Therefore, it is recommended that the IV fluid administration should be medicated for resuscitated OHCA patients.
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Affiliation(s)
- Phichet Nongchang
- PhD Scholar, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand
| | - Wongsa Laohasiri Wong
- Associate Professor, Faculty of Public Health and Research and Training Center for Enhancing Quality of Life for Working Age People, Khon Kaen University, Khon Kaen, Thailand
| | - Somsak Pitaksanurat
- Assistant Professor, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand
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8
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Soar J, Nolan J, Böttiger B, Perkins G, Lott C, Carli P, Pellis T, Sandroni C, Skrifvars M, Smith G, Sunde K, Deakin C. Erweiterte Reanimationsmaßnahmen für Erwachsene („adult advanced life support“). Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0330-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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9
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Aktuelle Empfehlungen zum Basic/Advanced Life Support. Med Klin Intensivmed Notfmed 2016; 111:670-681. [DOI: 10.1007/s00063-016-0216-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 08/10/2016] [Accepted: 08/23/2016] [Indexed: 10/20/2022]
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10
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Manara AR, Dominguez-Gil B, Pérez-Villares JM, Soar J. What follows refractory cardiac arrest: Death, extra-corporeal cardiopulmonary resuscitation (E-CPR), or uncontrolled donation after circulatory death? Resuscitation 2016; 108:A3-A5. [PMID: 27614286 DOI: 10.1016/j.resuscitation.2016.08.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 08/30/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Alexander R Manara
- Intensive Care Medicine and Anaesthesia, Southmead Hospital, Bristol BS10 5NB, United Kingdom.
| | - Beatriz Dominguez-Gil
- Organización Nacional de Trasplantes, C/Sinesio Delgado 6, pabellón 3, 28029 Madrid, Spain
| | - Jose Miguel Pérez-Villares
- Division of Critical Care Medicine, Neurocritical Care Unit, Complejo Hospitalario, Universitario de Granada, Avenida del Conocimiento 33, 18016 Granada, Spain
| | - Jasmeet Soar
- Intensive Care Medicine and Anaesthesia, Southmead Hospital, Bristol BS10 5NB, United Kingdom
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11
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Soar J, Nolan JP, Böttiger BW, Perkins GD, Lott C, Carli P, Pellis T, Sandroni C, Skrifvars MB, Smith GB, Sunde K, Deakin CD. European Resuscitation Council Guidelines for Resuscitation 2015: Section 3. Adult advanced life support. Resuscitation 2016; 95:100-47. [PMID: 26477701 DOI: 10.1016/j.resuscitation.2015.07.016] [Citation(s) in RCA: 926] [Impact Index Per Article: 115.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK.
| | - Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, UK
| | - Bernd W Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Germany
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Heart of England NHS Foundation Trust, Birmingham, UK
| | - Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University, Mainz, Germany
| | - Pierre Carli
- SAMU de Paris, Department of Anaesthesiology and Intensive Care, Necker University Hospital, Paris, France
| | - Tommaso Pellis
- Anaesthesia, Intensive Care and Emergency Medical Service, Santa Maria degli Angeli Hospital, Pordenone, Italy
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
| | - Markus B Skrifvars
- Division of Intensive Care, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Gary B Smith
- Centre of Postgraduate Medical Research & Education, Bournemouth University, Bournemouth, UK
| | - Kjetil Sunde
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Charles D Deakin
- Cardiac Anaesthesia and Cardiac Intensive Care, NIHR Southampton Respiratory Biomedical Research Unit, University Hospital Southampton, Southampton, UK
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12
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Soar J, Nolan J, Böttiger B, Perkins G, Lott C, Carli P, Pellis T, Sandroni C, Skrifvars M, Smith G, Sunde K, Deakin C. Erweiterte Reanimationsmaßnahmen für Erwachsene („adult advanced life support“). Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0085-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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13
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Miclescu A, Sharma HS, Wiklund L. Crystalloid vs. hypertonic crystalloid-colloid solutions for induction of mild therapeutic hypothermia after experimental cardiac arrest. Resuscitation 2012; 84:256-62. [PMID: 22771870 DOI: 10.1016/j.resuscitation.2012.06.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2012] [Revised: 06/07/2012] [Accepted: 06/25/2012] [Indexed: 11/18/2022]
Abstract
PURPOSE To compare cerebral and hemodynamic consequences of different volumes of cold acetated Ringer's solution or cold hypertonic saline dextran administered in order to achieve mild hypothermia after cardiac arrest (CA) in a pig model of experimental cardiopulmonary resuscitation (CPR). METHODS Using an experimental pig model of 12 min CA (followed by 8 min CPR or no resuscitation) we compared four groups of piglets: a control group, a normothermic group and two groups with different solutions administered for induction of hypothermia. The control group of 5 piglets underwent 12 min CA without subsequent CPR, after which the brain of the animals was removed immediately. After restoration of spontaneous circulation (ROSC) the resuscitated piglets were randomized into a normothermic group (NT group=10), and two hypothermic groups that received cold infusions of either 30 mL/kg acetated Ringer's solution (Much fluid group, M, n=10) or 3mL/kg hypertonic saline dextran solution (Less fluid group, L, n=10), respectively, administered during 30 min. Additional external cooling with ice packs was used in hypothermic groups. Sixty or 180min after ROSC the experiment was terminated. Immediately after arrest the brain was removed for histological analyses. RESULTS The median time to reach the target core temperature of 34 °C after ROSC was 51.5±7.8 min in L group and 48.8±8.6 min in M group. Less cerebral tissue content of water (p<0.001), sodium (p<0.0001), potassium (p<0.0001) and less central venous pressure (CVP) at 5 and 15 min after ROSC were demonstrated in L group. Increased brain damage was demonstrated over time in NT group (p<0.001). Less neurologic damage and BBB disruptions (albumin leakage) was observed at 180min in M group in comparison with both NT and L groups (p<0.001). CONCLUSION No statistical differences were observed between the hypothermic groups in the time to achieve mild hypothermia. Although inclusion of cold hypertonic crystalloid-colloidal solutions in the early resuscitation after ROSC may be more effective than cold crystalloids in reducing brain edema, this study demonstrates that mild hypothermia induced with small volumes of cold hypertonic crystalloid-colloids is less as effective as crystalloid's induced hypothermia in mitigating brain injury after cardiac arrest.
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Affiliation(s)
- Adriana Miclescu
- Department of Surgical Sciences, Anaesthesiology and Critical Care Medicine, Uppsala University, SE-751 85 Uppsala, Sweden.
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14
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Abstract
The best chance of survival with a good neurological outcome after cardiac arrest is afforded by early recognition and high-quality cardiopulmonary resuscitation (CPR), early defibrillation of ventricular fibrillation (VF), and subsequent care in a specialist center. Compression-only CPR should be used by responders who are unable or unwilling to perform mouth-to-mouth ventilations. After the first defibrillator shock, further rhythm checks and defibrillation attempts should be performed after 2 min of CPR. The underlying cause of cardiac arrest can be identified and treated during CPR. Drugs have a limited effect on long-term outcomes after cardiac arrest, although epinephrine improves the success of resuscitation, and amiodarone increases the success of defibrillation for refractory VF. Supraglottic airway devices are an alternative to tracheal intubation, which should be attempted only by skilled rescuers. Care after cardiac arrest includes controlled reoxygenation, therapeutic hypothermia for comatose survivors, percutaneous coronary intervention, circulatory support, and control of blood-glucose levels and seizures. Prognostication in comatose survivors of cardiac arrest needs a careful, multimodal approach using clinical and electrophysiological assessments after at least 72 h.
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Affiliation(s)
- Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Combe Park, Bath BA1 3NG, UK
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15
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Breil M, Krep H, Heister U, Bartsch A, Bender R, Schaefers B, Hoeft A, Fischer M. Randomised study of hypertonic saline infusion during resuscitation from out-of-hospital cardiac arrest. Resuscitation 2012; 83:347-52. [DOI: 10.1016/j.resuscitation.2011.09.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Revised: 08/29/2011] [Accepted: 09/02/2011] [Indexed: 11/16/2022]
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16
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Use of ice-cold crystalloid for inducing mild therapeutic hypothermia following out-of-hospital cardiac arrest. Resuscitation 2012; 83:151-8. [DOI: 10.1016/j.resuscitation.2011.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Revised: 09/13/2011] [Accepted: 10/04/2011] [Indexed: 11/24/2022]
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17
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Cholecystokinin octapeptide induces hypothermia and improves outcomes in a rat model of cardiopulmonary resuscitation. Crit Care Med 2011; 39:2407-12. [PMID: 21705891 DOI: 10.1097/ccm.0b013e3182257660] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To investigate the effects of cholecystokinin octapeptide on thermoregulation, postresuscitation myocardial function, neurologic outcome, and duration of survival in a rat model of cardiopulmonary resuscitation. DESIGN : Prospective, randomized, placebo-controlled experimental study. SETTING University-affiliated animal research laboratory. SUBJECTS Ten male Sprague-Dawley rats. INTERVENTIONS Ventricular fibrillation was induced and untreated for 6 mins. Defibrillation was attempted after 8 mins of cardiopulmonary resuscitation. Animal temperature was adjusted to 37.0 °C with the aid of a heating lamp. At 30 mins after resuscitation, animals were randomized to receive an intravenous injection of either cholecystokinin octapeptide (200 μg/kg in 0.3 mL saline) or vehicle placebo (0.3 mL saline). The ambient temperature settings and that of the distance of the heating lamp from the animal remained the same in both groups throughout the entire experiment. MEASUREMENTS AND MAIN RESULTS Body temperature, hemodynamic measurements, and postresuscitation myocardial function, including cardiac output, left ventricular ejection fraction, and myocardial performance index, were measured together with neurologic deficit scores and duration of survival. RESULTS After injection of cholecystokinin octapeptide, blood temperature decreased progressively from 37.0 °C to 34.8 °C 5 hrs after resuscitation and returned to 37.0 °C at 9 hrs after injection. In the control group, blood temperature was sustained at 37.0 °C ± 0.2 °C during the same period of observation. Myocardial and neurologic function and duration of survival were significantly better in the cholecystokinin octapeptide-treated animals when compared to the control group. CONCLUSIONS : In a rat model of cardiopulmonary resuscitation, cholecystokinin octapeptide induced mild hypothermia, attenuated postresuscitation myocardial dysfunction, and improved neurologic outcome and duration of survival.
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18
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Schwarzl M, Steendijk P, Huber S, Truschnig-Wilders M, Obermayer-Pietsch B, Maechler H, Pieske B, Post H. The induction of mild hypothermia improves systolic function of the resuscitated porcine heart at no further sympathetic activation. Acta Physiol (Oxf) 2011; 203:409-18. [PMID: 21658179 DOI: 10.1111/j.1748-1716.2011.02332.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM Mild hypothermia (MH) after cardiac arrest attenuates hypoxic brain injury and improves survival. As MH increases contractility in normal hearts, we hypothesized that MH improves cardiovascular function after cardiac arrest. METHODS In 16 anaesthetized pigs (64 ± 2 kg), ventricular fibrillation was induced electrically for 5 min. At 10 min after resuscitation and return of spontaneous circulation (ROSC), pigs were assigned to normothermia (NT, 38°C, n = 8) or MH (33°C, n = 8, intravascular cooling). RESULTS At ROSC 6 h vs. baseline, heart rate (HR) was unchanged in NT, but decreased in MH. Cardiac output (CO, l min(-1)) decreased in MH (3.5 ± 0.2 vs. 5.5 ± 0.4, P < 0.05) more than in NT (4.8 ± 0.4 vs. 5.7 ± 0.4, P = ns). Mixed venous oxygen saturation decreased in NT (56 ± 2 vs. 66 ± 3%, P < 0.05), but remained constant in MH (64 ± 2 vs. 65 ± 2%) due to a 35% decrease of whole body oxygen consumption. Left ventricular (LV) dP/dt(max) (mmHg s(-1)) decreased in NT (1163 ± 97 vs. 1665 ± 134, P < 0.05), but was preserved in MH (1602 ± 102 vs. 1603 ± 96), whereas LV relaxation was profoundly slowed during MH. Pressure-volume analysis confirmed improved LV systolic function during MH, but also demonstrated decreased LV end-diastolic distensibility, which was further potentiated by right atrial pacing at baseline HR. MH did not increase plasma catecholamine levels. Spectral analysis of heart rate variability revealed reduced sympathetic activation during MH. CONCLUSION The induction of MH after cardiac resuscitation improves systolic myocardial function without further sympathetic activation. A reduced metabolism during MH outweighs a decreased CO and thereby acts favourably on systemic oxygen supply/demand balance.
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Affiliation(s)
- M Schwarzl
- Department of Cardiology, Medical University of Graz, Austria
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Gruenewald M, Meybohm P, Broch O, Caliebe A, Koerner S, Renner J, Steinfath M, Bein B. Visual evaluation of left ventricular performance predicts volume responsiveness early after resuscitation from cardiac arrest. Resuscitation 2011; 82:1553-7. [PMID: 21762759 DOI: 10.1016/j.resuscitation.2011.06.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Revised: 06/21/2011] [Accepted: 06/27/2011] [Indexed: 02/08/2023]
Abstract
PURPOSE Haemodynamic optimisation is a fundamental goal of post-cardiac arrest therapy. Therefore, predicting volume responsiveness is a key issue in therapy of these high-risk patients and transoesophageal echocardiography (TEE) may provide helpful information. The aim of the present study was to evaluate the performance of visual evaluation (eyeballing) of standardised TEE-loops to predict volume responsiveness during post-cardiac arrest period. METHODS After approval of the local animal investigation committee, TEE mid-oesophageal long-axis views were recorded before a 5 ml/kg volume bolus at baseline and both 1 and 4h after return of spontaneous circulation (ROSC) from 8 min electrically induced cardiac arrest. Post-hoc, TEE loops were independently presented in randomized order to 7 blinded TEE-experts and 14 blinded TEE novices who were asked to predict whether the ventricle will increase stroke volume ≥ 15% after volume loading or not. Statistics were performed calculating sensitivity and specificity for the correct evaluation and agreement of raters. RESULTS 14 out of 20 pigs were successfully resuscitated, and 924 ratings from 21 echocardiographers were included into analysis. Overall, we observed a sensitivity between 71 and 100%, whereas the specificity showed rather low values between 0 and 67% for prediction of volume responsiveness. Best prediction was recorded 1h after ROSC with median sensitivity (95% CI) of 100% (89-100%) and median specificity of 67% (61-72%). No significant difference was found between ratings of experienced and inexperienced echocardiographers. The concordance rate within the two groups was comparable. CONCLUSIONS In post-cardiac arrest period, visual evaluation of long-axis TEE loops allows prediction of volume responsiveness with good sensitivity and reasonable specificity even by novice users, and may therefore be suitable for implementation into treatment protocols.
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Affiliation(s)
- Matthias Gruenewald
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Schwanenweg 21, D-24119 Kiel, Germany.
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Nolan JP, Soar J, Zideman DA, Biarent D, Bossaert LL, Deakin C, Koster RW, Wyllie J, Böttiger B. European Resuscitation Council Guidelines for Resuscitation 2010 Section 1. Executive summary. Resuscitation 2011; 81:1219-76. [PMID: 20956052 DOI: 10.1016/j.resuscitation.2010.08.021] [Citation(s) in RCA: 847] [Impact Index Per Article: 65.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, 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: 751] [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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Hemodynamic, respiratory, and perfusion parameters during asphyxia, resuscitation, and post-resuscitation in a pediatric model of cardiac arrest. Intensive Care Med 2010; 37:147-55. [PMID: 20838762 DOI: 10.1007/s00134-010-2006-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2010] [Accepted: 06/09/2010] [Indexed: 01/11/2023]
Abstract
PURPOSE To analyze the evolution of hemodynamic, respiratory, and tissue perfusion parameters in an infant animal model of asphyxial cardiac arrest (CA). METHODS This was a secondary analysis of a prospective observational study conducted at a laboratory research department of a university hospital. Seventy-one, 2-month-old piglets were studied. CA was induced by removal of mechanical ventilation. Cardiopulmonary resuscitation (CPR) was performed by means of manual external chest compressions, mechanical ventilation, epinephrine and/or terlipressin intravenous administration. RESULTS The evolution of hemodynamic (heart rate, blood pressure, cardiac index), respiratory (end-tidal CO(2), blood gas analysis), and tissue perfusion (intramucosal gastric pH, central, cerebral, and renal hemoglobin saturation) parameters was analyzed during three periods: asphyxia, CPR, and after return of spontaneous circulation (ROSC). During asphyxia, a severe arterial and tissue hypoxia with hypercapnia and lactic acidosis quickly developed. Bradycardia, hypotension, and increasing of systemic vascular resistances and pulmonary arterial pressure were also observed. During CPR, arterial, cerebral, and tissue oxygenation were low in spite of ventilation with oxygen 100%. After ROSC a rapid restoration of hemodynamic and respiratory parameters was observed. However, 30 min after ROSC, lactic acidosis and low intramucosal gastric pH persisted. CONCLUSIONS Asphyxia leads to sudden hypoxia and hypercapnia with tissue hypoxia and progressive bradycardia. Standard CPR is not able to maintain an adequate tissue oxygenation during CPR in this animal model. When ROSC is achieved, a rapid restoration of the normal values of general hemodynamic and respiratory parameters is observed, although lactic acidosis and splanchnic hypoperfusion persist in time.
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Abstract
PURPOSE OF REVIEW The purpose of this study is to discuss recent data relating to the treatment of cardiac arrest survivors. This is a rapidly evolving component of resuscitation medicine that impacts significantly on the quality of survival after cardiac arrest. RECENT FINDINGS The postcardiac arrest syndrome comprises postcardiac arrest brain injury, postcardiac arrest myocardial dysfunction, the systemic ischaemia/reperfusion response, and the persistent precipitating disease. Primary percutaneous coronary intervention is the preferred method for restoring coronary perfusion when cardiac arrest has been caused by an ST-elevation myocardial infarction. Many cardiac arrest survivors with non-ST-elevation myocardial infarction may also benefit from urgent percutaneous coronary intervention. Comatose cardiac arrest survivors should be managed with a moderate blood glucose target range of below 10 mmol/l (180 mg/dl). Therapeutic hypothermia is now generally accepted as part of a treatment strategy for comatose survivors of cardiac arrest, but its use may render conventional methods of prognostication unreliable. SUMMARY Survivors from cardiac arrest develop a postcardiac arrest syndrome. Postresuscitation care, including primary percutaneous coronary intervention, therapeutic hypothermia, and control of blood sugar, improves survival and neurological outcome in cardiac arrest survivors. Completely reliable prognostication in comatose survivors of cardiac arrest is difficult to achieve.
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Heradstveit BE, Guttormsen AB, Langørgen J, Hammersborg SM, Wentzel-Larsen T, Fanebust R, Larsson EM, Heltne JK. Capillary leakage in post-cardiac arrest survivors during therapeutic hypothermia - a prospective, randomised study. Scand J Trauma Resusc Emerg Med 2010; 18:29. [PMID: 20500876 PMCID: PMC2890528 DOI: 10.1186/1757-7241-18-29] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2010] [Accepted: 05/25/2010] [Indexed: 12/24/2022] Open
Abstract
Background Fluids are often given liberally after the return of spontaneous circulation. However, the optimal fluid regimen in survivors of cardiac arrest is unknown. Recent studies indicate an increased fluid requirement in post-cardiac arrest patients. During hypothermia, animal studies report extravasation in several organs, including the brain. We investigated two fluid strategies to determine whether the choice of fluid would influence fluid requirements, capillary leakage and oedema formation. Methods 19 survivors with witnessed cardiac arrest of primary cardiac origin were allocated to either 7.2% hypertonic saline with 6% poly (O-2-hydroxyethyl) starch solution (HH) or standard fluid therapy (Ringer's Acetate and saline 9 mg/ml) (control). The patients were treated with the randomised fluid immediately after admission and continued for 24 hours of therapeutic hypothermia. Results During the first 24 hours, the HH patients required significantly less i.v. fluid than the control patients (4750 ml versus 8010 ml, p = 0.019) with comparable use of vasopressors. Systemic vascular resistance was significantly reduced from 0 to 24 hours (p = 0.014), with no difference between the groups. Colloid osmotic pressure (COP) in serum and interstitial fluid (p < 0.001 and p = 0.014 respectively) decreased as a function of time in both groups, with a more pronounced reduction in interstitial COP in the crystalloid group. Magnetic resonance imaging of the brain did not reveal vasogenic oedema. Conclusions Post-cardiac arrest patients have high fluid requirements during therapeutic hypothermia, probably due to increased extravasation. The use of HH reduced the fluid requirement significantly. However, the lack of brain oedema in both groups suggests no superior fluid regimen. Cardiac index was significantly improved in the group treated with crystalloids. Although we do not associate HH with the renal failures that developed, caution should be taken when using hypertonic starch solutions in these patients. Trial registration NCT00347477.
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Affiliation(s)
- Bård E Heradstveit
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway.
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