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Duh M, Skok K, Perc M, Markota A, Gosak M. Computational modeling of targeted temperature management in post-cardiac arrest patients. Biomech Model Mechanobiol 2022; 21:1407-1424. [PMID: 35763192 DOI: 10.1007/s10237-022-01598-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 05/23/2022] [Indexed: 11/28/2022]
Abstract
Our core body temperature is held around [Formula: see text]C by an effective internal thermoregulatory system. However, various clinical scenarios have a more favorable outcome under external temperature regulation. Therapeutic hypothermia, for example, was found beneficial for the outcome of resuscitated cardiac arrest patients due to its protection against cerebral ischemia. Nonetheless, practice shows that outcomes of targeted temperature management vary considerably in dependence on individual tissue damage levels and differences in therapeutic strategies and protocols. Here, we address these differences in detail by means of computational modeling. We develop a multi-segment and multi-node thermoregulatory model that takes into account details related to specific post-cardiac arrest-related conditions, such as thermal imbalances due to sedation and anesthesia, increased metabolic rates induced by inflammatory processes, and various external cooling techniques. In our simulations, we track the evolution of the body temperature in patients subjected to post-resuscitation care, with particular emphasis on temperature regulation via an esophageal heat transfer device, on the examination of the alternative gastric cooling with ice slurry, and on how anesthesia and the level of inflammatory response influence thermal behavior. Our research provides a better understanding of the heat transfer processes and therapies used in post-cardiac arrest patients.
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Affiliation(s)
- Maja Duh
- Faculty of Natural Sciences and Mathematics, University of Maribor, Koroška cesta 160, 2000, Maribor, Slovenia
| | - Kristijan Skok
- Faculty of Medicine, University of Maribor, Taborska ulica 8, 2000, Maribor, Slovenia.,Department of Pathology, General Hospital Graz II, Location West, Göstinger Straße 22, 8020, Graz, Austria
| | - Matjaž Perc
- Faculty of Natural Sciences and Mathematics, University of Maribor, Koroška cesta 160, 2000, Maribor, Slovenia.,Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, 404332, Taiwan.,Alma Mater Europaea, Slovenska ulica 17, 2000, Maribor, Slovenia.,Complexity Science Hub Vienna, Josefstädterstraße 39, 1080, Vienna, Austria
| | - Andrej Markota
- Faculty of Medicine, University of Maribor, Taborska ulica 8, 2000, Maribor, Slovenia.,Medical Intensive Care Unit, University Medical Centre Maribor, Ljubljanska 5, 2000, Maribor, Slovenia
| | - Marko Gosak
- Faculty of Natural Sciences and Mathematics, University of Maribor, Koroška cesta 160, 2000, Maribor, Slovenia. .,Faculty of Medicine, University of Maribor, Taborska ulica 8, 2000, Maribor, Slovenia.
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Skok K, Duh M, Stožer A, Markota A, Gosak M. Thermoregulation: A journey from physiology to computational models and the intensive care unit. WILEY INTERDISCIPLINARY REVIEWS. SYSTEMS BIOLOGY AND MEDICINE 2020; 13:e1513. [PMID: 33251759 DOI: 10.1002/wsbm.1513] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 10/24/2020] [Accepted: 11/02/2020] [Indexed: 12/19/2022]
Abstract
Thermoregulation plays a vital role in homeostasis. Many species of animals as well as humans have evolved various physiological mechanisms for body temperature control, which are characteristically flexible and enable a fine-tuned spatial and temporal regulation of body temperature in different environmental conditions and circumstances. Human beings normally maintain a core body temperature at around 37°C, and maintenance of this relatively high temperature is critical for survival. Therefore, principles of thermoregulatory control have also important clinical implications. Infections can cause the body temperature to rise internally and several diseases can cause a dysfunction of thermoregulatory mechanisms. Moreover, the utilization of thermotherapies in treating various diseases has been known for thousands of years with a recent resurgence of interest. An increasing amount of research suggests that targeted temperature management is of paramount importance to patient outcomes in certain clinical scenarios. We provide a concise summary of the basic concepts of thermoregulation. Emphasis is given to the principles of thermoregulation in humans in basic pathological states and to targeted temperature management strategies in the clinical environment, with special attention on therapeutic hypothermia in postcardiac arrest patients. Finally, the discussion is focused on the potential offered by computational thermophysiological models for predicting thermal responses of patients in various clinical circumstances, for proposing new perspectives in the design of novel thermal therapies, and to optimize targeted temperature management strategies. This article is categorized under: Cardiovascular Diseases > Cardiovascular Diseases>Computational Models Cardiovascular Diseases > Cardiovascular Diseases>Environmental Factors Cardiovascular Diseases > Cardiovascular Diseases>Biomedical Engineering.
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Affiliation(s)
- Kristijan Skok
- Department of Pathology, General Hospital Graz II, Location West, Graz, Austria
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Maja Duh
- Faculty of Natural Sciences and Mathematics, University of Maribor, Koros̆ka cesta, Maribor, Slovenia
| | - Andraž Stožer
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Andrej Markota
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
- Medical Intensive Care Unit, University Medical Centre Maribor, Maribor, Slovenia
| | - Marko Gosak
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
- Faculty of Natural Sciences and Mathematics, University of Maribor, Koros̆ka cesta, Maribor, Slovenia
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Sawyer KN, Mooney M, Norris G, Devlin T, Lundbye J, Doshi PB, Hewett JK, Kono AT, Jorgensen JP, O'Neil BJ. COOL-ARREST: Results from a Pilot Multicenter, Prospective, Single-Arm Observational Trial to Assess Intravascular Temperature Management in the Treatment of Cardiac Arrest. Ther Hypothermia Temp Manag 2018; 9:56-62. [PMID: 29883298 DOI: 10.1089/ther.2018.0007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Targeted temperature management (TTM) is recommended postcardiac arrest. The cooling method with the highest safety and efficacy is unknown. The COOL-ARREST pilot trial aimed to evaluate the safety and efficacy of the most contemporary ZOLL Thermogard XP Intravascular Temperature Management (IVTM) system for providing mild TTM postcardiac arrest. This multicenter, prospective, single-arm, observational pilot trial enrolled patients at eight U.S. hospitals between July 28, 2014, and July 24, 2015. Adult (≥18 years old), out-of-hospital cardiac arrest subjects of presumed cardiac etiology who achieved return of spontaneous circulation (ROSC) were considered for inclusion. Patients were excluded if (1) awake or consistently following commands after ROSC, (2) significant prearrest neurological dysfunction, (3) terminal illness or advanced directives precluding aggressive care, and (4) severe hemodynamic instability or shock. Patient temperature was maintained at 33.0°C ± 0.3°C for a total of 24 hours followed by controlled rewarming (0.1-0.2°C/h). Logistic regressions were used to assess association of good functional outcome (modified Rankin Scale ≤3) measured at the time of hospital discharge with shockable rhythm (yes/no), age, gender, race/ethnicity, lay-rescuer cardiopulmonary resuscitation, time to basic life support (minutes), time to ROSC (minutes), lactate (mg/dL), and pH on admission. The ZOLL IVTM system was effective at inducing TTM (median time to target temperature from initiation, 89 minutes [interquartile range 42-155]). Adverse events most often included electrolyte abnormalities and dysrhythmias. Of patients surviving to hospital discharge, 16/20 patients had a good functional outcome. A total of 18 patients survived through 90-day follow-up, at which time 94% (17/18) of patients had good functional outcome. The COOL-ARREST pilot trial demonstrates high safety and efficacy of the ZOLL Thermogard XP IVTM system in the application of mild TTM postcardiac arrest. This observational trial also revealed noteworthy variability in the management of postcardiac arrest patients, particularly with the use of early withdrawal of life-sustaining therapy.
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Affiliation(s)
- Kelly N Sawyer
- 1 Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
| | - Michael Mooney
- 2 Minneapolis Heart Institute Foundation , Minneapolis, Minnesota
| | - Gregory Norris
- 3 Department of Neurology, McLaren Health , Flint, Michigan
| | - Thomas Devlin
- 4 Department of Neurology, University of Tennessee College of Medicine , Chattanooga Center, Chattanooga, Tennessee
| | - Justin Lundbye
- 5 The Greater Waterbury Health Network , Waterbury, Connecticut
| | - Pratik B Doshi
- 6 Division of Critical Care, Department of Emergency Medicine, McGovern Medical School , UT Health, Houston, Texas
| | - Jonathan Kyle Hewett
- 7 Division of Cardiology, University of South Carolina School of Medicine , Palmetto Health, Columbia, South Carolina
| | - Alan T Kono
- 8 Cardiovascular Medicine, Geisel School of Medicine at Dartmouth College , Dartmouth, New Hampshire
| | - Jesse P Jorgensen
- 9 Division of Cardiology, Heart & Vascular Institute, University of South Carolina School of Medicine-Greenville , Greenville, South Carolina
| | - Brian J O'Neil
- 10 Department of Emergency Medicine, Wayne State University , School of Medicine, Detroit, Michigan
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Herrera-Marschitz M, Perez-Lobos R, Lespay-Rebolledo C, Tapia-Bustos A, Casanova-Ortiz E, Morales P, Valdes JL, Bustamante D, Cassels BK. Targeting Sentinel Proteins and Extrasynaptic Glutamate Receptors: a Therapeutic Strategy for Preventing the Effects Elicited by Perinatal Asphyxia? Neurotox Res 2018; 33:461-473. [PMID: 28844085 PMCID: PMC5766721 DOI: 10.1007/s12640-017-9795-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 08/04/2017] [Accepted: 08/07/2017] [Indexed: 12/29/2022]
Abstract
Perinatal asphyxia (PA) is a relevant cause of death at the time of labour, and when survival is stabilised, associated with short- and long-term developmental disabilities, requiring inordinate care by health systems and families. Its prevalence is high (1 to 10/1000 live births) worldwide. At present, there are few therapeutic options, apart from hypothermia, that regrettably provides only limited protection if applied shortly after the insult.PA implies a primary and a secondary insult. The primary insult relates to the lack of oxygen, and the secondary one to the oxidative stress triggered by re-oxygenation, formation of reactive oxygen (ROS) and reactive nitrogen (RNS) species, and overactivation of glutamate receptors and mitochondrial deficiencies. PA induces overactivation of a number of sentinel proteins, including hypoxia-induced factor-1α (HIF-1α) and the genome-protecting poly(ADP-ribose) polymerase-1 (PARP-1). Upon activation, PARP-1 consumes high amounts of ATP at a time when this metabolite is scarce, worsening in turn the energy crisis elicited by asphyxia. The energy crisis also impairs ATP-dependent transport, including glutamate re-uptake by astroglia. Nicotinamide, a PARP-1 inhibitor, protects against the metabolic cascade elicited by the primary stage, avoiding NAD+ exhaustion and the energetic crisis. Upon re-oxygenation, however, oxidative stress leads to nuclear translocation of the NF-κB subunit p65, overexpression of the pro-inflammatory cytokines IL-1β and TNF-α, and glutamate-excitotoxicity, due to impairment of glial-glutamate transport, extracellular glutamate overflow, and overactivation of NMDA receptors, mainly of the extrasynaptic type. This leads to calcium influx, mitochondrial impairment, and inactivation of antioxidant enzymes, increasing further the activity of pro-oxidant enzymes, thereby making the surviving neonate vulnerable to recurrent metabolic insults whenever oxidative stress is involved. Here, we discuss evidence showing that (i) inhibition of PARP-1 overactivation by nicotinamide and (ii) inhibition of extrasynaptic NMDA receptor overactivation by memantine can prevent the short- and long-term consequences of PA. These hypotheses have been evaluated in a rat preclinical model of PA, aiming to identify the metabolic cascades responsible for the long-term consequences induced by the insult, also assessing postnatal vulnerability to recurrent oxidative insults. Thus, we present and discuss evidence demonstrating that PA induces long-term changes in metabolic pathways related to energy and oxidative stress, priming vulnerability of cells with both the neuronal and the glial phenotype. The effects induced by PA are region dependent, the substantia nigra being particularly prone to cell death. The issue of short- and long-term consequences of PA provides a framework for addressing a fundamental issue referred to plasticity of the CNS, since the perinatal insult triggers a domino-like sequence of events making the developing individual vulnerable to recurrent adverse conditions, decreasing his/her coping repertoire because of a relevant insult occurring at birth.
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Affiliation(s)
- Mario Herrera-Marschitz
- Programme of Molecular & Clinical Pharmacology, ICBM, Faculty of Medicine, University of Chile, Av. Independencia, PO Box 8389100, 1027 Santiago, Chile
| | - Ronald Perez-Lobos
- Programme of Molecular & Clinical Pharmacology, ICBM, Faculty of Medicine, University of Chile, Av. Independencia, PO Box 8389100, 1027 Santiago, Chile
- Escuela de Tecnologia Medica, Facultad de Medicina, Universidad Andres Bello, PO Box 8370146, Santiago, Chile
| | - Carolyne Lespay-Rebolledo
- Programme of Molecular & Clinical Pharmacology, ICBM, Faculty of Medicine, University of Chile, Av. Independencia, PO Box 8389100, 1027 Santiago, Chile
| | - Andrea Tapia-Bustos
- Programme of Molecular & Clinical Pharmacology, ICBM, Faculty of Medicine, University of Chile, Av. Independencia, PO Box 8389100, 1027 Santiago, Chile
| | - Emmanuel Casanova-Ortiz
- Programme of Molecular & Clinical Pharmacology, ICBM, Faculty of Medicine, University of Chile, Av. Independencia, PO Box 8389100, 1027 Santiago, Chile
| | - Paola Morales
- Programme of Molecular & Clinical Pharmacology, ICBM, Faculty of Medicine, University of Chile, Av. Independencia, PO Box 8389100, 1027 Santiago, Chile
- Faculty of Sciences, University of Chile, Santiago, Chile
| | | | - Diego Bustamante
- Programme of Molecular & Clinical Pharmacology, ICBM, Faculty of Medicine, University of Chile, Av. Independencia, PO Box 8389100, 1027 Santiago, Chile
| | - Bruce K. Cassels
- Department of Neuroscience, Faculty of Medicine, University of Chile, Santiago, Chile
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Rittenberger J, Kurz M, Polderman KH. Therapeutic Hypothermia in Postcardiac Arrest. Ther Hypothermia Temp Manag 2017; 7:184-187. [PMID: 29027885 DOI: 10.1089/ther.2017.29036.jjr] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jon Rittenberger
- 1 Department of Emergency Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Michael Kurz
- 2 Department of Emergency Medicine, University of Alabama at Birmingham , Birmingham, Alabama
| | - Kees H Polderman
- 3 Department of Critical Care Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
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Deconstructing the “Time to Target Temperature” interval: Emphasis on timing rather than depth. Resuscitation 2017; 113:A4-A5. [DOI: 10.1016/j.resuscitation.2017.01.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Accepted: 01/16/2017] [Indexed: 11/18/2022]
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Kurz M, Lundbye J, Lyden PD. Clinical Studies Targeting Stroke and In-Hospital Cardiac Arrest. Ther Hypothermia Temp Manag 2016; 6:6-8. [PMID: 26799665 DOI: 10.1089/ther.2016.29008.mjk] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Affiliation(s)
- Michael Kurz
- 1 Department of Emergency Medicine, University of Alabama at Birmingham , Birmingham, Alabama
| | - Justin Lundbye
- 2 Department of Cardiology, Hospital of Central Connecticut , New Britain, Connecticut
| | - Patrick D Lyden
- 3 Department of Neurology, Cedars-Sinai Medical Center , Los Angeles, California
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Polderman KH, Noc M, Kurz M, Aibiki M. Therapeutic Hypothermia in Post-Cardiac Arrest and Myocardial Infarction. Ther Hypothermia Temp Manag 2015; 5:193-7. [PMID: 26545102 DOI: 10.1089/ther.2015.29005.kjp] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kees H Polderman
- 1 Department of Critical Care Medicine, University of Pittsburgh Medical Center , Pittsburgh, Pennsylvania
| | - Marko Noc
- 2 Center for Intensive Internal Medicine, University Medical Center Ljubliana , Ljubliana, Slovenia
| | - Michael Kurz
- 3 Department of Emergency Medicine, School of Medicine, University of Alabama at Birmingham , Birmingham, Alabama
| | - Mayuki Aibiki
- 4 Department of Emergency Medicine and Critical Care Medicine, Ehime University , Matsuyama, Ehime, Japan
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