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Piel S, McManus MJ, Heye KN, Beaulieu F, Fazelinia H, Janowska JI, MacTurk B, Starr J, Gaudio H, Patel N, Hefti MM, Smalley ME, Hook JN, Kohli NV, Bruton J, Hallowell T, Delso N, Roberts A, Lin Y, Ehinger JK, Karlsson M, Berg RA, Morgan RW, Kilbaugh TJ. Effect of dimethyl fumarate on mitochondrial metabolism in a pediatric porcine model of asphyxia-induced in-hospital cardiac arrest. Sci Rep 2024; 14:13852. [PMID: 38879681 PMCID: PMC11180202 DOI: 10.1038/s41598-024-64317-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 06/07/2024] [Indexed: 06/19/2024] Open
Abstract
Neurological and cardiac injuries are significant contributors to morbidity and mortality following pediatric in-hospital cardiac arrest (IHCA). Preservation of mitochondrial function may be critical for reducing these injuries. Dimethyl fumarate (DMF) has shown potential to enhance mitochondrial content and reduce oxidative damage. To investigate the efficacy of DMF in mitigating mitochondrial injury in a pediatric porcine model of IHCA, toddler-aged piglets were subjected to asphyxia-induced CA, followed by ventricular fibrillation, high-quality cardiopulmonary resuscitation, and random assignment to receive either DMF (30 mg/kg) or placebo for four days. Sham animals underwent similar anesthesia protocols without CA. After four days, tissues were analyzed for mitochondrial markers. In the brain, untreated CA animals exhibited a reduced expression of proteins of the oxidative phosphorylation system (CI, CIV, CV) and decreased mitochondrial respiration (p < 0.001). Despite alterations in mitochondrial content and morphology in the myocardium, as assessed per transmission electron microscopy, mitochondrial function was unchanged. DMF treatment counteracted 25% of the proteomic changes induced by CA in the brain, and preserved mitochondrial structure in the myocardium. DMF demonstrates a potential therapeutic benefit in preserving mitochondrial integrity following asphyxia-induced IHCA. Further investigation is warranted to fully elucidate DMF's protective mechanisms and optimize its therapeutic application in post-arrest care.
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Affiliation(s)
- Sarah Piel
- Resuscitation Science Center of Emphasis, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, USA.
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany.
- CARID, Cardiovascular Research Institute Düsseldorf, Medical Faculty of the Heinrich-Heine-University, Düsseldorf, Germany.
| | - Meagan J McManus
- Resuscitation Science Center of Emphasis, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Kristina N Heye
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Forrest Beaulieu
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Hossein Fazelinia
- Proteomics Core Facility, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Joanna I Janowska
- Resuscitation Science Center of Emphasis, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Bryce MacTurk
- Resuscitation Science Center of Emphasis, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Jonathan Starr
- Resuscitation Science Center of Emphasis, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Hunter Gaudio
- Resuscitation Science Center of Emphasis, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Nisha Patel
- Resuscitation Science Center of Emphasis, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Marco M Hefti
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Martin E Smalley
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Jordan N Hook
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Neha V Kohli
- Resuscitation Science Center of Emphasis, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - James Bruton
- Resuscitation Science Center of Emphasis, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Thomas Hallowell
- Resuscitation Science Center of Emphasis, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Nile Delso
- Resuscitation Science Center of Emphasis, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Anna Roberts
- Resuscitation Science Center of Emphasis, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Yuxi Lin
- Resuscitation Science Center of Emphasis, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Johannes K Ehinger
- Mitochondrial Medicine, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Otorhinolaryngology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Otorhinolaryngology, Head and Neck Surgery, Skåne University Hospital, Lund, Sweden
| | | | - Robert A Berg
- Resuscitation Science Center of Emphasis, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Ryan W Morgan
- Resuscitation Science Center of Emphasis, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Todd J Kilbaugh
- Resuscitation Science Center of Emphasis, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, USA
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Andersen LW, Vammen L, Granfeldt A. Animal research in cardiac arrest. Resusc Plus 2024; 17:100511. [PMID: 38148966 PMCID: PMC10750107 DOI: 10.1016/j.resplu.2023.100511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023] Open
Abstract
The purpose of this narrative review is to provide an overview of lessons learned from experimental cardiac arrest studies, limitations, translation to clinical studies, ethical considerations and future directions. Cardiac arrest animal studies have provided valuable insights into the pathophysiology of cardiac arrest, the effects of various interventions, and the development of resuscitation techniques. However, there are limitations to animal models that should be considered when interpreting results. Systematic reviews have demonstrated that animal models rarely reflect the clinical condition seen in humans, nor the complex treatment that occurs during and after a cardiac arrest. Furthermore, animal models of cardiac arrest are at a significant risk of bias due to fundamental issues in performing and/or reporting critical methodological aspects. Conducting clinical trials targeting the management of rare cardiac arrest causes like e.g. hyperkalemia and pulmonary embolism is challenging due to the scarcity of eligible patients. For these research questions, animal models might provide the highest level of evidence and can potentially guide clinical practice. To continuously push cardiac arrest science forward, animal studies must be conducted and reported rigorously, designed to avoid bias and answer specific research questions. To ensure the continued relevance and generation of valuable new insights from animal studies, new approaches and techniques may be needed, including animal register studies, systematic reviews and multilaboratory trials.
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Affiliation(s)
- Lars W. Andersen
- Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Denmark
- Department of Anesthesiology and Intensive Care, Viborg Regional Hospital, Viborg, Denmark
- Prehospital Emergency Medical Services, Central Region Denmark, Denmark
| | - Lauge Vammen
- Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Asger Granfeldt
- Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Denmark
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Morin CMD, Cheung PY, Lee TF, O'Reilly M, Schmölzer GM. Chest compressions superimposed with sustained inflations during cardiopulmonary resuscitation in asphyxiated pediatric piglets. Pediatr Res 2024; 95:988-995. [PMID: 36932182 DOI: 10.1038/s41390-023-02563-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 02/13/2023] [Accepted: 02/27/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND Pediatric resuscitation guidelines recommend continuous chest compression with asynchronized ventilation (CCaV) during cardiopulmonary resuscitation. We recently described that providing a constant high distending pressure, or sustained inflation (SI) while performing continuous chest compressions (CC = CC + SI) reduces time to return of spontaneous circulation (ROSC) in neonatal and pediatric piglets with asphyxia-induced cardiac arrest. METHODS To determine if CC + SI compared to CCaV will improve frequency of achieving ROSC and reduce time to ROSC in asphyxiated pediatric piglets. Twenty-eight pediatric piglets (21-24 days old) were anesthetized and asphyxiated by clamping the endotracheal tube. Piglets were randomized to CC + SI or CCaV for resuscitation (n = 14/group). Heart rate, arterial blood pressure, carotid blood flow, cerebral oxygenation, and respiratory parameters were continuously recorded throughout the experiment. RESULTS The mean(SD) duration of resuscitation was significantly reduced with CC + SI compared to CCaV with 208(190) vs. 388(258)s, p = 0.045, respectively. The number of piglets achieving ROSC with CC + SI and CCaV were 12/14 vs. 6/14, p = 0.046. Minute ventilation, end-tidal carbon dioxide, ventilation rate, and positive end expiratory pressures were also significantly improved with CC + SI. CONCLUSIONS CC + SI improves duration of resuscitation and increases number of piglets achieving ROSC secondary to improved minute ventilation. IMPACT Chest compressions superimposed with sustained inflation resulted in shorter duration of resuscitation Chest compressions superimposed with sustained inflation resulted in higher number of piglets achieving return of spontaneous circulation Further animal studies are needed to examine chest compressions superimposed with sustained inflation.
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Affiliation(s)
- Chelsea M D Morin
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Po-Yin Cheung
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Tze-Fun Lee
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Megan O'Reilly
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada.
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
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Gottula AL, Maciel CB, Nishikimi M, Kalra R, Sunshine J, Morgan RW. Wolf Creek XVII part 9: Wolf Creek Innovator in Cardiac Arrest and Resuscitation Science Award. Resusc Plus 2024; 17:100519. [PMID: 38076386 PMCID: PMC10698667 DOI: 10.1016/j.resplu.2023.100519] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2023] Open
Abstract
The Wolf Creek Conferences on Cardiac Arrest Resuscitation began in 1975, and have served as an important forum for thought leaders and scientists from industry and academia to come together with the common goal of advancing the field of cardiac arrest resuscitation. The Wolf Creek XVII Conference was hosted by the Max Harry Weil Institute of Critical Care Research and Innovation in Ann Arbor, Michigan on June 14-17, 2023. A new component of the conference was the Wolf Creek Innovator in Cardiac Arrest and Resuscitation Science Award competition. The competition was designed to recognize early career investigators from around the world who's science is challenging the current paradigms in the field. Finalists were selected by a panel of international experts and invited to present in-person at the conference. The winner was chosen by electronic vote of conference participants and awarded a $10,0000 cash prize. Finalists included Carolina Barbosa Maciel from the University of Florida, Adam Gottula from the University of Michigan, Rajat Kalra from the University of Minnesota, Ryan Morgan from the Children's Hospital of Philadelphia, Mitsuaki Nishikimi form Hiroshima University, and Jacob Sunshine from the University of Washington. Ryan Morgan from the Children's Hospital of Philadelphia was selected as the 2023 Wolf Creek Innovator Awardee. This manuscript provides a summary of the work presented by each of the finalists and provides a preview of the future of resuscitation science.
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Affiliation(s)
- Adam L. Gottula
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI 48109, USA
- Texas IPS, San Antonio, TX 78229, USA
- Institute for Extracorporeal Life Support, San Antonio, TX 78229, USA
| | - Carolina B. Maciel
- Department of Neurology, Division of Neurocritical Care, University of Florida College of Medicine, Gainesville, FL 32611, USA
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA
- Department of Neurology, University of Utah, Salt Lake City, UT 84132, USA
| | - Mitsuaki Nishikimi
- Laboratory of Critical Care Physiology, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY 11030, USA
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 7348551, Japan
| | - Rajat Kalra
- Cardiovascular Division, University of Minnesota, Minneapolis, MN 55455, USA
| | - Jacob Sunshine
- Department of Anesthesiology, University of Washington, Seattle, WA 98195, USA
| | - Ryan W. Morgan
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Resuscitation Science Center, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
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Morgan RW, Reeder RW, Bender D, Cooper KK, Friess SH, Graham K, Meert KL, Mourani PM, Murray R, Nadkarni VM, Nataraj C, Palmer CA, Srivastava N, Tilford B, Wolfe HA, Yates AR, Berg RA, Sutton RM. Associations Between End-Tidal Carbon Dioxide During Pediatric Cardiopulmonary Resuscitation, Cardiopulmonary Resuscitation Quality, and Survival. Circulation 2024; 149:367-378. [PMID: 37929615 PMCID: PMC10841728 DOI: 10.1161/circulationaha.123.066659] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/27/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Supported by laboratory and clinical investigations of adult cardiopulmonary arrest, resuscitation guidelines recommend monitoring end-tidal carbon dioxide (ETCO2) as an indicator of cardiopulmonary resuscitation (CPR) quality, but they note that "specific values to guide therapy have not been established in children." METHODS This prospective observational cohort study was a National Heart, Lung, and Blood Institute-funded ancillary study of children in the ICU-RESUS trial (Intensive Care Unit-Resuscitation Project; NCT02837497). Hospitalized children (≤18 years of age and ≥37 weeks postgestational age) who received chest compressions of any duration for cardiopulmonary arrest, had an endotracheal or tracheostomy tube at the start of CPR, and evaluable intra-arrest ETCO2 data were included. The primary exposure was event-level average ETCO2 during the first 10 minutes of CPR (dichotomized as ≥20 mm Hg versus <20 mm Hg on the basis of adult literature). The primary outcome was survival to hospital discharge. Secondary outcomes were sustained return of spontaneous circulation, survival to discharge with favorable neurological outcome, and new morbidity among survivors. Poisson regression measured associations between ETCO2 and outcomes as well as the association between ETCO2 and other CPR characteristics: (1) invasively measured systolic and diastolic blood pressures, and (2) CPR quality and chest compression mechanics metrics (ie, time to CPR start; chest compression rate, depth, and fraction; ventilation rate). RESULTS Among 234 included patients, 133 (57%) had an event-level average ETCO2 ≥20 mm Hg. After controlling for a priori covariates, average ETCO2 ≥20 mm Hg was associated with a higher incidence of survival to hospital discharge (86/133 [65%] versus 48/101 [48%]; adjusted relative risk, 1.33 [95% CI, 1.04-1.69]; P=0.023) and return of spontaneous circulation (95/133 [71%] versus 59/101 [58%]; adjusted relative risk, 1.22 [95% CI, 1.00-1.49]; P=0.046) compared with lower values. ETCO2 ≥20 mm Hg was not associated with survival with favorable neurological outcome or new morbidity among survivors. Average 2 ≥20 mm Hg was associated with higher systolic and diastolic blood pressures during CPR, lower CPR ventilation rates, and briefer pre-CPR arrest durations compared with lower values. Chest compression rate, depth, and fraction did not differ between ETCO2 groups. CONCLUSIONS In this multicenter study of children with in-hospital cardiopulmonary arrest, ETCO2 ≥20 mm Hg was associated with better outcomes and higher intra-arrest blood pressures, but not with chest compression quality metrics.
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Affiliation(s)
- Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania (R.W.M., K.K.C., K.G., V.M.N., H.A.W., R.A.B., R.M.S.)
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City (R.W.R., C.A.P.)
| | - Dieter Bender
- Villanova Center for Analytics of Dynamic Systems, Villanova University, PA (D.B., C.N.)
| | - Kellimarie K Cooper
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania (R.W.M., K.K.C., K.G., V.M.N., H.A.W., R.A.B., R.M.S.)
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO (S.H.F.)
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania (R.W.M., K.K.C., K.G., V.M.N., H.A.W., R.A.B., R.M.S.)
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit (K.L.M., B.T.)
| | - Peter M Mourani
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (P.M.M.)
| | - Robert Murray
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus (R.M., A.R.Y.)
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania (R.W.M., K.K.C., K.G., V.M.N., H.A.W., R.A.B., R.M.S.)
| | - Chandrasekhar Nataraj
- Villanova Center for Analytics of Dynamic Systems, Villanova University, PA (D.B., C.N.)
| | - Chella A Palmer
- Department of Pediatrics, University of Utah, Salt Lake City (R.W.R., C.A.P.)
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles (N.S.)
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit (K.L.M., B.T.)
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania (R.W.M., K.K.C., K.G., V.M.N., H.A.W., R.A.B., R.M.S.)
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus (R.M., A.R.Y.)
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania (R.W.M., K.K.C., K.G., V.M.N., H.A.W., R.A.B., R.M.S.)
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania (R.W.M., K.K.C., K.G., V.M.N., H.A.W., R.A.B., R.M.S.)
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Kucher NM, Marquez AM, Guerguerian AM, Moga MA, Vargas-Gutierrez M, Todd M, Honjo O, Haller C, Goco G, Floh AA. Epinephrine Dosing Use During Extracorporeal Cardiopulmonary Resuscitation: Single-Center Retrospective Cohort. Pediatr Crit Care Med 2023; 24:e531-e539. [PMID: 37439601 DOI: 10.1097/pcc.0000000000003323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
OBJECTIVES During pediatric cardiac arrest, contemporary guidelines recommend dosing epinephrine at regular intervals, including in patients requiring extracorporeal membrane oxygenation (ECMO). The impact of epinephrine-induced vasoconstriction on systemic afterload and venoarterial ECMO support is not well-defined. DESIGN Nested retrospective observational study within a single center. The primary exposure was time from last dose of epinephrine to initiation of ECMO flow; secondary exposures included cumulative epinephrine dose and arrest time. Systemic afterload was assessed by mean arterial pressure and use of systemic vasodilator therapy; ECMO pump flow and Vasoactive-Inotrope Score (VIS) were used as measures of ECMO support. Clearance of lactate was followed post-cannulation as a marker of systemic perfusion. SETTING PICU and cardiac ICU in a quaternary-care center. PATIENTS Patients 0-18 years old who required ECMO cannulation during resuscitation over the 6 years, 2014-2020. Patients were excluded if ECMO was initiated before cardiac arrest or if the resuscitation record was incomplete. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 92 events in 87 patients, with 69 events having complete data for analysis. The median (interquartile range) of total epinephrine dosing was 65 mcg/kg (37-101 mcg/kg), with the last dose given 6 minutes (2-16 min) before the initiation of ECMO flows. Shorter interval between last epinephrine dose and ECMO initiation was associated with increased use of vasodilators within 6 hours of ECMO ( p = 0.05), but not with mean arterial pressure after 1 hour of support (estimate, -0.34; p = 0.06). No other associations were identified between epinephrine delivery and mean arterial blood pressure, vasodilator use, pump speed, VIS, or lactate clearance. CONCLUSIONS There is limited evidence to support the idea that regular dosing of epinephrine during cardiac arrest is associated with increased in afterload after ECMO cannulation. Additional studies are needed to validate findings against ECMO flows and clinically relevant outcomes.
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Affiliation(s)
- Nicholas M Kucher
- Department of Critical Care Medicine, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Alexandra M Marquez
- Department of Critical Care Medicine, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Anne-Marie Guerguerian
- Department of Critical Care Medicine, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Michael-Alice Moga
- Department of Critical Care Medicine, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
- Labatt Family Heart Centre, Division of Pediatric Cardiology, Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada
| | - Mariella Vargas-Gutierrez
- Department of Critical Care Medicine, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Mark Todd
- Department of Respiratory Therapy, The Hospital for Sick Children, Toronto, ON, Canada
| | - Osami Honjo
- Labatt Family Heart Centre, Division of Cardiac Surgery, Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada
| | - Christoph Haller
- Labatt Family Heart Centre, Division of Cardiac Surgery, Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada
| | - Geraldine Goco
- Department of Critical Care Medicine, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Alejandro A Floh
- Department of Critical Care Medicine, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
- Labatt Family Heart Centre, Division of Pediatric Cardiology, Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada
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7
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Silva LEV, Shi L, Gaudio HA, Padmanabhan V, Morgan RW, Slovis JM, Forti RM, Morton S, Lin Y, Laurent GH, Breimann J, Yun BH, Ranieri NR, Bowe M, Baker WB, Kilbaugh TJ, Ko TS, Tsui FR. Prediction of Return of Spontaneous Circulation in a Pediatric Swine Model of Cardiac Arrest Using Low-Resolution Multimodal Physiological Waveforms. IEEE J Biomed Health Inform 2023; 27:4719-4727. [PMID: 37478027 PMCID: PMC10756325 DOI: 10.1109/jbhi.2023.3297927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2023]
Abstract
Monitoring physiological waveforms, specifically hemodynamic variables (e.g., blood pressure waveforms) and end-tidal CO2 (EtCO2), during pediatric cardiopulmonary resuscitation (CPR) has been demonstrated to improve survival rates and outcomes when compared to standard depth-guided CPR. However, waveform guidance has largely been based on thresholds for single parameters and therefore does not leverage all the information contained in multimodal data. We hypothesize that the combination of multimodal physiological features improves the prediction of the return of spontaneous circulation (ROSC), the clinical indicator of short-term CPR success. We used machine learning algorithms to evaluate features extracted from eight low-resolution (4 samples per minute) physiological waveforms to predict ROSC. The waveforms were acquired from the 2nd to 10th minute of CPR in pediatric swine models of cardiac arrest (N = 89, 8-12 kg). The waveforms were divided into segments with increasing length (both forward and backward) for feature extraction, and machine learning algorithms were trained for ROSC prediction. For the full CPR period (2nd to 10th minute), the area under the receiver operating characteristics curve (AUC) was 0.93 (95% CI: 0.87-0.99) for the multivariate model, 0.70 (0.55-0.85) for EtCO2 and 0.80 (0.67-0.93) for coronary perfusion pressure. The best prediction performances were achieved when the period from the 6th to the 10th minute was included. Poor predictions were observed for some individual waveforms, e.g., right atrial pressure. In conclusion, multimodal waveform features carry relevant information for ROSC prediction. Using multimodal waveform features in CPR guidance has the potential to improve resuscitation success and reduce mortality.
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Rappold TE, Morgan RW, Reeder RW, Cooper KK, Weeks MK, Widmann NJ, Graham K, Berg RA, Sutton RM. The association of arterial blood pressure waveform-derived area duty cycle with intra-arrest hemodynamics and cardiac arrest outcomes. Resuscitation 2023; 191:109950. [PMID: 37634859 PMCID: PMC10829972 DOI: 10.1016/j.resuscitation.2023.109950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/16/2023] [Accepted: 08/17/2023] [Indexed: 08/29/2023]
Abstract
AIM Develop a novel, physiology-based measurement of duty cycle (Arterial Blood Pressure-Area Duty Cycle [ABP-ADC]) and evaluate the association of ABP-ADC with intra-arrest hemodynamics and patient outcomes. METHODS This was a secondary retrospective study of prospectively collected data from the ICU-RESUS trial (NCT02837497). Invasive arterial waveform data were used to derive ABP-ADC. The primary exposure was ABP-ADC group (<30%; 30-35%; >35%). The primary outcome was systolic blood pressure (sBP). Secondary outcomes included intra-arrest physiologic goals, CPR quality targets, and patient outcomes. In an exploratory analysis, adjusted splines and receiver operating characteristic (ROC) curves were used to determine an optimal ABP-ADC associated with improved hemodynamics and outcomes using a multivariable model. RESULTS Of 1129 CPR events, 273 had evaluable arterial waveform data. Mean age is 2.9 years + 4.9 months. Mean ABP-ADC was 32.5% + 5.0%. In univariable analysis, higher ABP-ADC was associated with lower sBP (p < 0.01) and failing to achieve sBP targets (p < 0.01). Other intra-arrest physiologic parameters, quality metrics, and patient outcomes were similar across ABP-ADC groups. Using spline/ROC analysis and clinical judgement, the optimal ABP-ADC cut point was set at 33%. On multivariable analysis, sBP was significantly higher (point estimate 13.18 mmHg, CI95 5.30-21.07, p < 0.01) among patients with ABP-ADC < 33%. Other intra-arrest physiologic and patient outcomes were similar. CONCLUSIONS In this multicenter cohort, a lower ABP-ADC was associated with higher sBPs during CPR. Although ABP-ADC was not associated with outcomes, further studies are needed to define the interactions between CPR mechanics and intra arrest patient physiology.
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Affiliation(s)
- Tommy E Rappold
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Kellimarie K Cooper
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - M Katie Weeks
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Nicholas J Widmann
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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9
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Gaudio HA, Padmanabhan V, Landis WP, Silva LEV, Slovis J, Starr J, Weeks MK, Widmann NJ, Forti RM, Laurent GH, Ranieri NR, Mi F, Degani RE, Hallowell T, Delso N, Calkins H, Dobrzynski C, Haddad S, Kao SH, Hwang M, Shi L, Baker WB, Tsui F, Morgan RW, Kilbaugh TJ, Ko TS. A Template for Translational Bioinformatics: Facilitating Multimodal Data Analyses in Preclinical Models of Neurological Injury. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.07.17.547582. [PMID: 37503137 PMCID: PMC10370067 DOI: 10.1101/2023.07.17.547582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Background Pediatric neurological injury and disease is a critical public health issue due to increasing rates of survival from primary injuries (e.g., cardiac arrest, traumatic brain injury) and a lack of monitoring technologies and therapeutics for the treatment of secondary neurological injury. Translational, preclinical research facilitates the development of solutions to address this growing issue but is hindered by a lack of available data frameworks and standards for the management, processing, and analysis of multimodal data sets. Methods Here, we present a generalizable data framework that was implemented for large animal research at the Children's Hospital of Philadelphia to address this technological gap. The presented framework culminates in an interactive dashboard for exploratory analysis and filtered data set download. Results Compared with existing clinical and preclinical data management solutions, the presented framework accommodates heterogeneous data types (single measure, repeated measures, time series, and imaging), integrates data sets across various experimental models, and facilitates dynamic visualization of integrated data sets. We present a use case of this framework for predictive model development for intra-arrest prediction of cardiopulmonary resuscitation outcome. Conclusions The described preclinical data framework may serve as a template to aid in data management efforts in other translational research labs that generate heterogeneous data sets and require a dynamic platform that can easily evolve alongside their research.
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10
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Ong GY, Chen ZJ, Niles DE, Srinivasan V, Sen AI, Skellett S, Ikeyama T, Del Castillo J, Berg RA, Nadkarni VM. Poor Concordance of One-Third Anterior-Posterior Chest Diameter Measurements With Absolute Age-Specific Chest Compression Depth Targets in Pediatric Cardiac Arrest Patients. J Am Heart Assoc 2023:e028418. [PMID: 37421276 PMCID: PMC10382104 DOI: 10.1161/jaha.122.028418] [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] [Received: 11/06/2022] [Accepted: 06/08/2023] [Indexed: 07/10/2023]
Abstract
Background Current pediatric cardiac arrest guidelines recommend depressing the chest by one-third anterior-posterior diameter (APD), which is presumed to equate to absolute age-specific chest compression depth targets (4 cm for infants and 5 cm for children). However, no clinical studies during pediatric cardiac arrest have validated this presumption. We aimed to study the concordance of measured one-third APD with absolute age-specific chest compression depth targets in a cohort of pediatric patients with cardiac arrest. Methods and Results This was a retrospective observational study from a multicenter, pediatric resuscitation quality collaborative (pediRES-Q [Pediatric Resuscitation Quality Collaborative]) from October 2015 to March 2022. In-hospital patients with cardiac arrest ≤12 years old with APD measurements recorded were included for analysis. One hundred eighty-two patients (118 infants >28 days old to <1 year old, and 64 children 1 to 12 years old) were analyzed. The mean one-third APD of infants was 3.2 cm (SD, 0.7 cm), which was significantly smaller than the 4 cm target depth (P<0.001). Seventeen percent of the infants had one-third APD measurements within the 4 cm ±10% target range. For children, the mean one-third APD was 4.3 cm (SD, 1.1 cm). Thirty-nine percent of children had one-third APD within the 5 cm ±10% range. Except for children 8 to 12 years old and overweight children, the measured mean one-third APD of the majority of the children was significantly smaller than the 5 cm depth target (P<0.05). Conclusions There was poor concordance between measured one-third APD and absolute age-specific chest compression depth targets, particularly for infants. Further study is needed to validate current pediatric chest compression depth targets and evaluate the optimal chest compression depth to improve cardiac arrest outcomes. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02708134.
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Affiliation(s)
- Gene Y Ong
- KK Women's and Children's Hospital Singapore
- Duke-NUS Graduate Medical School Singapore
| | - Zhao Jin Chen
- Yong Loo Lin School of Medicine National University of Singapore Singapore
- Saw Swee Hock School of Public Health National University of Singapore Singapore
| | - Dana E Niles
- Department of Anesthesiology, Critical Care, and Pediatrics, Children's Hospital of Philadelphia University of Pennsylvania School of Medicine Philadelphia PA USA
| | - Vijay Srinivasan
- Department of Anesthesiology, Critical Care, and Pediatrics, Children's Hospital of Philadelphia University of Pennsylvania School of Medicine Philadelphia PA USA
| | - Anita I Sen
- New York-Presbyterian Morgan Stanley Children's Hospital New York NY USA
| | - Sophie Skellett
- Department of Paediatric Intensive Care Great Ormond Street Hospital for Children NHS Foundation Trust London United Kingdom
| | - Takanari Ikeyama
- Center for Pediatric Emergency and Critical Care Medicine Aichi Children's Health and Medical Center Obu Aichi Japan
- Comprehensive Pediatric Medicine Nagoya University Graduate School of Medicine Nagoya Japan
| | | | - Robert A Berg
- Department of Anesthesiology, Critical Care, and Pediatrics, Children's Hospital of Philadelphia University of Pennsylvania School of Medicine Philadelphia PA USA
| | - Vinay M Nadkarni
- Department of Anesthesiology, Critical Care, and Pediatrics, Children's Hospital of Philadelphia University of Pennsylvania School of Medicine Philadelphia PA USA
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11
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Kienzle MF, Morgan RW, Alvey JS, Reeder R, Berg RA, Nadkarni V, Topjian AA, Lasa JJ, Raymond TT, Sutton RM. Clinician-reported physiologic monitoring of cardiopulmonary resuscitation quality during pediatric in-hospital cardiac arrest: A propensity-weighted cohort study. Resuscitation 2023; 188:109807. [PMID: 37088272 PMCID: PMC10773163 DOI: 10.1016/j.resuscitation.2023.109807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/31/2023] [Accepted: 04/17/2023] [Indexed: 04/25/2023]
Abstract
AIMS The primary objective was to determine the association between clinician-reported use of end-tidal CO2 (ETCO2) or diastolic blood pressure (DBP) to monitor cardiopulmonary resuscitation (CPR) quality during pediatric in-hospital cardiac arrest (pIHCA) and survival outcomes. DESIGN A retrospective cohort study was performed in two cohorts: (1) Patients with an invasive airway in place at the time of arrest to evaluate ETCO2 use, and (2) patients with an arterial line in place at the time of arrest to evaluate DBP use. The primary exposure was clinician-reported use of ETCO2 or DBP. The primary outcome was return of spontaneous circulation (ROSC). Propensity-weighted logistic regression evaluated the association between monitoring and outcomes. SETTING Hospitals reporting to the American Heart Association's Get With The Guidelines®- Resuscitation registry (2007-2021). PATIENTS Children with index IHCA with an invasive airway or arterial line at the time of arrest. RESULTS Between January 2007 and May 2021, there were 15,280 pediatric CPR events with an invasive airway or arterial line in place at the time of arrest. Of 7159 events with an invasive airway, 6829 were eligible for analysis. Of 2978 events with an arterial line, 2886 were eligible. Clinicians reported using ETCO2 in 1335/6829 (20%) arrests and DBP in 1041/2886 (36%). Neither exposure was associated with ROSC. ETCO2 monitoring was associated with higher odds of 24-hour survival (aOR 1.17 [1.02, 1.35], p = 0.03). CONCLUSIONS Neither clinician-reported ETCO2 monitoring nor DBP monitoring during pIHCA were associated with ROSC. Monitoring of ETCO2 was associated with 24-hour survival.
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Affiliation(s)
- Martha F Kienzle
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States.
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Jessica S Alvey
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Ron Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Alexis A Topjian
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Javier J Lasa
- Department of Pediatrics, Children's Medical Center, University of Texas - Southwestern, Dallas, TX, United States
| | - Tia T Raymond
- Department of Pediatrics, Medical City Children's Hospital, Dallas, TX, United States
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
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12
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Morgan RW, Berg RA, Reeder RW, Carpenter TC, Franzon D, Frazier AH, Graham K, Meert KL, Nadkarni VM, Naim MY, Tilford B, Wolfe HA, Yates AR, Sutton RM. The physiologic response to epinephrine and pediatric cardiopulmonary resuscitation outcomes. Crit Care 2023; 27:105. [PMID: 36915182 PMCID: PMC10012560 DOI: 10.1186/s13054-023-04399-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 03/08/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Epinephrine is provided during cardiopulmonary resuscitation (CPR) to increase systemic vascular resistance and generate higher diastolic blood pressure (DBP) to improve coronary perfusion and attain return of spontaneous circulation (ROSC). The DBP response to epinephrine during pediatric CPR and its association with outcomes have not been well described. Thus, the objective of this study was to measure the association between change in DBP after epinephrine administration during CPR and ROSC. METHODS This was a prospective multicenter study of children receiving ≥ 1 min of CPR with ≥ 1 dose of epinephrine and evaluable invasive arterial BP data in the 18 ICUs of the ICU-RESUS trial (NCT02837497). Blood pressure waveforms underwent compression-by-compression quantitative analysis. The mean DBP before first epinephrine dose was compared to mean DBP two minutes post-epinephrine. Patients with ≥ 5 mmHg increase in DBP were characterized as "responders." RESULTS Among 147 patients meeting inclusion criteria, 66 (45%) were characterized as responders and 81 (55%) were non-responders. The mean increase in DBP with epinephrine was 4.4 [- 1.9, 11.5] mmHg (responders: 13.6 [7.5, 29.3] mmHg versus non-responders: - 1.5 [- 5.0, 1.5] mmHg; p < 0.001). After controlling for a priori selected covariates, epinephrine response was associated with ROSC (aRR 1.60 [1.21, 2.12]; p = 0.001). Sensitivity analyses identified similar associations between DBP response thresholds of ≥ 10, 15, and 20 mmHg and ROSC; DBP responses of ≥ 10 and ≥ 15 mmHg were associated with higher aRR of survival to hospital discharge and survival with favorable neurologic outcome (Pediatric Cerebral Performance Category score of 1-3 or no worsening from baseline). CONCLUSIONS The change in DBP following epinephrine administration during pediatric in-hospital CPR was associated with return of spontaneous circulation.
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Affiliation(s)
- Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Wood Building - 6104, Philadelphia, PA, 19104, USA.
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Wood Building - 6104, Philadelphia, PA, 19104, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Aisha H Frazier
- Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.,Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Wood Building - 6104, Philadelphia, PA, 19104, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Wood Building - 6104, Philadelphia, PA, 19104, USA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Wood Building - 6104, Philadelphia, PA, 19104, USA
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Wood Building - 6104, Philadelphia, PA, 19104, USA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Wood Building - 6104, Philadelphia, PA, 19104, USA
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13
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Perkins GD, Couper K. Improving vasopressor use in cardiac arrest. Crit Care 2023; 27:81. [PMID: 36864469 PMCID: PMC9979497 DOI: 10.1186/s13054-023-04301-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 01/04/2023] [Indexed: 03/04/2023] Open
Abstract
The Chain of Survival highlights the effectiveness of early recognition of cardiac arrest and call for help, early cardiopulmonary resuscitation and early defibrillation. Most patients, however, remain in cardiac arrest despite these interventions. Drug treatments, particularly the use of vasopressors, have been included in resuscitation algorithms since their inception. This narrative review describes the current evidence base for vasopressors and reports that adrenaline (1 mg) is highly effective at achieving return of spontaneous circulation (number needed to treat 4) but is less effective on long-term outcomes (survival to 30 days, number needed to treat 111) with uncertain effects on survival with a favourable neurological outcome. Randomised trials evaluating vasopressin, either as an alternative to or in addition to adrenaline, and high-dose adrenaline have failed to find evidence of improved long-term outcomes. There is a need for future trials to evaluate the interaction between steroids and vasopressin. Evidence for other vasopressors (e.g. noradrenaline, phenylephedrine) is insufficient to support or refute their use. The use of intravenous calcium chloride as a routine intervention in out of hospital cardiac arrest is not associated with benefit and may cause harm. The optimal route for vascular access between peripheral intravenous versus intraosseous routes is currently the subject of two large randomised trials. Intracardiac, endobronchial, and intramuscular routes are not recommended. Central venous administration should be limited to patients where an existing central venous catheter is in situ and patent.
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Affiliation(s)
- Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.
| | - Keith Couper
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
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14
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Cournoyer A, Cavayas YA. Central venous pressure amplitude: A novel marker of resuscitation quality. Resuscitation 2023; 185:109749. [PMID: 36842673 DOI: 10.1016/j.resuscitation.2023.109749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 02/17/2023] [Indexed: 02/26/2023]
Affiliation(s)
- Alexis Cournoyer
- Faculty of Medicine, Department of Family Medicine and Emergency Medicine, Université de Montréal, Montréal, Québec, Canada; Centre de Recherche de l'Hôpital du Sacré-Cœur de Montréal, Montréal, Québec, Canada; Department of Emergency Medicine, Hôpital du Sacré-Cœur de Montréal, CIUSSS-NIM, Montréal, Québec, Canada; Department of Emergency Medicine, Hôpital Maisonneuve-Rosemont, CIUSSS-EIM, Montréal, Québec, Canada; Corporation d'Urgences-santé, Montréal, Québec, Canada.
| | - Yiorgos Alexandros Cavayas
- Centre de Recherche de l'Hôpital du Sacré-Cœur de Montréal, Montréal, Québec, Canada; Faculty of Medicine, Department of Medicine, Université de Montréal, Montréal, Québec; Department of Medicine, Service of Intensive Care Medicine, Hôpital du Sacré-Cœur de Montréal, CIUSSS-NIM, Montréal, Québec, Canada; Department of Surgery, Service of Intensive Care Medicine, Institut de Cardiologie de Montréal, Montréal, Québec, Canada
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15
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Slovis JC, Volk L, Mavroudis C, Hefti M, Landis WP, Roberts AL, Delso N, Hallowell T, Graham K, Starr J, Lin Y, Melchior R, Nadkarni V, Sutton RM, Berg RA, Piel S, Morgan RW, Kilbaugh TJ. Pediatric Extracorporeal Cardiopulmonary Resuscitation: Development of a Porcine Model and the Influence of Cardiopulmonary Resuscitation Duration on Brain Injury. J Am Heart Assoc 2023; 12:e026479. [PMID: 36789866 PMCID: PMC10111482 DOI: 10.1161/jaha.122.026479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 12/08/2022] [Indexed: 02/16/2023]
Abstract
Background The primary objective was to develop a porcine model of prolonged (30 or 60 minutes) pediatric cardiopulmonary resuscitation (CPR) followed by 22- to 24-hour survival with extracorporeal life support, and secondarily to evaluate differences in neurologic injury. Methods and Results Ten-kilogram, 4-week-old female piglets were used. First, model development established the technique (n=8). Then, a pilot study was conducted (n=15). After 80% survival was achieved in the final 5 pilot animals, a proof-of-concept randomized study was completed (n=11). Shams (n=6) underwent anesthesia only. Severe neurological injury was determined by a composite score of mitochondrial function, neuropathology, and cerebral metabolism: scale of 0-6 (severe: >3). Among 15 piglets in the pilot study, overall survival was 10 (67%); of the final 5, overall survival was 4 (80%). Eleven piglets were then randomized to 60 (CPR60, n=5) or 30 minutes of CPR (CPR30, n=5); 1 animal was excluded from prerandomization for intra-abdominal hemorrhage (10/11, 91% survival). Three of 5 animals in the CPR60 group had severe neurological injury scores versus 1 of 5 in the CPR30 group (P=0.52). During ECMO, CPR60 animals had lower pH (CPR60: 7.4 [IQR 7.4-7.4] versus CPR30: 7.5 [IQR 7.4-7.5], P=0.022), higher lactate (CPR60: 6.8 [IQR 6.8-11] versus CPR30: 4.2 [IQR 4.1-4.3] mmol/L; P=0.012), and higher ICP (CPR60: 19.3 [IQR 11.7-29.3] versus CPR30: 7.9 [IQR 6.7-9.3] mm Hg; P=0.037). Both groups had greater mitochondrial injury than shams (CPR60: P<0.001; CPR30: P<0.001). CPR60 did not differ from CPR30 in mitochondrial respiration, neuropathology, or cerebral metabolism. Conclusions A pediatric porcine model of extracorporeal cardiopulmonary resuscitation after 60 and 30 minutes of CPR consistently resulted in 24-hour survival with more severe lactic acidosis in the 60-minute cohort.
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Affiliation(s)
- Julia C Slovis
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
- Department of Anesthesiology and Critical Care Medicine Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Lindsay Volk
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
- Department of Surgery Robert Wood Johnson University Hospital New Brunswick NJ
| | - Constantine Mavroudis
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
- Department of Surgery, Division of Cardiothoracic Surgery Children's Hospital of Philadelphia Philadelphia PA
| | - Marco Hefti
- Department of Pathology University of Iowa Carver College of Medicine Iowa City IA
| | - William P Landis
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
| | - Anna L Roberts
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
| | - Nile Delso
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
| | - Thomas Hallowell
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
| | - Jonathan Starr
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
| | - Yuxi Lin
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
| | - Richard Melchior
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
- Department of Anesthesiology and Critical Care Medicine Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
- Department of Anesthesiology and Critical Care Medicine Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
- Department of Anesthesiology and Critical Care Medicine Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Sarah Piel
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
- Department of Anesthesiology and Critical Care Medicine Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
- Department of Anesthesiology and Critical Care Medicine Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
- Department of Anesthesiology and Critical Care Medicine Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
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16
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Berg RA, Morgan RW, Reeder RW, Ahmed T, Bell MJ, Bishop R, Bochkoris M, Burns C, Carcillo JA, Carpenter TC, Dean JM, Diddle JW, Federman M, Fernandez R, Fink EL, Franzon D, Frazier AH, Friess SH, Graham K, Hall M, Hehir DA, Horvat CM, Huard LL, Maa T, Manga A, McQuillen PS, Meert KL, Mourani PM, Nadkarni VM, Naim MY, Notterman D, Palmer CA, Pollack MM, Sapru A, Schneiter C, Sharron MP, Srivastava N, Tabbutt S, Tilford B, Viteri S, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Sutton RM. Diastolic Blood Pressure Threshold During Pediatric Cardiopulmonary Resuscitation and Survival Outcomes: A Multicenter Validation Study. Crit Care Med 2023; 51:91-102. [PMID: 36519983 PMCID: PMC9970166 DOI: 10.1097/ccm.0000000000005715] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Arterial diastolic blood pressure (DBP) greater than 25 mm Hg in infants and greater than 30 mm Hg in children greater than 1 year old during cardiopulmonary resuscitation (CPR) was associated with survival to hospital discharge in one prospective study. We sought to validate these potential hemodynamic targets in a larger multicenter cohort. DESIGN Prospective observational study. SETTING Eighteen PICUs in the ICU-RESUScitation prospective trial from October 2016 to March 2020. PATIENTS Children less than or equal to 18 years old with CPR greater than 30 seconds and invasive blood pressure (BP) monitoring during CPR. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Invasive BP waveform data and Utstein-style CPR data were collected, including prearrest patient characteristics, intra-arrest interventions, and outcomes. Primary outcome was survival to hospital discharge, and secondary outcomes were return of spontaneous circulation (ROSC) and survival to hospital discharge with favorable neurologic outcome. Multivariable Poisson regression models with robust error estimates evaluated the association of DBP greater than 25 mm Hg in infants and greater than 30 mm Hg in older children with these outcomes. Among 1,129 children with inhospital cardiac arrests, 413 had evaluable DBP data. Overall, 85.5% of the patients attained thresholds of mean DBP greater than or equal to 25 mm Hg in infants and greater than or equal to 30 mm Hg in older children. Initial return of circulation occurred in 91.5% and 25% by placement on extracorporeal membrane oxygenator. Survival to hospital discharge occurred in 58.6%, and survival with favorable neurologic outcome in 55.4% (i.e. 94.6% of survivors had favorable neurologic outcomes). Mean DBP greater than 25 mm Hg for infants and greater than 30 mm Hg for older children was significantly associated with survival to discharge (adjusted relative risk [aRR], 1.32; 1.01-1.74; p = 0.03) and ROSC (aRR, 1.49; 1.12-1.97; p = 0.002) but did not reach significance for survival to hospital discharge with favorable neurologic outcome (aRR, 1.30; 0.98-1.72; p = 0.051). CONCLUSIONS These validation data demonstrate that achieving mean DBP during CPR greater than 25 mm Hg for infants and greater than 30 mm Hg for older children is associated with higher rates of survival to hospital discharge, providing potential targets for DBP during CPR.
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Affiliation(s)
- Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Robert Bishop
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Matthew Bochkoris
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Richard Fernandez
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Aisha H Frazier
- Alfred I. duPont Hospital for Children, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Peter M Mourani
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
- Department of Pediatrics, University of Arkansas for Medical Sciences, and Arkansas Children's Research Institute, Little Rock, AR
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ
| | - Chella A Palmer
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Sarah Tabbutt
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Shirley Viteri
- Alfred I. duPont Hospital for Children, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
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17
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Hwang M, Sridharan A, Freeman CW, Viaene AN, Kilbaugh TJ. Contrast-Enhanced Ultrasound of Brain Perfusion in Cardiopulmonary Resuscitation. Ultrasound Q 2022; 38:257-261. [PMID: 35221316 PMCID: PMC9402813 DOI: 10.1097/ruq.0000000000000596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT To evaluate the feasibility and potential utility of contrast-enhanced ultrasound for real-time imaging of whole-brain perfusion during cardiopulmonary resuscitation (CPR), cardiac arrest was induced in 8- to 7-week-old 10-kg piglets ( Sus scrofa domesticus ). Contrast-enhanced ultrasound was performed through a parietal cranial window in the coronal plane visualizing the thalami during hemodynamic-directed CPR. Whole-brain mean and maximum pixel intensities in each slice during resuscitation were calculated. Piglets were monitored for 24 hours postarrest. Seven piglets achieved return of spontaneous circulation and 6 survived to 24 hours. Of the 6 surviving piglets, 2 piglets demonstrated greater intra-CPR brain enhancement at maximum 73.2% and 42.1% and mean 36.7% and 31.9% enhancement above background, respectively, compared with maximum 5.8%, 22.9%, 6.0%, and 26.6% and mean 5.1%, 8.9%, 2.9%, and 6.6% above background, respectively, in the other 4. Intra-CPR average mean arterial pressures were similar between all 6 surviving piglets. One piglet achieved return of spontaneous circulation but expired 10 minutes later with enhancement maximum 45.2% and mean 18.9% enhancement above background. The final piglet did not achieve return of spontaneous circulation and exhibited minimal enhancement at maximum 2.8% and mean 0.9% enhancement above background. Contrast-enhanced ultrasound can detect brain perfusion during CPR, identifying a spectrum of cerebral blood flow responses in the brain despite similar systemic hemodynamics. This novel application can form the basis for future large animal model studies and eventually human clinical studies to further explore the neurologic implications of cerebral blood flow responses during resuscitation and stimulate novel strategies for optimizing brain perfusion restoration.
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Affiliation(s)
- Misun Hwang
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Anush Sridharan
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Colbey W. Freeman
- Department of Radiology, University of Pennsylvania Health System, Philadelphia, PA
| | - Angela N. Viaene
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Health System, Philadelphia, PA
- Department of Pathology and Laboratory Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Todd J. Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
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18
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White BR, Ko TS, Morgan RW, Baker WB, Benson EJ, Lafontant A, Starr JP, Landis WP, Andersen K, Jahnavi J, Breimann J, Delso N, Morton S, Roberts AL, Lin Y, Graham K, Berg RA, Yodh AG, Licht DJ, Kilbaugh TJ. Low frequency power in cerebral blood flow is a biomarker of neurologic injury in the acute period after cardiac arrest. Resuscitation 2022; 178:12-18. [PMID: 35817269 PMCID: PMC9580006 DOI: 10.1016/j.resuscitation.2022.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 06/29/2022] [Accepted: 07/04/2022] [Indexed: 11/22/2022]
Abstract
AIM Cardiac arrest often results in severe neurologic injury. Improving care for these patients is difficult as few noninvasive biomarkers exist that allow physicians to monitor neurologic health. The amount of low-frequency power (LFP, 0.01-0.1 Hz) in cerebral haemodynamics has been used in functional magnetic resonance imaging as a marker of neuronal activity. Our hypothesis was that increased LFP in cerebral blood flow (CBF) would be correlated with improvements in invasive measures of neurologic health. METHODS We adapted the use of LFP for to monitoring of CBF with diffuse correlation spectroscopy. We asked whether LFP (or other optical biomarkers) correlated with invasive microdialysis biomarkers (lactate-pyruvate ratio - LPR - and glycerol concentration) of neuronal injury in the 4 h after return of spontaneous circulation in a swine model of paediatric cardiac arrest (Sus scrofa domestica, 8-11 kg, 51% female). Associations were tested using a mixed linear effects model. RESULTS We found that higher LFP was associated with higher LPR and higher glycerol concentration. No other biomarkers were associated with LPR; cerebral haemoglobin concentration, oxygen extraction fraction, and one EEG metric were associated with glycerol concentration. CONCLUSION Contrary to expectations, higher LFP in CBF was correlated with worse invasive biomarkers. Higher LFP may represent higher neurologic activity, or disruptions in neurovascular coupling. Either effect may be harmful in the acute period after cardiac arrest. Thus, these results suggest our methodology holds promise for development of new, clinically relevant biomarkers than can guide resuscitation and post-resuscitation care. Institutional protocol number: 19-001327.
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Affiliation(s)
- Brian R White
- Division of Pediatric Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, United States.
| | - Tiffany S Ko
- Division of Neurology, Department of Pediatrics, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, United States
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, United States
| | - Wesley B Baker
- Division of Neurology, Department of Pediatrics, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, United States
| | - Emilie J Benson
- Department of Physics and Astronomy, University of Pennsylvania, United States
| | - Alec Lafontant
- Division of Neurology, Department of Pediatrics, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, United States
| | - Jonathan P Starr
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, United States
| | - William P Landis
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, United States
| | - Kristen Andersen
- Division of Neurology, Department of Pediatrics, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, United States
| | - Jharna Jahnavi
- Division of Neurology, Department of Pediatrics, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, United States
| | - Jake Breimann
- Division of Neurology, Department of Pediatrics, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, United States
| | - Nile Delso
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, United States
| | - Sarah Morton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, United States
| | - Anna L Roberts
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, United States
| | - Yuxi Lin
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, United States
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, United States
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, United States
| | - Arjun G Yodh
- Department of Physics and Astronomy, University of Pennsylvania, United States
| | - Daniel J Licht
- Division of Neurology, Department of Pediatrics, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, United States
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, United States
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19
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Bhandari S, Coult J, Counts CR, Bulger NE, Kwok H, Latimer AJ, Sayre MR, Rea TD, Johnson NJ. Investigating the Airway Opening Index during Cardiopulmonary Resuscitation. Resuscitation 2022; 178:96-101. [PMID: 35850376 DOI: 10.1016/j.resuscitation.2022.07.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 06/27/2022] [Accepted: 07/11/2022] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Chest compressions during CPR induce oscillations in capnography (ETCO2) waveforms. Studies suggest ETCO2 oscillation characteristics are associated with intrathoracic airflow dependent on airway patency. Oscillations can be quantified by the Airway Opening Index (AOI). We sought to evaluate multiple methods of computing AOI and their association with return of spontaneous circulation (ROSC). METHODS We conducted a retrospective study of 307 out-of-hospital cardiac arrest (OHCA) cases in Seattle, WA during 2019. ETCO2 and chest impedance waveforms were annotated for the presence of intubation and CPR. We developed four methods for computing AOI based on peak ETCO2 and the oscillations in ETCO2 during CCs (ΔETCO2). We examined the feasibility of automating ΔETCO2 and AOI calculation and evaluated differences in AOI across the methods using nonparametric testing (p=0.05). RESULTS Median [interquartile range] AOI across all cases using Methods 1-4 was 28.0% [17.9-45.5%], 20.6% [13.0-36.6%], 18.3% [11.4-30.4%], and 22.4% [12.8-38.5%], respectively (p<0.001). Cases with ROSC had a higher median AOI than those without ROSC across all methods, though not statistically significant. Cases with ROSC had a significantly higher median [interquartile range] ΔETCO2 of 7.3 mmHg [4.5-13.6 mmHg] compared to those without ROSC (4.8 mmHg [2.6-9.1 mmHg], p<0.001). CONCLUSION We calculated AOI using four proposed methods resulting in significantly different AOI. Additionally, AOI and ΔETCO2 were larger in cases achieving ROSC. Further investigation is required to characterize AOI's ability to predict OHCA outcomes, and whether this information can improve resuscitation care.
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Affiliation(s)
- Shiv Bhandari
- Department of Medicine, University of Washington, Seattle, WA.
| | - Jason Coult
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Natalie E Bulger
- Department of Emergency Medicine, University of Washington, Seattle, WA
| | - Heemun Kwok
- Department of Emergency Medicine, University of Washington, Seattle, WA
| | - Andrew J Latimer
- Department of Emergency Medicine, University of Washington, Seattle, WA; University of Washington Airlift Northwest, Seattle, WA
| | - Michael R Sayre
- Department of Emergency Medicine, University of Washington, Seattle, WA; Seattle Fire Department, Seattle, WA
| | - Thomas D Rea
- Department of Medicine, University of Washington, Seattle, WA; Division of Emergency Medical Services, Public Health - Seattle & King County
| | - Nicholas J Johnson
- Division of Emergency Medical Services, Public Health - Seattle & King County; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
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20
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Senthil K, Hefti MM, Singh LN, Morgan RW, Mavroudis CD, Ko T, Gaudio H, Nadkarni VM, Ehinger J, Berg RA, Sutton RM, McGowan FX, Kilbaugh TJ. Transcriptome and metabolome after porcine hemodynamic-directed CPR compared with standard CPR and sham controls. Resusc Plus 2022; 10:100243. [PMID: 35592874 PMCID: PMC9111986 DOI: 10.1016/j.resplu.2022.100243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 04/07/2022] [Accepted: 04/24/2022] [Indexed: 11/18/2022] Open
Abstract
Objective The effect of cardiac arrest (CA) on cerebral transcriptomics and metabolomics is unknown. We previously demonstrated hemodynamic-directed CPR (HD-CPR) improves survival with favorable neurologic outcomes versus standard CPR (Std-CPR). We hypothesized HD-CPR would preserve the cerebral transcriptome and metabolome compared to Std-CPR. Design Randomized pre-clinical animal trial. Setting Large animal resuscitation laboratory at an academic children’s hospital. Subjects Four-week-old female piglets (8–11 kg). Interventions Pigs (1-month-old), three groups: 1) HD-CPR (compression depth to systolic BP 90 mmHg, vasopressors to coronary perfusion pressure 20 mmHg); 2) Std-CPR and 3) shams (no CPR). HD-CPR and Std-CPR underwent asphyxia, induced ventricular fibrillation, 10–20 min of CPR and post-resuscitation care. Primary outcomes at 24 h in cerebral cortex: 1) transcriptomic analysis (n = 4 per treatment arm, n = 8 sham) of 1727 genes using differential gene expression and 2) metabolomic analysis (n = 5 per group) of 27 metabolites using one-way ANOVA, post-hoc Tukey HSD. Measurements and main results 65 genes were differentially expressed between HD-CPR and Std-CPR and 72 genes between Std-CPR and sham, but only five differed between HD-CPR and sham. Std-CPR increased the concentration of five AA compared to HD-CPR and sham, including the branched chain amino acids (BCAA), but zero metabolites differed between HD-CPR and sham. Conclusions In cerebral cortex 24 h post CA, Std-CPR resulted in a different transcriptome and metabolome compared with either HD-CPR or sham. HD-CPR preserves the transcriptome and metabolome, and is neuroprotective. Global molecular analyses may be a novel method to assess efficacy of clinical interventions and identify therapeutic targets. Institutional protocol number IAC 16-001023.
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Affiliation(s)
- Kumaran Senthil
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Department of Anesthesiology and Critical Care Medicine, United States
- Corresponding author at: Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, United States.
| | - Marco M. Hefti
- University of Iowa, Division of Pathology, United States
| | - Larry N. Singh
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Department of Anesthesiology and Critical Care Medicine, United States
| | - Ryan W. Morgan
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Department of Anesthesiology and Critical Care Medicine, United States
| | - Constantine D. Mavroudis
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Department of Cardiothoracic Surgery, United States
| | - Tiffany Ko
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Department of Neurology, United States
| | - Hunter Gaudio
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Department of Anesthesiology and Critical Care Medicine, United States
| | - Vinay M. Nadkarni
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Department of Anesthesiology and Critical Care Medicine, United States
| | - Johannes Ehinger
- Lund University, Mitochondrial Medicine, Sweden
- Skåne University Hospital, Department of Otorhinolaryngology, Head and Neck Surgery, Sweden
| | - Robert A. Berg
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Department of Anesthesiology and Critical Care Medicine, United States
| | - Robert M. Sutton
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Department of Anesthesiology and Critical Care Medicine, United States
| | - Francis X. McGowan
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Department of Anesthesiology and Critical Care Medicine, United States
| | - Todd J. Kilbaugh
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Department of Anesthesiology and Critical Care Medicine, United States
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21
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Shin SS, Sridharan A, Khaw K, Hallowell T, Morgan RW, Kilbaugh TJ, Hwang M. Intracranial Pressure and Cerebral Hemodynamic Monitoring After Cardiac Arrest in Pediatric Pigs Using Contrast Ultrasound-Derived Parameters. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:1425-1432. [PMID: 34524698 PMCID: PMC8920953 DOI: 10.1002/jum.15825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/20/2021] [Accepted: 08/12/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES We explore the correlation of contrast-enhanced ultrasound (CEUS) parameters to intracranial pressure (ICP) in a porcine experimental model of pediatric cardiac arrest. METHODS Eleven pediatric pigs underwent electrically induced cardiac arrest followed by cardiopulmonary resuscitation. ICP was measured using intracranial bolt monitor and CEUS was monitored through a cranial window. Various CEUS parameters were monitored at baseline, immediately post return of spontaneous circulation (ROSC), 1 hour-post ROSC, and 3 hours post-ROSC. RESULTS There was significant ICP correlation with wash-out slope assessed by CEUS time intensity curve analysis at immediate post-ROSC. At 3 hours post-ROSC there was also significant negative correlation between ICP and peak enhancement which may be due to the evolution of anoxic injury. CONCLUSION The use of CEUS in assessing disruption of cerebral hemodynamics and ICP post cardiac arrest will need future validation and comparison to other imaging modalities. The correlation between CEUS parameters and ICP may be due to the alterations in cerebral autoregulation that result from anoxic brain injury.
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Affiliation(s)
- Samuel S Shin
- Department of Neurocritical Care, Hospital of University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anush Sridharan
- Department of Radiology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kristina Khaw
- Department of Radiology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas Hallowell
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Misun Hwang
- Department of Radiology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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22
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Sutton RM, Wolfe HA, Reeder RW, Ahmed T, Bishop R, Bochkoris M, Burns C, Diddle JW, Federman M, Fernandez R, Franzon D, Frazier AH, Friess SH, Graham K, Hehir D, Horvat CM, Huard LL, Landis WP, Maa T, Manga A, Morgan RW, Nadkarni VM, Naim MY, Palmer CA, Schneiter C, Sharron MP, Siems A, Srivastava N, Tabbutt S, Tilford B, Viteri S, Berg RA, Bell MJ, Carcillo JA, Carpenter TC, Dean JM, Fink EL, Hall M, McQuillen PS, Meert KL, Mourani PM, Notterman D, Pollack MM, Sapru A, Wessel D, Yates AR, Zuppa AF. Effect of Physiologic Point-of-Care Cardiopulmonary Resuscitation Training on Survival With Favorable Neurologic Outcome in Cardiac Arrest in Pediatric ICUs: A Randomized Clinical Trial. JAMA 2022; 327:934-945. [PMID: 35258533 PMCID: PMC8905390 DOI: 10.1001/jama.2022.1738] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
IMPORTANCE Approximately 40% of children who experience an in-hospital cardiac arrest survive to hospital discharge. Achieving threshold intra-arrest diastolic blood pressure (BP) targets during cardiopulmonary resuscitation (CPR) and systolic BP targets after the return of circulation may be associated with improved outcomes. OBJECTIVE To evaluate the effectiveness of a bundled intervention comprising physiologically focused CPR training at the point of care and structured clinical event debriefings. DESIGN, SETTING, AND PARTICIPANTS A parallel, hybrid stepped-wedge, cluster randomized trial (Improving Outcomes from Pediatric Cardiac Arrest-the ICU-Resuscitation Project [ICU-RESUS]) involving 18 pediatric intensive care units (ICUs) from 10 clinical sites in the US. In this hybrid trial, 2 clinical sites were randomized to remain in the intervention group and 2 in the control group for the duration of the study, and 6 were randomized to transition from the control condition to the intervention in a stepped-wedge fashion. The index (first) CPR events of 1129 pediatric ICU patients were included between October 1, 2016, and March 31, 2021, and were followed up to hospital discharge (final follow-up was April 30, 2021). INTERVENTION During the intervention period (n = 526 patients), a 2-part ICU resuscitation quality improvement bundle was implemented, consisting of CPR training at the point of care on a manikin (48 trainings/unit per month) and structured physiologically focused debriefings of cardiac arrest events (1 debriefing/unit per month). The control period (n = 548 patients) consisted of usual pediatric ICU management of cardiac arrest. MAIN OUTCOMES AND MEASURES The primary outcome was survival to hospital discharge with a favorable neurologic outcome defined as a Pediatric Cerebral Performance Category score of 1 to 3 or no change from baseline (score range, 1 [normal] to 6 [brain death or death]). The secondary outcome was survival to hospital discharge. RESULTS Among 1389 cardiac arrests experienced by 1276 patients, 1129 index CPR events (median patient age, 0.6 [IQR, 0.2-3.8] years; 499 girls [44%]) were included and 1074 were analyzed in the primary analysis. There was no significant difference in the primary outcome of survival to hospital discharge with favorable neurologic outcomes in the intervention group (53.8%) vs control (52.4%); risk difference (RD), 3.2% (95% CI, -4.6% to 11.4%); adjusted OR, 1.08 (95% CI, 0.76 to 1.53). There was also no significant difference in survival to hospital discharge in the intervention group (58.0%) vs control group (56.8%); RD, 1.6% (95% CI, -6.2% to 9.7%); adjusted OR, 1.03 (95% CI, 0.73 to 1.47). CONCLUSIONS AND RELEVANCE In this randomized clinical trial conducted in 18 pediatric intensive care units, a bundled intervention of cardiopulmonary resuscitation training at the point of care and physiologically focused structured debriefing, compared with usual care, did not significantly improve patient survival to hospital discharge with favorable neurologic outcome among pediatric patients who experienced cardiac arrest in the ICU. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02837497.
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Affiliation(s)
| | | | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit
| | - Robert Bishop
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora
| | - Matthew Bochkoris
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Candice Burns
- Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California. Los Angeles
| | - Richard Fernandez
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco
| | - Aisha H Frazier
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University, Wilmington, Delaware
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - David Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University, Wilmington, Delaware
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California. Los Angeles
| | - William P Landis
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Chella A Palmer
- Department of Pediatrics, University of Utah, Salt Lake City
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Ashley Siems
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California. Los Angeles
| | - Sarah Tabbutt
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit
| | - Shirley Viteri
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University, Wilmington, Delaware
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Michael J Bell
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit
| | - Peter M Mourani
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, New Jersey
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California. Los Angeles
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
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23
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Francoeur C, Landis WP, Winters M, Naim MY, Donoghue A, Dominick CL, Huh JW, MacDonald JM, Lang SS, Yuan I, Berg RA, Nadkarni VM, Kilbaugh TJ, Sutton RM, Kirschen MP, Morgan RW, Topjian AA. Near-infrared spectroscopy during cardiopulmonary resuscitation for pediatric cardiac arrest: a prospective, observational study. Resuscitation 2022; 174:35-41. [PMID: 35314211 PMCID: PMC9724995 DOI: 10.1016/j.resuscitation.2022.03.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 03/09/2022] [Accepted: 03/13/2022] [Indexed: 02/04/2023]
Abstract
AIM Cerebral oxygenation (rSO2) is not routinely measured during pediatric cardiopulmonary resuscitation (CPR). We aimed to determine whether higher intra-arrest rSO2 was associated with return of spontaneous circulation (ROSC) and survival to hospital discharge. METHODS Prospective, single-center observational study of cerebral oximetry using near-infrared spectroscopy (NIRS) during pediatric cardiac arrest from 2016 to 2020. Eligible patients had ≥30 s of rSO2 data recorded during CPR. We compared median rSO2 and percentage of rSO2 measurements above a priori thresholds for the entire event and the final five minutes of the CPR event between patients with and without ROSC and survival to discharge. RESULTS Twenty-one patients with 23 CPR events were analyzed. ROSC was achieved in 17/23 (73.9%) events and five/21 (23.8%) patients survived to discharge. The median rSO2 was higher for events with ROSC vs. no ROSC for the overall event (62% [56%, 70%] vs. 45% [35%, 51%], p = 0.025) and for the final 5 minutes of the event (66% [55%, 72%] vs. 43% [35%, 44%], p = 0.01). Patients with ROSC had a higher percentage of measurements above 50% during the final five minutes of CPR (100% [100%, 100%] vs. 0% [0%, 29%], p = 0.01). There was no association between rSO2 and survival to discharge. CONCLUSIONS Higher cerebral rSO2 during CPR for pediatric cardiac arrest was associated with higher rates of ROSC but not with survival to discharge.
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Affiliation(s)
- C Francoeur
- Department of Pediatrics, CHU de Québec - Université Laval Research Center, Quebec, Canada.
| | - W P Landis
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - M Winters
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - M Y Naim
- The Cardiac Center, Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - A Donoghue
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - C L Dominick
- Department of Respiratory Therapy, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - J W Huh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - J M MacDonald
- Division of Pediatric Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, OH, USA
| | - S S Lang
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - I Yuan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - R A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - V M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - T J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - R M Sutton
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - M P Kirschen
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - R W Morgan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - A A Topjian
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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24
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Zhang L, Jin K, Sun F, Xu J, Yu X, Zhu H, Fu Y, Liu D, Yu S. Assessment of a new volumetric capnography-derived parameter to reflect compression quality and to predict return of spontaneous circulation during cardiopulmonary resuscitation in a porcine model. J Clin Monit Comput 2022; 36:199-207. [PMID: 33511562 DOI: 10.1007/s10877-020-00637-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 12/17/2020] [Indexed: 11/25/2022]
Abstract
We aimed to evaluate a volumetric capnography (Vcap)-derived parameter, the volume of CO2 eliminated per minute and per kg body weight (VCO2/kg), as an indicator of the quality of chest compression (CC) and to predict the return to spontaneous circulation (ROSC) under stable ventilation status. Twelve male domestic pigs were utilized for the randomized crossover study. After 4 min of untreated ventricular fibrillation (VF), mechanical cardiopulmonary resuscitation and ventilation were administered. Following 5-min washout periods, each animal underwent two sessions of experiments: three types of CC quality for 5 min stages in the first session, followed by advanced life support, consecutively in two sessions. Different CC quality had a significant effect on the partial pressure of end-tidal carbon dioxide (PetCO2), VCO2/kg, aortic pressure (mean), aortic systolic pressure, aortic diastolic pressure, right atrial pressure (mean), and carotid blood flow (P < 0.05). With the improvement in CC quality, the values of PetCO2 and VCO2/kg also increased, and the difference between the groups was statistically significant (P < 0.05). The Spearman rank test revealed a significant correlation between the Vcap-derived parameters and hemodynamics. PetCO2 and VCO2/kg have similar capabilities for discriminating survivors from non-survivors, and the area under the curve for both was 0.97. VCO2/kg had similar performance as PetCO2 in reflecting the quality of CC and prediction of achieving ROSC under stable ventilation status in a porcine model of VF-related cardiac arrest. However, VCO2/kg requires a longer time to achieve a stable state after adjusting for quality of CC than PetCO2.
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Affiliation(s)
- Lili Zhang
- Emergency Department, Peking Union Medical College Hospital, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Kui Jin
- Emergency Department, Peking Union Medical College Hospital, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Feng Sun
- Emergency Department, Jiangsu Province Hospital, Nanjing, Jiangsu, China
| | - Jun Xu
- Emergency Department, Peking Union Medical College Hospital, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China.
| | - Xuezhong Yu
- Emergency Department, Peking Union Medical College Hospital, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China.
| | - Huadong Zhu
- Emergency Department, Peking Union Medical College Hospital, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Yangyang Fu
- Emergency Department, Peking Union Medical College Hospital, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Danyu Liu
- Emergency Department, Peking Union Medical College Hospital, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Shanshan Yu
- Emergency Department, Peking Union Medical College Hospital, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
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25
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Use of an end-tidal carbon dioxide-guided algorithm during cardiopulmonary resuscitation improves short-term survival in paediatric swine. Resusc Plus 2021; 8:100174. [PMID: 34820656 PMCID: PMC8600153 DOI: 10.1016/j.resplu.2021.100174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 08/28/2021] [Accepted: 09/28/2021] [Indexed: 01/09/2023] Open
Abstract
Aim To evaluate an algorithm that uses an end-tidal carbon dioxide (ETCO2) target of ≥ 30 torr to guide specific changes in chest compression rate and epinephrine administration during cardiopulmonary resuscitation (CPR) in paediatric swine. Methods Swine underwent asphyxial cardiac arrest followed by resuscitation with either standard or ETCO2-guided algorithm CPR. The standard group received chest compressions at a rate of 100/min and epinephrine every 4 min during advanced life support consistent with the American Heart Association paediatric resuscitation guidelines. In the ETCO2-guided algorithm group, chest compression rate was increased by 10 compressions/min for every minute that the ETCO2 was < 30 torr, and the epinephrine administration interval was decreased to every 2 min if the ETCO2 remained < 30 torr. Short-term survival and physiologic data during active resuscitation were compared. Results Short-term survival was significantly greater in the ETCO2-guided algorithm CPR group than in the standard CPR group (16/28 [57.1%] versus 4/28 [14.3%]; p = 0.002). Additionally, the algorithm group had higher predicted mean ETCO2, chest compression rate, diastolic and mean arterial pressure, and myocardial perfusion pressure throughout resuscitation. Swine in the algorithm group also exhibited significantly greater improvement in diastolic and mean arterial pressure and cerebral perfusion pressure after the first dose of epinephrine than did those in the standard group. Incidence of resuscitation-related injuries was similar in the two groups. Conclusions Use of a resuscitation algorithm with stepwise guidance for changes in the chest compression rate and epinephrine administration interval based on a goal ETCO2 level improved survival and intra-arrest hemodynamics in this porcine cardiac arrest model.
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26
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Shepard LN, Berg RA, Morgan RW. Pulse oximetry plethysmography: A new approach for physiology-directed CPR? Resuscitation 2021; 169:198-200. [PMID: 34757060 DOI: 10.1016/j.resuscitation.2021.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 10/25/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Lindsay N Shepard
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States.
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27
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Putzer G, Martini J, Spraider P, Abram J, Hornung R, Schmidt C, Bauer M, Pinggera D, Krapf C, Hell T, Glodny B, Helbok R, Mair P. Adrenaline improves regional cerebral blood flow, cerebral oxygenation and cerebral metabolism during CPR in a porcine cardiac arrest model using low-flow extracorporeal support. Resuscitation 2021; 168:151-159. [PMID: 34363854 DOI: 10.1016/j.resuscitation.2021.07.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 07/05/2021] [Accepted: 07/28/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND The effects of adrenaline on cerebral blood vessels during cardiopulmonary resuscitation (CPR) are not well understood. We developed an extracorporeal CPR model that maintains constant low systemic blood flow while allowing adrenaline-associated effects on cerebral vasculature to be assessed at different mean arterial pressure (MAP) levels independently of the effects on systemic blood flow. METHODS After eight minutes of cardiac arrest, low-flow extracorporeal life support (ECLS) (30 ml/kg/min) was started in fourteen pigs. After ten minutes, continuous adrenaline administration was started to achieve MAP values of 40 (n = 7) or 60 mmHg (n = 7). Measurements included intracranial pressure (ICP), cerebral perfusion pressure (CePP), laser-Doppler-derived regional cerebral blood flow (CBF), cerebral regional oxygen saturation (rSO2), brain tissue oxygen tension (PbtO2) and extracellular cerebral metabolites assessed by cerebral microdialysis. RESULTS During ECLS without adrenaline, regional CBF increased by only 5% (25th to 75th percentile: -3 to 14; p=0.2642) and PbtO2 by 6% (0-15; p=0.0073) despite a significant increase in MAP to 28 mmHg (25-30; p<0.0001) and CePP to 10 mmHg (8-13; p<0.0001). Accordingly, cerebral microdialysis parameters showed a profound hypoxic-ischemic pattern. Adrenaline administration significantly improved regional CBF to 29±14% (p=0.0098) and 61±25% (p<0.001) and PbtO2 to 15±11% and 130±82% (both p<0.001) of baseline in the MAP 40 mmHg and MAP 60 mmHg groups, respectively. Importantly, MAP of 60 mmHg was associated with metabolic improvement. CONCLUSION This study shows that adrenaline administration during constant low systemic blood flow increases CePP, regional CBF, cerebral oxygenation and cerebral metabolism.
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Affiliation(s)
- Gabriel Putzer
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Austria
| | - Judith Martini
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Austria.
| | - Patrick Spraider
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Austria
| | - Julia Abram
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Austria
| | - Rouven Hornung
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Austria
| | - Christine Schmidt
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Austria
| | - Marlies Bauer
- Department of Neurosurgery, Medical University of Innsbruck, Austria
| | - Daniel Pinggera
- Department of Neurosurgery, Medical University of Innsbruck, Austria
| | - Christoph Krapf
- Department of Cardiac Surgery, Medical University of Innsbruck, Austria
| | - Tobias Hell
- Department of Mathematics, Faculty of Mathematics, Computer Science and Physics, University of Innsbruck, Austria
| | - Bernhard Glodny
- Department of Radiology, Medical University of Innsbruck, Austria
| | - Raimund Helbok
- Department of Neurology, Medical University of Innsbruck, Austria
| | - Peter Mair
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Austria
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28
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Kool M, Atkins DL, Van de Voorde P, Maconochie IK, Scholefield BR. Focused echocardiography, end-tidal carbon dioxide, arterial blood pressure or near-infrared spectroscopy monitoring during paediatric cardiopulmonary resuscitation: A scoping review. Resusc Plus 2021; 6:100109. [PMID: 34228034 PMCID: PMC8244529 DOI: 10.1016/j.resplu.2021.100109] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 03/04/2021] [Accepted: 03/04/2021] [Indexed: 11/17/2022] Open
Abstract
AIM To evaluate the individual use and predictive value of focused echocardiography, end-tidal carbon dioxide (EtCO2), invasive arterial blood pressure (BP) and near-infrared spectroscopy (NIRS) during cardiopulmonary resuscitation (CPR) in children. METHODS This scoping review was undertaken as part of the continuous evidence evaluation process of the International Liaison Committee on Resuscitation (ILCOR) and based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) extension for scoping reviews. PubMed, MEDLINE, CINAHL and EMBASE were searched from the last ILCOR reviews until September 2020. We included all published studies evaluating the effect of echocardiography, EtCO2, BP or NIRS guided CPR on clinical outcomes and quality of CPR. RESULTS We identified eight observational studies, including 288 children. Two case series reported the use of echocardiography, one in detecting pulmonary emboli, the second in cardiac standstill, where contractility was regained with the use of extracorporeal membrane oxygenation. The two studies describing EtCO2 were ambivalent regarding the association between mean values and any outcomes. Mean diastolic BP was associated with increased survival and favourable neurological outcome, but not with new substantive morbidity in two studies describing an overlapping population. NIRS values reflected changes in EtCO2 and cerebral blood volume index in two studies, with lower values in patients who did not achieve return of circulation. CONCLUSION Although there seems some beneficial effect of these intra-arrest variables, higher quality paediatric studies are needed to evaluate whether echocardiography, EtCO2, BP or NIRS guided CPR could improve outcomes.
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Key Words
- Arterial blood pressure
- BP, blood pressure (invasive arterial)
- BVI, blood volume index
- CA, cardiac arrest
- CI, confidence interval
- CPR, cardiopulmonary resuscitation
- CSF, cerebrospinal fluid
- Cardiopulmonary resuscitation
- CoSTR, consensus on science with treatment recommendations
- ECG, electrocardiogram
- ECMO, extracorporeal membrane oxygenation
- ECPR, extracorporeal cardiopulmonary resuscitation
- ED, emergency department
- End-tidal CO2
- EtCO2, end-tidal carbon dioxide
- ICP, intracranial pressure
- IHCA, in-hospital cardiac arrest
- ILCOR, international liaison committee on resuscitation
- NICU, neonatal intensive care unit
- NIRS, near-infrared spectroscopy
- Near-infrared spectroscopy
- OHCA, out-of-hospital cardiac arrest
- OR, odds ratio
- PCICU, paediatric cardiac intensive care unit
- PE, pulmonary emboli
- PICU, paediatric intensive care unit
- PRISMA, preferred reporting items for systematic reviews and meta-analyses
- Paediatric life support
- Point-of-care ultrasound
- RCT, randomized controlled trial
- ROC, receiver operating characteristic
- ROSC, return of spontaneous circulation
- RR, relative risk
- RV, right ventricle
- SD, standard deviation
- USA, United States of America
- rcSO2, regional cerebral oxygen saturations
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Affiliation(s)
- Mirjam Kool
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
- Paediatric Intensive Care Unit, Birmingham Children's Hospital NHS Trust, Steelhouse Lane, Birmingham, United Kingdom
| | - Dianne L Atkins
- Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Patrick Van de Voorde
- Department of Emergency Medicine, Ghent University Hospital, Ghent, Belgium
- EMS Dispatch Center Eastern Flanders, Federal Department of Health, Belgium
| | - Ian K Maconochie
- Paediatric Emergency Department, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Barnaby R Scholefield
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
- Paediatric Intensive Care Unit, Birmingham Children's Hospital NHS Trust, Steelhouse Lane, Birmingham, United Kingdom
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Senthil K, Morgan RW, Hefti MM, Karlsson M, Lautz AJ, Mavroudis CD, Ko T, Nadkarni VM, Ehinger J, Berg RA, Sutton RM, McGowan FX, Kilbaugh TJ. Haemodynamic-directed cardiopulmonary resuscitation promotes mitochondrial fusion and preservation of mitochondrial mass after successful resuscitation in a pediatric porcine model. Resusc Plus 2021; 6:100124. [PMID: 34223382 PMCID: PMC8244484 DOI: 10.1016/j.resplu.2021.100124] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 04/02/2021] [Accepted: 04/05/2021] [Indexed: 01/09/2023] Open
Abstract
Objective Cerebral mitochondrial dysfunction is a key mediator of neurologic injury following cardiac arrest (CA) and is regulated by the balance of fusion and fission (mitochondrial dynamics). Under stress, fission can decrease mitochondrial mass and signal apoptosis, while fusion promotes oxidative phosphorylation efficiency. This study evaluates mitochondrial dynamics and content in brain tissue 24 h after CA between two cardiopulmonary resuscitation (CPR) strategies. Interventions Piglets (1 month), previously randomized to three groups: (1) Std-CPR (n = 5); (2) HD-CPR (n = 5; goal systolic blood pressure 90 mmHg, goal coronary perfusion pressure 20 mmHg); (3) Shams (n = 7). Std-CPR and HD-CPR groups underwent 7 min of asphyxia, 10 min of CPR, and standardized post-resuscitation care. Primary outcomes: (1) cerebral cortical mitochondrial protein expression for fusion (OPA1, OPA1 long to short chain ratio, MFN2) and fission (DRP1, FIS1), and (2) mitochondrial mass by citrate synthase activity. Secondary outcomes: (1) intra-arrest haemodynamics and (2) cerebral performance category (CPC) at 24 h. Results HD-CPR subjects had higher total OPA1 expression compared to Std-CPR (1.52; IQR 1.02-1.69 vs 0.67; IQR 0.54-0.88, p = 0.001) and higher OPA1 long to short chain ratio than both Std-CPR (0.63; IQR 0.46-0.92 vs 0.26; IQR 0.26-0.31, p = 0.016) and shams. Citrate synthase activity was lower in Std-CPR than sham (11.0; IQR 10.15-12.29 vs 13.4; IQR 12.28-15.66, p = 0.047), but preserved in HD-CPR. HD-CPR subjects had improved intra-arrest haemodynamics and CPC scores at 24 h compared to Std-CPR. Conclusions Following asphyxia-associated CA, HD-CPR exhibits increased pro-mitochondrial fusion protein expression, preservation of mitochondrial mass, improved haemodynamics and superior neurologic scoring compared to Std-CPR. Institutional protocol number IAC 16-001023.
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Affiliation(s)
- Kumaran Senthil
- Children's Hospital of Philadelphia and Perelman School of Medicine at University of Pennsylvania, Department of Anesthesiology and Critical Care Medicine, United States
| | - Ryan W Morgan
- Children's Hospital of Philadelphia and Perelman School of Medicine at University of Pennsylvania, Department of Anesthesiology and Critical Care Medicine, United States
| | - Marco M Hefti
- University of Iowa, Division of Pathology, United States
| | | | - Andrew J Lautz
- Cincinnati Children's Hospital Medical Center, Division of Critical Care Medicine, United States
| | - Constantine D Mavroudis
- Department of Neurosurgery, Righospitalet, Copenhagen, Denmark.,Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Division of Cardiothoracic Surgery, United States
| | - Tiffany Ko
- Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Division of Neurology, United States
| | - Vinay M Nadkarni
- Children's Hospital of Philadelphia and Perelman School of Medicine at University of Pennsylvania, Department of Anesthesiology and Critical Care Medicine, United States
| | | | - Robert A Berg
- Children's Hospital of Philadelphia and Perelman School of Medicine at University of Pennsylvania, Department of Anesthesiology and Critical Care Medicine, United States
| | - Robert M Sutton
- Children's Hospital of Philadelphia and Perelman School of Medicine at University of Pennsylvania, Department of Anesthesiology and Critical Care Medicine, United States
| | - Francis X McGowan
- Children's Hospital of Philadelphia and Perelman School of Medicine at University of Pennsylvania, Department of Anesthesiology and Critical Care Medicine, United States
| | - Todd J Kilbaugh
- Children's Hospital of Philadelphia and Perelman School of Medicine at University of Pennsylvania, Department of Anesthesiology and Critical Care Medicine, United States
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30
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Ong GYK, Ang AJF, S O Aurangzeb A, Fong ESS, Tan JY, Chen ZJ, Chan YH, Tang PH, Pek JH, Maconochie I, Ng KC, Nadkarni V. What is the potential for over-compression using current paediatric chest compression guidelines? - A chest computed tomography study. Resusc Plus 2021; 6:100112. [PMID: 34223372 PMCID: PMC8244421 DOI: 10.1016/j.resplu.2021.100112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 03/08/2021] [Accepted: 03/11/2021] [Indexed: 02/03/2023] Open
Abstract
Aim We explored the potential for over-compression from current paediatric chest compression depth guidelines using chest computed tomography(CT) images of a large, heterogenous, Asian population. Methods A retrospective review of consecutive children, less than 18-years old, with chest CT images performed between from 2005 to 2017 was done. Demographic data were extracted from the electronic medical records. Measurements for internal and external anterior-posterior diameters (APD) were taken at lower half of the sternum. Simulated chest compressions were performed to evaluate the proportion of the population with residual internal cavity dimensions less than 0 mm (RICD < 0 mm, representing definite over-compression; with chest compression depth exceeding internal APD), and RICD less than 10 mm (RICD < 10 mm, representing potential over-compression). Results 592 paediatric chest CT studies were included for the study. Simulated chest compressions of one-third external APD had the least potential for over-compression; no infants and 0.3% children had potential over-compression (RICD < 10 mm). 4 cm simulated chest compressions led to 18% (95% CI 13%-24%) of infants with potential over-compression, and this increased to 34% (95% CI 27%-41%) at 4.4 cm (upper limit of "approximately" 4 cm; 4 cm + 10%). 5 cm simulated compressions resulted in 8% (95% CI 4%-12%) of children 1 to 8-years-old with potential over-compression, and this increased to 22% (95% CI 16%-28%) at 5.5 cm (upper limit of "approximately" 5 cm, 5 cm + 10%). Conclusion In settings whereby chest compression depths can be accurately measured, compressions at the current recommended chest compression of approximately 4 cm (in infants) and 5 cm (in young children) could result in potential for over-compression.
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Affiliation(s)
| | | | | | | | - Jun Yuan Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Zhao Jin Chen
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Phua Hwee Tang
- Department of Diagnostic Imaging, KK Women's and Children's Hospital, Singapore
| | - Jen Heng Pek
- Department of Emergency Medicine, Sengkang General Hospital, Singapore
| | - Ian Maconochie
- Accident and Emergency Service, St Mary's Hospital, London, United Kingdom.,Department of Medicine, Imperial College, Kensington, London, United Kingdom
| | - Kee Chong Ng
- Children's Emergency, KK Women's and Children's Hospital, Singapore
| | - Vinay Nadkarni
- Center for Simulation, Advanced Education and Innovation, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, USA
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Morgan RW, Sutton RM, Himebauch AS, Roberts AL, Landis WP, Lin Y, Starr J, Ranganathan A, Delso N, Mavroudis CD, Volk L, Slovis J, Marquez AM, Nadkarni VM, Hefti M, Berg RA, Kilbaugh TJ. A randomized and blinded trial of inhaled nitric oxide in a piglet model of pediatric cardiopulmonary resuscitation. Resuscitation 2021; 162:274-283. [PMID: 33766668 DOI: 10.1016/j.resuscitation.2021.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 02/22/2021] [Accepted: 03/09/2021] [Indexed: 01/17/2023]
Abstract
AIM Inhaled nitric oxide (iNO) during cardiopulmonary resuscitation (CPR) improved systemic hemodynamics and outcomes in a preclinical model of adult in-hospital cardiac arrest (IHCA) and may also have a neuroprotective role following cardiac arrest. The primary objectives of this study were to determine if iNO during CPR would improve cerebral hemodynamics and mitochondrial function in a pediatric model of lipopolysaccharide-induced shock-associated IHCA. METHODS After lipopolysaccharide infusion and ventricular fibrillation induction, 20 1-month-old piglets received hemodynamic-directed CPR and were randomized to blinded treatment with or without iNO (80 ppm) during and after CPR. Defibrillation attempts began at 10 min with a 20-min maximum CPR duration. Cerebral tissue from animals surviving 1-h post-arrest underwent high-resolution respirometry to evaluate the mitochondrial electron transport system and immunohistochemical analyses to assess neuropathology. RESULTS During CPR, the iNO group had higher mean aortic pressure (41.6 ± 2.0 vs. 36.0 ± 1.4 mmHg; p = 0.005); diastolic BP (32.4 ± 2.4 vs. 27.1 ± 1.7 mmHg; p = 0.03); cerebral perfusion pressure (25.0 ± 2.6 vs. 19.1 ± 1.8 mmHg; p = 0.02); and cerebral blood flow relative to baseline (rCBF: 243.2 ± 54.1 vs. 115.5 ± 37.2%; p = 0.02). Among the 8/10 survivors in each group, the iNO group had higher mitochondrial Complex I oxidative phosphorylation in the cerebral cortex (3.60 [3.56, 3.99] vs. 3.23 [2.44, 3.46] pmol O2/s mg; p = 0.01) and hippocampus (4.79 [4.35, 5.18] vs. 3.17 [2.75, 4.58] pmol O2/s mg; p = 0.02). There were no other differences in mitochondrial respiration or brain injury between groups. CONCLUSIONS Treatment with iNO during CPR resulted in superior systemic hemodynamics, rCBF, and cerebral mitochondrial Complex I respiration in this pediatric cardiac arrest model.
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Affiliation(s)
- Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States; Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, United States.
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States; Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, United States
| | - Adam S Himebauch
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States; Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, United States
| | - Anna L Roberts
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States
| | - William P Landis
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States
| | - Yuxi Lin
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States
| | - Jonathan Starr
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States
| | - Abhay Ranganathan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States
| | - Nile Delso
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States
| | - Constantine D Mavroudis
- Department of Surgery, Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, United States
| | - Lindsay Volk
- Department of Surgery, Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, United States
| | - Julia Slovis
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States
| | - Alexandra M Marquez
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States; Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, United States
| | - Marco Hefti
- Department of Pathology, University of Iowa Carver College of Medicine, United States
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States; Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, United States
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States; Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, United States
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32
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Bender D, Morgan RW, Nadkarni VM, Berg RA, Zhang B, Kilbaugh TJ, Sutton RM, Nataraj C. MLWAVE: A novel algorithm to classify primary versus secondary asphyxia-associated ventricular fibrillation. Resusc Plus 2021; 5:100052. [PMID: 33569548 PMCID: PMC7869586 DOI: 10.1016/j.resplu.2020.100052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/08/2020] [Accepted: 11/10/2020] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION/HYPOTHESIS The outcome of cardiopulmonary resuscitation (CPR) depends on timely recognition of the underlying cause of cardiac arrest. Ventricular fibrillation (VF) waveform analysis to differentiate primary VF from secondary asphyxia-associated VF may allow tailoring of therapies to improve cardiac arrest outcomes. Therefore, the primary goal of this investigation was to develop a novel technique utilizing wavelet synchrosqueezed transform (WSST) and decision-tree classifier that was specifically adapted to discriminate between these two incidents of VF. METHODS Secondary analytical investigation of electrocardiography (ECG) data obtained from swine models of either primary VF (n=18) or secondary asphyxia-associated VF (7min of asphyxia prior to VF induction; n=12). In the primary analysis, WSST technique was applied to the first 35s of the VF ECG signal to identify the most differentiating characteristics of the signal for use as features to develop a machine learning algorithm to classify the arrest as either primary VF vs. secondary asphyxia-associated VF. The performance of this new interactive Machine Learning algorithm with Wavelet Energy features of ECG (MLWAVE) was assessed using both classification accuracy and area under the receiver operating characteristic curve (AUCROC). To evaluate the validity of the new technique, the amplitude spectrum area (AMSA)-based technique, a well-established defibrillation classification method, was also applied to the same ECG signals. The classification accuracy and AUCROC were then compared between the two techniques. RESULTS For the primary analysis evaluating the first 35s of the VF waveform, the MLWAVE technique classified the type of VF with high accuracy (28/28 [100%], AUCROC: 1.00). The MLWAVE technique performed better than the AMSA technique across all comparisons, but given the small sample sizes, differences were not statistically significant (accuracy: 100% vs. 85.7%; p=0.24; AUCROC: 1.00 vs. 0.82; p=0.24). CONCLUSION This analytical investigation illustrates the advantages of the MLWAVE signal processing method which was associated with 100% accuracy in classifying the type of VF waveform: primary vs. asphyxia-associated. Such classification could lead to personalized tailoring of resuscitation (e.g., immediate defibrillation vs. continued CPR and treatment of reversible cardiac arrest causes before defibrillation) to improve outcomes for cardiac arrest.
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Affiliation(s)
- Dieter Bender
- Villanova Center for Analytics of Dynamic Systems, Villanova University, Villanova, PA, USA
| | - Ryan W. Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Vinay M. Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Bingqing Zhang
- Healthcare Analytics Unit, Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Todd J. Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert M. Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - C. Nataraj
- Moritz Professor & Director, Villanova Center for Analytics of Dynamic Systems, Villanova University, Villanova, PA, USA
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Morgan RW, Kirschen MP, Kilbaugh TJ, Sutton RM, Topjian AA. Pediatric In-Hospital Cardiac Arrest and Cardiopulmonary Resuscitation in the United States: A Review. JAMA Pediatr 2021; 175:293-302. [PMID: 33226408 PMCID: PMC8787313 DOI: 10.1001/jamapediatrics.2020.5039] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
IMPORTANCE Pediatric in-hospital cardiac arrest (IHCA) occurs frequently and is associated with high morbidity and mortality. The objective of this narrative review is to summarize the current knowledge and recommendations regarding pediatric IHCA and cardiopulmonary resuscitation (CPR). OBSERVATIONS Each year, more than 15 000 children receive CPR for cardiac arrest during hospitalization in the United States. As many as 80% to 90% survive the event, but most patients do not survive to hospital discharge. Most IHCAs occur in intensive care units and other monitored settings and are associated with respiratory failure or shock. Bradycardia with poor perfusion is the initial rhythm in half of CPR events, and only about 10% of events have an initial shockable rhythm. Pre-cardiac arrest systems focus on identifying at-risk patients and ensuring that they are in monitored settings. Important components of CPR include high-quality chest compressions, timely defibrillation when indicated, appropriate ventilation and airway management, administration of epinephrine to increase coronary perfusion pressure, and treatment of the underlying cause of cardiac arrest. Extracorporeal CPR and measurement of physiological parameters are evolving areas in improving outcomes. Structured post-cardiac arrest care focused on targeted temperature management, optimization of hemodynamics, and careful intensive care unit management is associated with improved survival and neurological outcomes. CONCLUSIONS AND RELEVANCE Pediatric IHCA occurs frequently and has a high mortality rate. Early identification of risk, prevention, delivery of high-quality CPR, and post-cardiac arrest care can maximize the chances of achieving favorable outcomes. More research in this field is warranted.
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Affiliation(s)
- Ryan W. Morgan
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Matthew P. Kirschen
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Todd J. Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Robert M. Sutton
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Alexis A. Topjian
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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Jouffroy R, Vivien B. Epinephrine's effects on cerebrovascular and systemic hemodynamics during cardiopulmonary resuscitation: metabolic changes may limit the persistence of the effect. Crit Care 2021; 25:67. [PMID: 33593399 PMCID: PMC7887812 DOI: 10.1186/s13054-020-03378-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 11/09/2020] [Indexed: 11/10/2022] Open
Affiliation(s)
- Romain Jouffroy
- Service de Médecine Intensive Réanimation, Hôpital Universitaire Ambroise Paré, APHP. Université Paris Saclay, Assistance Publique - Hôpitaux de Paris, Boulogne Billancourt, France.,Université de Versailles Saint Quentin, Versailles, France
| | - Benoît Vivien
- SAMU de Paris, Service d'Anesthésie-Réanimation, Hôpital Universitaire Necker - Enfants Malades, APHP. Centre, Assistance Publique - Hôpitaux de Paris, Paris, France. .,Université de Paris, Paris, France.
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Non-invasive diffuse optical neuromonitoring during cardiopulmonary resuscitation predicts return of spontaneous circulation. Sci Rep 2021; 11:3828. [PMID: 33589662 PMCID: PMC7884428 DOI: 10.1038/s41598-021-83270-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 01/28/2021] [Indexed: 11/08/2022] Open
Abstract
Neurologic injury is a leading cause of morbidity and mortality following pediatric cardiac arrest. In this study, we assess the feasibility of quantitative, non-invasive, frequency-domain diffuse optical spectroscopy (FD-DOS) neuromonitoring during cardiopulmonary resuscitation (CPR), and its predictive utility for return of spontaneous circulation (ROSC) in an established pediatric swine model of cardiac arrest. Cerebral tissue optical properties, oxy- and deoxy-hemoglobin concentration ([HbO2], [Hb]), oxygen saturation (StO2) and total hemoglobin concentration (THC) were measured by a FD-DOS probe placed on the forehead in 1-month-old swine (8–11 kg; n = 52) during seven minutes of asphyxiation followed by twenty minutes of CPR. ROSC prediction and time-dependent performance of prediction throughout early CPR (< 10 min), were assessed by the weighted Youden index (Jw, w = 0.1) with tenfold cross-validation. FD-DOS CPR data was successfully acquired in 48/52 animals; 37/48 achieved ROSC. Changes in scattering coefficient (785 nm), [HbO2], StO2 and THC from baseline were significantly different in ROSC versus No-ROSC subjects (p < 0.01) after 10 min of CPR. Change in [HbO2] of + 1.3 µmol/L from 1-min of CPR achieved the highest weighted Youden index (0.96) for ROSC prediction. We demonstrate feasibility of quantitative, non-invasive FD-DOS neuromonitoring, and stable, specific, early ROSC prediction from the third minute of CPR.
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Kirschen MP, Morgan RW, Majmudar T, Landis WP, Ko T, Balu R, Balasubramanian S, Topjian A, Sutton RM, Berg RA, Kilbaugh TJ. The association between early impairment in cerebral autoregulation and outcome in a pediatric swine model of cardiac arrest. Resusc Plus 2020; 4:100051. [PMID: 34223325 PMCID: PMC8244245 DOI: 10.1016/j.resplu.2020.100051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/03/2020] [Accepted: 11/08/2020] [Indexed: 12/26/2022] Open
Abstract
AIMS Evaluate cerebral autoregulation (CAR) by intracranial pressure reactivity index (PRx) and cerebral blood flow reactivity index (CBFx) during the first four hours following return of spontaneous circulation (ROSC) in a porcine model of pediatric cardiac arrest. Determine whether impaired CAR is associated with neurologic outcome. METHODS Four-week-old swine underwent seven minutes of asphyxia followed by ventricular fibrillation induction and hemodynamic-directed CPR. Those achieving ROSC had arterial blood pressure, intracranial pressure (ICP), and microvascular cerebral blood flow (CBF) monitored for 4 h. Animals were assigned an 8 -h post-ROSC swine cerebral performance category score (1 = normal; 2-4=abnormal neurologic function). In this secondary analytic study, we calculated PRx and CBFx using a continuous, moving correlation coefficient between mean arterial pressure (MAP) and ICP, and between MAP and CBF, respectively. Burden of impaired CAR was the area under the PRx or CBFx curve using a threshold of 0.3 and normalized as percentage of monitoring duration. RESULTS Among 23 animals, median PRx was 0.14 [0.06,0.25] and CBFx was 0.36 [0.05,0.44]. Median burden of impaired CAR was 21% [18,27] with PRx and 30% [17,40] with CBFx. Neurologically abnormal animals (n = 10) did not differ from normal animals (n = 13) in post-ROSC MAP (63 vs. 61 mmHg, p = 0.74), ICP (15 vs. 14 mmHg, p = 0.78) or CBF (274 vs. 397 Perfusion Units, p = 0.12). CBFx burden was greater among abnormal than normal animals (45% vs. 24%, p = 0.001), but PRx burden was not (25% vs. 20%, p = 0.38). CONCLUSION CAR is impaired early after ROSC. A greater burden of CAR impairment measured by CBFx was associated with abnormal neurologic outcome.CHOP Institutional Animal Care and Use Committee protocol 19-001327.
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Affiliation(s)
- Matthew P Kirschen
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, USA
- Department of Pediatrics, Children’s Hospital of Philadelphia, USA
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, USA
| | - Ryan W. Morgan
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, USA
- Department of Pediatrics, Children’s Hospital of Philadelphia, USA
| | - Tanmay Majmudar
- School of Biomedical Engineering, Science and Health Systems, Drexel University, USA
| | - William P. Landis
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, USA
| | - Tiffany Ko
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, USA
| | - Ramani Balu
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, USA
| | | | - Alexis Topjian
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, USA
- Department of Pediatrics, Children’s Hospital of Philadelphia, USA
| | - Robert M. Sutton
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, USA
- Department of Pediatrics, Children’s Hospital of Philadelphia, USA
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, USA
- Department of Pediatrics, Children’s Hospital of Philadelphia, USA
| | - Todd J. Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, USA
- Department of Pediatrics, Children’s Hospital of Philadelphia, USA
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Slovis JC, Morgan RW, Landis WP, Roberts AL, Marquez AM, Mavroudis CD, Lin Y, Ko T, Nadkarni VM, Berg RA, Sutton RM, Kilbaugh TJ. The physiologic response to rescue therapy with vasopressin versus epinephrine during experimental pediatric cardiac arrest. Resusc Plus 2020; 4:100050. [PMID: 34223324 PMCID: PMC8244440 DOI: 10.1016/j.resplu.2020.100050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 11/02/2020] [Accepted: 11/03/2020] [Indexed: 11/26/2022] Open
Abstract
Aim Compare vasopressin to a second dose of epinephrine as rescue therapy after ineffective initial doses of epinephrine in diverse models of pediatric in-hospital cardiac arrest. Methods 67 one- to three-month old female swine (10−30 kg) in six experimental cohorts from one laboratory received hemodynamic-directed CPR, a resuscitation method where high quality chest compressions are provided and vasopressor administration is titrated to coronary perfusion pressure (CoPP) ≥20 mmHg. Vasopressors are given when CoPP is <20 mmHg, in sequences of two doses of 0.02 mg/kg epinephrine separated by minimum one-minute, then a rescue dose of 0.4 U/kg vasopressin followed by minimum two-minutes. Invasive measurements were used to evaluate and compare the hemodynamic and neurologic effects of each vasopressor dose. Results Increases in CoPP and cerebral blood flow (CBF) were greater with vasopressin rescue than epinephrine rescue (CoPP: +8.16 [4.35, 12.06] mmHg vs. + 5.43 [1.56, 9.82] mmHg, p = 0.02; CBF: +14.58 [-0.05, 38.12] vs. + 0.00 [-0.77, 18.24] perfusion units (PFU), p = 0.005). Twenty animals (30%) failed to achieve CoPP ≥20 mmHg after two doses of epinephrine; 9/20 (45%) non-responders achieved CoPP ≥20 mmHg after vasopressin. Among all animals, the increase in CBF was greater with vasopressin (+14.58 [-0.58, 38.12] vs. 0.00 [-0.77, 18.24] PFU, p = 0.005). Conclusions CoPP and CBF rose significantly more after rescue vasopressin than after rescue epinephrine. Importantly, CBF increased after vasopressin rescue, but not after epinephrine rescue. In the 30% that failed to meet CoPP of 20 mmHg after two doses of epinephrine, 45% achieved target CoPP with a single rescue vasopressin dose.
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Affiliation(s)
- Julia C Slovis
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 3401 Civic Center Boulevard, Division of Critical Care Medicine - 6 Wood, Philadelphia, PA 19104, US
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 3401 Civic Center Boulevard, Division of Critical Care Medicine - 6 Wood, Philadelphia, PA 19104, US
| | - William P Landis
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 3401 Civic Center Boulevard, Division of Critical Care Medicine - 6 Wood, Philadelphia, PA 19104, US
| | - Anna L Roberts
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 3401 Civic Center Boulevard, Division of Critical Care Medicine - 6 Wood, Philadelphia, PA 19104, US
| | - Alexandra M Marquez
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 3401 Civic Center Boulevard, Division of Critical Care Medicine - 6 Wood, Philadelphia, PA 19104, US
| | - Constantine D Mavroudis
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 3401 Civic Center Boulevard, Division of Critical Care Medicine - 6 Wood, Philadelphia, PA 19104, US
| | - Yuxi Lin
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 3401 Civic Center Boulevard, Division of Critical Care Medicine - 6 Wood, Philadelphia, PA 19104, US
| | - Tiffany Ko
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 3401 Civic Center Boulevard, Division of Critical Care Medicine - 6 Wood, Philadelphia, PA 19104, US
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 3401 Civic Center Boulevard, Division of Critical Care Medicine - 6 Wood, Philadelphia, PA 19104, US
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 3401 Civic Center Boulevard, Division of Critical Care Medicine - 6 Wood, Philadelphia, PA 19104, US
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 3401 Civic Center Boulevard, Division of Critical Care Medicine - 6 Wood, Philadelphia, PA 19104, US
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 3401 Civic Center Boulevard, Division of Critical Care Medicine - 6 Wood, Philadelphia, PA 19104, US
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Mavroudis CD, Ko TS, Morgan RW, Volk LE, Landis WP, Smood B, Xiao R, Hefti M, Boorady TW, Marquez A, Karlsson M, Licht DJ, Nadkarni VM, Berg RA, Sutton RM, Kilbaugh TJ. Epinephrine's effects on cerebrovascular and systemic hemodynamics during cardiopulmonary resuscitation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:583. [PMID: 32993753 PMCID: PMC7522922 DOI: 10.1186/s13054-020-03297-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 09/17/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Despite controversies, epinephrine remains a mainstay of cardiopulmonary resuscitation (CPR). Recent animal studies have suggested that epinephrine may decrease cerebral blood flow (CBF) and cerebral oxygenation, possibly potentiating neurological injury during CPR. We investigated the cerebrovascular effects of intravenous epinephrine in a swine model of pediatric in-hospital cardiac arrest. The primary objectives of this study were to determine if (1) epinephrine doses have a significant acute effect on CBF and cerebral tissue oxygenation during CPR and (2) if the effect of each subsequent dose of epinephrine differs significantly from that of the first. METHODS One-month-old piglets (n = 20) underwent asphyxia for 7 min, ventricular fibrillation, and CPR for 10-20 min. Epinephrine (20 mcg/kg) was administered at 2, 6, 10, 14, and 18 min of CPR. Invasive (laser Doppler, brain tissue oxygen tension [PbtO2]) and noninvasive (diffuse correlation spectroscopy and diffuse optical spectroscopy) measurements of CBF and cerebral tissue oxygenation were simultaneously recorded. Effects of subsequent epinephrine doses were compared to the first. RESULTS With the first epinephrine dose during CPR, CBF and cerebral tissue oxygenation increased by > 10%, as measured by each of the invasive and noninvasive measures (p < 0.001). The effects of epinephrine on CBF and cerebral tissue oxygenation decreased with subsequent doses. By the fifth dose of epinephrine, there were no demonstrable increases in CBF of cerebral tissue oxygenation. Invasive and noninvasive CBF measurements were highly correlated during asphyxia (slope effect 1.3, p < 0.001) and CPR (slope effect 0.20, p < 0.001). CONCLUSIONS This model suggests that epinephrine increases CBF and cerebral tissue oxygenation, but that effects wane following the third dose. Noninvasive measurements of neurological health parameters hold promise for developing and directing resuscitation strategies.
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Affiliation(s)
- Constantine D Mavroudis
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA. .,Division of Cardiovascular Surgery, The University of Pennsylvania, Philadelphia, PA, USA.
| | - Tiffany S Ko
- Department of Neurology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lindsay E Volk
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - William P Landis
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Benjamin Smood
- Division of Cardiovascular Surgery, The University of Pennsylvania, Philadelphia, PA, USA
| | - Rui Xiao
- Department of Pediatrics, Division of Biostatistics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Marco Hefti
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Timothy W Boorady
- Department of Neurology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alexandra Marquez
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Daniel J Licht
- Department of Neurology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Kilbaugh TJ, Morgan RW, Berg RA. The neurologic impact of epinephrine during cardiac arrest: Much to learn. Resuscitation 2020; 156:263-264. [PMID: 32890652 DOI: 10.1016/j.resuscitation.2020.07.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 07/22/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States; Perelman School of Medicine at the University of Pennsylvania, United States
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States; Perelman School of Medicine at the University of Pennsylvania, United States
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States; Perelman School of Medicine at the University of Pennsylvania, United States.
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Abstract
There are approximately 350,000 out-of-hospital cardiac arrests and 200,000 in-hospital cardiac arrests annually in the United States, with survival rates of approximately 5% to 10% and 24%, respectively. The critical factors that have an impact on cardiac arrest survival include prompt recognition and activation of prehospital care, early cardiopulmonary resuscitation, and rapid defibrillation. Advanced life support protocols are continually refined to optimize intracardiac arrest management and improve survival with favorable neurologic outcome. This article focuses on current treatment recommendations for adult nontraumatic cardiac arrest, with emphasis on the latest evidence and controversies regarding intracardiac arrest management.
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Affiliation(s)
- Vivian Lam
- Department of Emergency Medicine, University of Michigan Medical School, 1500 East Medical Center Drive, B1-380 Taubman Center, SPC 5305, Ann Arbor, MI 48109-5305, USA
| | - Cindy H Hsu
- Department of Emergency Medicine, Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, NCRC B026-309N, 2800 Plymouth Road, Ann Arbor, MI 48109-2800, USA; Department of Surgery, Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, NCRC B026-309N, 2800 Plymouth Road, Ann Arbor, MI 48109-2800, USA.
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41
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Marquez AM, Morgan RW, Ko T, Landis WP, Hefti MM, Mavroudis CD, McManus MJ, Karlsson M, Starr J, Roberts AL, Lin Y, Nadkarni V, Licht DJ, Berg RA, Sutton RM, Kilbaugh TJ. Oxygen Exposure During Cardiopulmonary Resuscitation Is Associated With Cerebral Oxidative Injury in a Randomized, Blinded, Controlled, Preclinical Trial. J Am Heart Assoc 2020; 9:e015032. [PMID: 32321350 PMCID: PMC7428577 DOI: 10.1161/jaha.119.015032] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background Hyperoxia during cardiopulmonary resuscitation (CPR) may lead to oxidative injury from mitochondrial‐derived reactive oxygen species, despite guidelines recommending 1.0 inspired oxygen during CPR. We hypothesized exposure to 1.0 inspired oxygen during CPR would result in cerebral hyperoxia, higher mitochondrial‐derived reactive oxygen species, increased oxidative injury, and similar survival compared with those exposed to 21% oxygen. Methods and Results Four‐week‐old piglets (n=25) underwent asphyxial cardiac arrest followed by randomization and blinding to CPR with 0.21 (n=10) or 1.0 inspired oxygen (n=10) through 10 minutes post return of spontaneous circulation. Sham was n=5. Survivors received 4 hours of protocolized postarrest care, whereupon brain was obtained for mitochondrial analysis and neuropathology. Groups were compared using Kruskal‐Wallis test, Wilcoxon rank‐sum test, and generalized estimating equations regression models. Both 1.0 and 0.21 groups were similar in systemic hemodynamics and cerebral blood flow, as well as survival (8/10). The 1.0 animals had relative cerebral hyperoxia during CPR and immediately following return of spontaneous circulation (brain tissue oxygen tension, 85% [interquartile range, 72%–120%] baseline in 0.21 animals versus 697% [interquartile range, 515%–721%] baseline in 1.0 animals; P=0.001 at 10 minutes postarrest). Cerebral mitochondrial reactive oxygen species production was higher in animals treated with 1.0 compared with 0.21 (P<0.03). Exposure to 1.0 oxygen led to increased cerebral oxidative injury to proteins and lipids, as evidenced by significantly higher protein carbonyls and 4‐hydroxynoneals compared with 0.21 (P<0.05) and sham (P<0.001). Conclusions Exposure to 1.0 inspired oxygen during CPR caused cerebral hyperoxia during resuscitation, and resultant increased mitochondrial‐derived reactive oxygen species and oxidative injury following cardiac arrest.
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Affiliation(s)
- Alexandra M Marquez
- Division of Critical Care Medicine Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia PA
| | - Ryan W Morgan
- Division of Critical Care Medicine Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia PA
| | - Tiffany Ko
- Division of Neurology Department of Pediatrics Children's Hospital of Philadelphia PA
| | - William P Landis
- Division of Critical Care Medicine Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia PA
| | - Marco M Hefti
- Department of Pathology University of Iowa Iowa City IA
| | - Constantine D Mavroudis
- Division of Cardiothoracic Surgery Department of Surgery Children's Hospital of Philadelphia PA
| | - Meagan J McManus
- Division of Critical Care Medicine Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia PA
| | | | - Jonathan Starr
- Division of Critical Care Medicine Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia PA
| | - Anna L Roberts
- Division of Critical Care Medicine Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia PA
| | - Yuxi Lin
- Division of Critical Care Medicine Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia PA
| | - Vinay Nadkarni
- Division of Critical Care Medicine Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia PA
| | - Daniel J Licht
- Division of Neurology Department of Pediatrics Children's Hospital of Philadelphia PA
| | - Robert A Berg
- Division of Critical Care Medicine Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia PA
| | - Robert M Sutton
- Division of Critical Care Medicine Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia PA
| | - Todd J Kilbaugh
- Division of Critical Care Medicine Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia PA
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Songstad NT, Klingenberg C, McGillick EV, Polglase GR, Zahra V, Schmölzer GM, Davis PG, Hooper SB, Crossley KJ. Efficacy of Intravenous, Endotracheal, or Nasal Adrenaline Administration During Resuscitation of Near-Term Asphyxiated Lambs. Front Pediatr 2020; 8:262. [PMID: 32582589 PMCID: PMC7282342 DOI: 10.3389/fped.2020.00262] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 04/27/2020] [Indexed: 12/27/2022] Open
Abstract
Objectives: Neonatal resuscitation guidelines recommend administering intravenous (IV) adrenaline if bradycardia persists despite adequate ventilation and chest compressions (CC). Rapid IV access is challenging, but little evidence exists for other routes of administration. We compared IV, endotracheal (ET), and intranasal routes for adrenaline administration during resuscitation of asphyxiated newborn lambs. Study design: Near-term lambs (n = 22) were delivered by caesarean section. Severe asphyxia was induced by clamping the umbilical cord while delaying ET ventilation until blood flow in the carotid artery ceased. Following a 30 s sustained inflation and ventilation for 30 s, we commenced uncoordinated CC at 90/min. We randomized four groups receiving repeated treatment doses (Tds) every 3rd min of (i) IV-Adrenaline (50 μg), (ii) ET-Adrenaline (500 μg), (iii) Nasal-Adrenaline via an atomizer (500 μg), and (iv) IV-saline. If return of spontaneous circulation (ROSC) was not achieved after three Tds by the assigned route, up to two rescue doses (Rds) of IV adrenaline were administered. Main outcome measures were achievement of ROSC and time from start of CC to ROSC, defined as heart rate >100/min, and mean carotid arterial pressure >30 mmHg. Results: In the IV-Adrenaline group, 5/6 lambs achieved ROSC after the first Td, whereas 1 lamb required two Tds before achieving ROSC. In the ET-Adrenaline group, 1/5 lambs required one Td, 1 lamb required three Tds, 2 lambs required 2 Rds, and 1 did not achieve ROSC. In the Nasal-Adrenaline group, 1/6 lambs required one Td, 2 required two Tds, whereas 3 lambs required either one (2 lambs) or two (1 lamb) Rds of adrenaline to achieve ROSC. In the IV-saline group, no lambs achieved ROSC until adrenaline Rds; 4/5 lambs required one Rd and 1 lamb required two Rds. Time to ROSC was shorter using IV-Adrenaline (2.4 ± 0.4 min) compared with ET-Adrenaline (10.3 ± 2.4 min), Nasal-Adrenaline (9.2 ± 2.2 min), and IV-saline (11.2 ± 1.2 min). Conclusion: IV adrenaline had superior efficacy compared with nasal or ET administration. Nasal administration had a similar effect as ET administration and is an easier route for early application. Nasal high-dose adrenaline administration for neonatal resuscitation merits further investigation.
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Affiliation(s)
- Nils T Songstad
- Department of Paediatric and Adolescent Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Claus Klingenberg
- Department of Paediatric and Adolescent Medicine, University Hospital of North Norway, Tromsø, Norway.,Paediatric Research Group, UiT-The Arctic University of Norway, Tromsø, Norway
| | - Erin V McGillick
- The Ritchie Centre, Hudson Institute of Medical Research Monash University, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research Monash University, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Valerie Zahra
- The Ritchie Centre, Hudson Institute of Medical Research Monash University, Melbourne, VIC, Australia
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Peter G Davis
- Neonatal Services and Newborn Research Centre, The Royal Women's Hospital, Melbourne, VIC, Australia.,Department of Obstetrics and Gynecology, The University of Melbourne, Melbourne, VIC, Australia.,Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research Monash University, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Kelly J Crossley
- The Ritchie Centre, Hudson Institute of Medical Research Monash University, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
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O'Brien CE, Reyes M, Santos PT, Heitmiller SE, Kulikowicz E, Kudchadkar SR, Lee JK, Hunt EA, Koehler RC, Shaffner DH. Pilot Study to Compare the Use of End-Tidal Carbon Dioxide-Guided and Diastolic Blood Pressure-Guided Chest Compression Delivery in a Swine Model of Neonatal Asphyxial Cardiac Arrest. J Am Heart Assoc 2019; 7:e009728. [PMID: 30371318 PMCID: PMC6404892 DOI: 10.1161/jaha.118.009728] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background The American Heart Association recommends use of physiologic feedback when available to optimize chest compression delivery. We compared hemodynamic parameters during cardiopulmonary resuscitation in which either end‐tidal carbon dioxide (ETCO2) or diastolic blood pressure (DBP) levels were used to guide chest compression delivery after asphyxial cardiac arrest. Methods and Results One‐ to 2‐week‐old swine underwent a 17‐minute asphyxial‐fibrillatory cardiac arrest followed by alternating 2‐minute periods of ETCO2‐guided and DBP‐guided chest compressions during 10 minutes of basic life support and 10 minutes of advanced life support. Ten animals underwent resuscitation. We found significant changes to ETCO2 and DBP levels within 30 s of switching chest compression delivery methods. The overall mean ETCO2 level was greater during ETCO2‐guided cardiopulmonary resuscitation (26.4±5.6 versus 22.5±5.2 mm Hg; P=0.003), whereas the overall mean DBP was greater during DBP‐guided cardiopulmonary resuscitation (13.9±2.3 versus 9.4±2.6 mm Hg; P=0.003). ETCO2‐guided chest compressions resulted in a faster compression rate (149±3 versus 120±5 compressions/min; P=0.0001) and a higher intracranial pressure (21.7±2.3 versus 16.0±1.1 mm Hg; P=0.002). DBP‐guided chest compressions were associated with a higher myocardial perfusion pressure (6.0±2.8 versus 2.4±3.2; P=0.02) and cerebral perfusion pressure (9.0±3.0 versus 5.5±4.3; P=0.047). Conclusions Using the ETCO2 or DBP level to optimize chest compression delivery results in physiologic changes that are method‐specific and occur within 30 s. Additional studies are needed to develop protocols for the use of these potentially conflicting physiologic targets to improve outcomes of prolonged cardiopulmonary resuscitation.
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Affiliation(s)
- Caitlin E O'Brien
- 1 Department of Anesthesiology/Critical Care Medicine Johns Hopkins University School of Medicine Baltimore MD
| | - Michael Reyes
- 1 Department of Anesthesiology/Critical Care Medicine Johns Hopkins University School of Medicine Baltimore MD
| | - Polan T Santos
- 1 Department of Anesthesiology/Critical Care Medicine Johns Hopkins University School of Medicine Baltimore MD
| | - Sophia E Heitmiller
- 1 Department of Anesthesiology/Critical Care Medicine Johns Hopkins University School of Medicine Baltimore MD
| | - Ewa Kulikowicz
- 1 Department of Anesthesiology/Critical Care Medicine Johns Hopkins University School of Medicine Baltimore MD
| | - Sapna R Kudchadkar
- 1 Department of Anesthesiology/Critical Care Medicine Johns Hopkins University School of Medicine Baltimore MD.,2 Department of Pediatrics Johns Hopkins University School of Medicine Baltimore MD.,3 Department of Physical Medicine & Rehabilitation Johns Hopkins University School of Medicine Baltimore MD
| | - Jennifer K Lee
- 1 Department of Anesthesiology/Critical Care Medicine Johns Hopkins University School of Medicine Baltimore MD
| | - Elizabeth A Hunt
- 1 Department of Anesthesiology/Critical Care Medicine Johns Hopkins University School of Medicine Baltimore MD.,2 Department of Pediatrics Johns Hopkins University School of Medicine Baltimore MD.,4 Division of Health Sciences Informatics Johns Hopkins University School of Medicine Baltimore MD
| | - Raymond C Koehler
- 1 Department of Anesthesiology/Critical Care Medicine Johns Hopkins University School of Medicine Baltimore MD
| | - Donald H Shaffner
- 1 Department of Anesthesiology/Critical Care Medicine Johns Hopkins University School of Medicine Baltimore MD
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Skulec R, Vojtisek P, Cerny V. Correlation between end-tidal carbon dioxide and the degree of compression of heart cavities measured by transthoracic echocardiography during cardiopulmonary resuscitation for out-of-hospital cardiac arrest. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:334. [PMID: 31665061 PMCID: PMC6819356 DOI: 10.1186/s13054-019-2607-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 09/11/2019] [Indexed: 11/10/2022]
Abstract
Background The concept of personalized cardiopulmonary resuscitation (CPR) requires a parameter that reflects its hemodynamic efficiency. While intra-arrest ultrasound is increasingly implemented into the advanced life support, we realized a pre-hospital clinical study to evaluate whether the degree of compression of the right ventricle (RV) and left ventricle (LV) induced by chest compressions during CPR for out-of-hospital cardiac arrest (OHCA) and measured by transthoracic echocardiography correlates with the levels of end-tidal carbon dioxide (EtCO2) measured at the time of echocardiographic investigation. Methods Thirty consecutive patients resuscitated for OHCA were included in the study. Transthoracic echocardiography was performed from a subcostal view during ongoing chest compressions in all of them. This was repeated three times during CPR in each patient, and EtCO2 levels were registered. From each investigation, a video loop was recorded. Afterwards, maximal and minimal diameters of LV and RV were obtained from the recorded loops and the compression index of LV (LVCI) and RV (RVCI) was calculated as (maximal − minimal/maximal diameter) × 100. Maximal compression index (CImax) defined as the value of LVCI or RVCI, whichever was greater was also assessed. Correlations between EtCO2 and LVCI, RVCI, and CImax were expressed as Spearman’s correlation coefficient (r). Results Evaluable echocardiographic records were found in 18 patients, and a total of 52 measurements of all parameters were obtained. Chest compressions induced significant compressions of all observed cardiac cavities (LVCI = 20.6 ± 13.8%, RVCI = 34.5 ± 21.6%, CImax = 37.4 ± 20.2%). We identified positive correlation of EtCO2 with LVCI (r = 0.672, p < 0.001) and RVCI (r = 0.778, p < 0.001). The strongest correlation was between EtCO2 and CImax (r = 0.859, p < 0.001). We identified that a CImax cut-off level of 17.35% predicted to reach an EtCO2 level > 20 mmHg with 100% sensitivity and specificity. Conclusions Evaluable echocardiographic records were reached in most of the patients. EtCO2 positively correlated with all parameters under consideration, while the strongest correlation was found between CImax and EtCO2. Therefore, CImax is a candidate parameter for the guidance of hemodynamic-directed CPR. Trial registration ClinicalTrial.gov, NCT03852225. Registered 21 February 2019 - Retrospectively registered.
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Affiliation(s)
- Roman Skulec
- Department of Anesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital Usti nad Labem, Socialni pece 3316/12A, 400 11, Usti nad Labem, Czech Republic. .,Emergency Medical Service of the Central Bohemian Region, Vancurova 1544, 272 01, Kladno, Czech Republic. .,Department of Anesthesiology and Intensive Care, Charles University, Faculty of Medicine in Hradec Kralove, University Hospital Hradec Kralove, Sokolska 581, 500 05, Hradec Kralove, Czech Republic.
| | - Petr Vojtisek
- Department of Anesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital Usti nad Labem, Socialni pece 3316/12A, 400 11, Usti nad Labem, Czech Republic.,Usti and Labem Region Emergency Medical Services, Socialni pece 799/7a, 400 11, Usti and Labem, Czech Republic
| | - Vladimir Cerny
- Department of Anesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital Usti nad Labem, Socialni pece 3316/12A, 400 11, Usti nad Labem, Czech Republic.,Emergency Medical Service of the Central Bohemian Region, Vancurova 1544, 272 01, Kladno, Czech Republic.,Department of Research and Development, Charles University in Prague, Faculty of Medicine in Hradec Kralove, University Hospital Hradec Kralove, Sokolska 581, 500 05, Hradec Kralove, Czech Republic.,Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, B3H 4R2, Canada
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Widmann N, Sutton R, Buchanan N, Niles DE, Nazareth G, Nadkarni V, Maltese MR. Simulating blood pressure and end tidal CO2 in a CPR training manikin. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2019; 180:105009. [PMID: 31437806 DOI: 10.1016/j.cmpb.2019.105009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 08/03/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND AND OBJECTIVE The American Heart Association supports titrating the mechanics of cardiopulmonary resuscitation (CPR) to blood pressure and end tidal carbon dioxide (ETCO2) thresholds during in-hospital cardiac arrest. However, current CPR manikin training systems do not prepare clinicians to use these metrics to gauge their performance, and currently provide only feedback on hand placement, depth, rate, release, and interruptions of chest compressions. We addressed this training hardware deficiency through development of a novel CPR training manikin that displays simulated blood pressure and ETCO2 waveforms in real time on a simulated clinical monitor visible to the learner, reflecting the mechanics of chest compressions provided to the manikin. Such a manikin could improve clinicians' CPR technique while also training them to titrate CPR quality to physiologic blood pressure and ETCO2 targets as performance indicators. METHODS We used data and key findings from 4 human and 6 animal studies (including 132 human subjects, 61 pigs, and 16 dogs in total) to develop an algorithm that simulates blood pressure and ETCO2 waveforms based on compression mechanics for a pediatric patient. We modified an off-the-shelf infant manikin to incorporate a microcontroller sufficient to process the aforementioned algorithm, and a tablet computer to wirelessly display the simulated waveform. We recruited clinicians with in-hospital CPR experience to perform compressions with the manikin and complete a post-test survey on their satisfaction with designated elements of the manikin and display. RESULTS 34 clinicians performed CPR on the prototype manikin system that simulates real-time bedside monitoring of blood pressure and ETCO2. 100% of clinicians surveyed reported "satisfaction" with the blood pressure waveform. 97% said they thought depth was accurately reflected in blood pressure (0% inaccurate, 3% not sure). 88% reported an accurate chest compression rate modification effect on blood pressure and ETCO2 (3% inaccurate, 9% not sure) and 59% an accurate effect of leaning (6% inaccurate, 35% not sure). Most importantly, all 34 respondents responded "yes" when asked if they thought this system would be helpful for CPR training. CONCLUSION A CPR manikin that simulates blood pressure and ETCO2 was successfully developed with acceptable relevance, performance and feasibility as a CPR quality training tool.
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Affiliation(s)
- Nicholas Widmann
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, 34th Street and Civic Center Blvd Philadelphia, PA 19104, USA; Department of Mechanical Engineering, Drexel University, 3141 Chestnut St, Philadelphia, PA 19104, USA.
| | - Robert Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, 34th Street and Civic Center Blvd Philadelphia, PA 19104, USA; The Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA.
| | - Newton Buchanan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, 34th Street and Civic Center Blvd Philadelphia, PA 19104, USA
| | - Dana E Niles
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, 34th Street and Civic Center Blvd Philadelphia, PA 19104, USA.
| | - Godfrey Nazareth
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, 34th Street and Civic Center Blvd Philadelphia, PA 19104, USA
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, 34th Street and Civic Center Blvd Philadelphia, PA 19104, USA; The Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA.
| | - Matthew R Maltese
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, 34th Street and Civic Center Blvd Philadelphia, PA 19104, USA; The Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA.
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46
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O'Brien CE, Santos PT, Reyes M, Adams S, Hopkins CD, Kulikowicz E, Hamrick JL, Hamrick JT, Lee JK, Kudchadkar SR, Hunt EA, Koehler RC, Shaffner DH. Association of diastolic blood pressure with survival during paediatric cardiopulmonary resuscitation. Resuscitation 2019; 143:50-56. [PMID: 31390531 DOI: 10.1016/j.resuscitation.2019.07.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/22/2019] [Accepted: 07/26/2019] [Indexed: 10/26/2022]
Abstract
AIM To examine the relationship between survival and diastolic blood pressure (DBP) throughout resuscitation from paediatric asphyxial cardiac arrest. METHODS Retrospective, secondary analysis of 200 swine resuscitations. Swine underwent asphyxial cardiac arrest and were resuscitated with predefined periods of basic and advanced life support (BLS and ALS, respectively). DBP was recorded every 30 s. Survival was defined as 20-min sustained return of spontaneous circulation (ROSC). RESULTS During BLS, DBP peaked between 1-3 min and was greater in survivors (20.0 [11.3, 33.3] mmHg) than in non-survivors (5.0 [1.0, 10.0] mmHg; p < 0.001). After this transient increase, the DBP in survivors progressively decreased but remained greater than that of non-survivors after 10 min of resuscitation (9.0 [6.0, 13.8] versus 3.0 [1.0, 6.8] mmHg; p < 0.001). During ALS, the magnitude of DBP change after the first adrenaline (epinephrine) administration was greater in survivors (22.0 [16.5, 36.5] mmHg) than in non-survivors (6.0 [2.0, 11.0] mmHg; p < 0.001). Survival rate was greater when DBP improved by ≥26 mmHg after the first dose of adrenaline (20/21; 95%) than when DBP improved by ≤10 mmHg (1/99; 1%). The magnitude of DBP change after the first adrenaline administration correlated with the timetoROSC (r = -0.54; p < 0.001). CONCLUSIONS Survival after asphyxial cardiac arrest is associated with a higher DBP throughout resuscitation, but the difference between survivors and non-survivors was reduced after prolonged BLS. During ALS, response to adrenaline administration correlates with survival and time to ROSC. If confirmed clinically, these findings may be useful for titrating adrenaline during resuscitation and prognosticating likelihood of ROSC. Institutional Protocol Numbers: SW14M223 and SW17M101.
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Affiliation(s)
- Caitlin E O'Brien
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, 1800 Orleans Street, Bloomberg Children's Center Suite 6302, Baltimore, MD 21287 United States
| | - Polan T Santos
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, 1800 Orleans Street, Bloomberg Children's Center Suite 6302, Baltimore, MD 21287 United States
| | - Michael Reyes
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, 1800 Orleans Street, Bloomberg Children's Center Suite 6302, Baltimore, MD 21287 United States
| | - Shawn Adams
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, 1800 Orleans Street, Bloomberg Children's Center Suite 6302, Baltimore, MD 21287 United States
| | - C Danielle Hopkins
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, 1800 Orleans Street, Bloomberg Children's Center Suite 6302, Baltimore, MD 21287 United States
| | - Ewa Kulikowicz
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, 1800 Orleans Street, Bloomberg Children's Center Suite 6302, Baltimore, MD 21287 United States
| | - Jennifer L Hamrick
- Department of Anesthesiology, Rady Children's Hospital, 3020 Children's Way, San Diego, CA 92123 United States
| | - Justin T Hamrick
- Department of Anesthesiology, Rady Children's Hospital, 3020 Children's Way, San Diego, CA 92123 United States
| | - Jennifer K Lee
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, 1800 Orleans Street, Bloomberg Children's Center Suite 6302, Baltimore, MD 21287 United States
| | - Sapna R Kudchadkar
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, 1800 Orleans Street, Bloomberg Children's Center Suite 6302, Baltimore, MD 21287 United States; Department of Pediatrics, Johns Hopkins University School of Medicine, 1800 Orleans Street, Bloomberg Children's Center Suite 6302, Baltimore, MD 21287 United States; Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, 600 N Wolfe St, Baltimore, MD 21287 United States
| | - Elizabeth A Hunt
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, 1800 Orleans Street, Bloomberg Children's Center Suite 6302, Baltimore, MD 21287 United States; Department of Pediatrics, Johns Hopkins University School of Medicine, 1800 Orleans Street, Bloomberg Children's Center Suite 6302, Baltimore, MD 21287 United States; Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, 2024 East Monument St. S 1-200, Baltimore, MD 21205 United States
| | - Raymond C Koehler
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, 1800 Orleans Street, Bloomberg Children's Center Suite 6302, Baltimore, MD 21287 United States
| | - Donald H Shaffner
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, 1800 Orleans Street, Bloomberg Children's Center Suite 6302, Baltimore, MD 21287 United States.
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47
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Li L, Poloyac SM, Watkins SC, St Croix CM, Alexander H, Gibson GA, Loughran PA, Kirisci L, Clark RS, Kochanek PM, Vazquez AL, Manole MD. Cerebral microcirculatory alterations and the no-reflow phenomenon in vivo after experimental pediatric cardiac arrest. J Cereb Blood Flow Metab 2019; 39:913-925. [PMID: 29192562 PMCID: PMC6501505 DOI: 10.1177/0271678x17744717] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Decreased cerebral blood flow (CBF) after cardiac arrest (CA) contributes to secondary ischemic injury in infants and children. We previously reported cortical hypoperfusion with tissue hypoxia early in a pediatric rat model of asphyxial CA. In order to identify specific alterations as potential therapeutic targets to improve cortical hypoperfusion post-CA, we characterize the CBF alterations at the cortical microvascular level in vivo using multiphoton microscopy. We hypothesize that microvascular constriction and disturbances of capillary red blood cell (RBC) flow contribute to cortical hypoperfusion post-CA. After resuscitation from 9 min asphyxial CA, transient dilation of capillaries and venules at 5 min was followed by pial arteriolar constriction at 30 and 60 min (19.6 ± 1.3, 19.3 ± 1.2 µm at 30, 60 min vs. 22.0 ± 1.2 µm at baseline, p < 0.05). At the capillary level, microcirculatory disturbances were highly heterogeneous, with RBC stasis observed in 25.4% of capillaries at 30 min post-CA. Overall, the capillary plasma mean transit time was increased post-CA by 139.7 ± 51.5%, p < 0.05. In conclusion, pial arteriolar constriction, the no-reflow phenomenon and increased plasma transit time were observed post-CA. Our results detail the microvascular disturbances in a pediatric asphyxial CA model and provide a powerful platform for assessing specific vascular-targeted therapies.
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Affiliation(s)
- Lingjue Li
- 1 Center of Clinical Pharmaceutical Sciences, University of Pittsburgh, PA, USA.,2 School of Pharmacy, University of Pittsburgh, PA, USA
| | - Samuel M Poloyac
- 1 Center of Clinical Pharmaceutical Sciences, University of Pittsburgh, PA, USA.,2 School of Pharmacy, University of Pittsburgh, PA, USA
| | - Simon C Watkins
- 3 Center for Biologic Imaging, University of Pittsburgh, PA, USA
| | | | - Henry Alexander
- 4 Safar Center for Resuscitation Research, University of Pittsburgh, PA, USA
| | - Gregory A Gibson
- 3 Center for Biologic Imaging, University of Pittsburgh, PA, USA
| | | | | | - Robert Sb Clark
- 4 Safar Center for Resuscitation Research, University of Pittsburgh, PA, USA.,5 Department of Critical Care Medicine, University of Pittsburgh, PA, USA
| | - Patrick M Kochanek
- 4 Safar Center for Resuscitation Research, University of Pittsburgh, PA, USA.,5 Department of Critical Care Medicine, University of Pittsburgh, PA, USA.,6 Department of Pediatrics, University of Pittsburgh, PA, USA
| | | | - Mioara D Manole
- 4 Safar Center for Resuscitation Research, University of Pittsburgh, PA, USA.,5 Department of Critical Care Medicine, University of Pittsburgh, PA, USA.,6 Department of Pediatrics, University of Pittsburgh, PA, USA
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48
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Physiology-directed cardiopulmonary resuscitation: advances in precision monitoring during cardiac arrest. Curr Opin Crit Care 2019; 24:143-150. [PMID: 29629927 DOI: 10.1097/mcc.0000000000000499] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW We review the recent advances in physiologic monitoring during cardiac arrest and offer an evidence-based framework for prioritizing physiologic targets during cardiopulmonary resuscitation (CPR). RECENT FINDINGS Current CPR guidelines recommend a uniform approach for all patients in cardiac arrest, but newer data support a precision strategy that uses the individual patient's physiology to guide resuscitation. Coronary perfusion pressure and arterial DBP are associated with survival outcomes in recent animal and human studies. End-tidal carbon dioxide is a reasonable noninvasive alternative, but may be inferior to invasive hemodynamic endpoints. Cerebral oximetry and cardiac ultrasound are emerging physiologic indicators of CPR effectiveness. SUMMARY Physiologic monitoring can and should be used to deliver precision CPR whenever possible and may improve outcomes after cardiac arrest.
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49
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Morgan RW, Landis WP, Marquez A, Graham K, Roberts AL, Lauridsen KG, Wolfe HA, Nadkarni VM, Topjian AA, Berg RA, Kilbaugh TJ, Sutton RM. Hemodynamic effects of chest compression interruptions during pediatric in-hospital cardiopulmonary resuscitation. Resuscitation 2019; 139:1-8. [PMID: 30946924 DOI: 10.1016/j.resuscitation.2019.03.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 03/12/2019] [Accepted: 03/20/2019] [Indexed: 11/30/2022]
Abstract
AIM Animal studies have established deleterious hemodynamic effects of interrupting chest compressions. The objective of this study was to evaluate the effect of interruptions on invasively measured blood pressures (BPs) during pediatric in-hospital cardiac arrest (IHCA). METHODS This was a single-center, observational study of pediatric (<18 years) intensive care unit IHCAs in patients with invasive arterial catheters in place. Interruptions were defined as ≥1 s between chest compressions. Diastolic BP (DBP) and systolic BP (SBP) were determined for individual compressions. For the primary analysis, the average DBP and SBP of the 20 compressions preceding each interruption were compared to the average DBP and SBP of the first 20 compressions following each interruption utilizing non-parametric paired analyses. Linear regression evaluated the change in DBP during interruptions and following interruptions. RESULTS Thirty-two IHCA events met inclusion criteria, yielding 161 evaluable interruptions. The median age was 2.1 years. Return of circulation was achieved in 24 (75%). The median interruption duration was 2.4 [1.4, 7.0] seconds. Most patients were intubated pre-arrest and received epinephrine during CPR. BPs were not different pre- vs. post-interruption (DBP: 28.7 [21.6, 38.2] vs. 28.3 [21.0, 37.4] mmHg, p = 0.81; SBP: 82.0 [51.7, 116.7] vs. 85.4 [55.7, 122.2] mmHg, p = 0.07). DBP decreased 8.41 ± 0.73 mmHg (p < 0.001) during the first second of interruptions and 0.19 ± 0.02 mmHg/s (p < 0.001) in subsequent seconds. CONCLUSIONS BPs following chest compression interruptions did not differ from pre-interruption BPs. These findings suggest that in the setting of high-quality in-hospital CPR, brief chest compression interruptions do not have persistent detrimental hemodynamic impact.
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Affiliation(s)
- Ryan W Morgan
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States.
| | - William P Landis
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Alexandra Marquez
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Kathryn Graham
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Anna L Roberts
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Kasper G Lauridsen
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Heather A Wolfe
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Vinay M Nadkarni
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Alexis A Topjian
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Robert A Berg
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Todd J Kilbaugh
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Robert M Sutton
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States
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50
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Lautz AJ, Morgan RW, Karlsson M, Mavroudis CD, Ko TS, Licht DJ, Nadkarni VM, Berg RA, Sutton RM, Kilbaugh TJ. Hemodynamic-Directed Cardiopulmonary Resuscitation Improves Neurologic Outcomes and Mitochondrial Function in the Heart and Brain. Crit Care Med 2019; 47:e241-e249. [PMID: 30779720 PMCID: PMC6561502 DOI: 10.1097/ccm.0000000000003620] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Less than half of the thousands of children who suffer in-hospital cardiac arrests annually survive, and neurologic injury is common among survivors. Hemodynamic-directed cardiopulmonary resuscitation improves short-term survival, but its impact on longer term survival and mitochondrial respiration-a potential neurotherapeutic target-remains unknown. The primary objectives of this study were to compare rates of 24-hour survival with favorable neurologic outcome after cardiac arrest treated with hemodynamic-directed cardiopulmonary resuscitation versus standard depth-guided cardiopulmonary resuscitation and to compare brain and heart mitochondrial respiration between groups 24 hours after resuscitation. DESIGN Randomized preclinical large animal trial. SETTING A large animal resuscitation laboratory at a large academic children's hospital. SUBJECTS Twenty-eight 4-week-old female piglets (8-11 kg). INTERVENTIONS Twenty-two swine underwent 7 minutes of asphyxia followed by ventricular fibrillation and randomized treatment with either hemodynamic-directed cardiopulmonary resuscitation (n = 10; compression depth titrated to aortic systolic pressure of 90 mm Hg, vasopressors titrated to coronary perfusion pressure ≥ 20 mm Hg) or depth-guided cardiopulmonary resuscitation (n = 12; depth 1/3 chest diameter, epinephrine every 4 min). Six animals (sham group) underwent anesthesia and instrumentation without cardiac arrest. The primary outcomes were favorable neurologic outcome (swine Cerebral Performance Category ≤ 2) and mitochondrial maximal oxidative phosphorylation utilizing substrate for complex I and complex II (OXPHOSCI+CII) in the cerebral cortex and hippocampus. MEASUREMENTS AND MAIN RESULTS Favorable neurologic outcome was more likely with hemodynamic-directed cardiopulmonary resuscitation (7/10) than depth-guided cardiopulmonary resuscitation (1/12; p = 0.006). Hemodynamic-directed cardiopulmonary resuscitation resulted in higher intra-arrest coronary perfusion pressure, aortic pressures, and brain tissue oxygenation. Hemodynamic-directed cardiopulmonary resuscitation resulted in higher OXPHOSCI+CII (pmol oxygen/s × mg/citrate synthase) in the cortex (6.00 ± 0.28 vs 3.88 ± 0.43; p < 0.05) and hippocampus (6.26 ± 0.67 vs 3.55 ± 0.65; p < 0.05) and higher complex I respiration (pmol oxygen/s × mg) in the right (20.62 ± 1.06 vs 15.88 ± 0.81; p < 0.05) and left ventricles (20.14 ± 1.40 vs 14.17 ± 1.53; p < 0.05). CONCLUSIONS In a model of asphyxia-associated pediatric cardiac arrest, hemodynamic-directed cardiopulmonary resuscitation increases rates of 24-hour survival with favorable neurologic outcome, intra-arrest hemodynamics, and cerebral and myocardial mitochondrial respiration.
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Affiliation(s)
- Andrew J. Lautz
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine; Department of Anesthesiology and Critical Care Medicine
- Cincinnati Children’s Hospital Medical Center; Division of Critical Care Medicine
| | - Ryan W. Morgan
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine; Department of Anesthesiology and Critical Care Medicine
| | - Michael Karlsson
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine; Department of Anesthesiology and Critical Care Medicine
| | - Constantine D. Mavroudis
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine; Department of Cardiothoracic Surgery
| | - Tiffany S. Ko
- University of Pennsylvania, Department of Bioengineering
| | - Daniel J. Licht
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine; Department of Pediatrics, Division of Neurology
| | - Vinay M. Nadkarni
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine; Department of Anesthesiology and Critical Care Medicine
| | - Robert A. Berg
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine; Department of Anesthesiology and Critical Care Medicine
| | - Robert M. Sutton
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine; Department of Anesthesiology and Critical Care Medicine
| | - Todd J. Kilbaugh
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine; Department of Anesthesiology and Critical Care Medicine
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