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Nippert AR, Chiang PP, Newman EA. Whisker-evoked neurovascular coupling is preserved during hypoglycemia in mouse cortical arterioles and capillaries. J Cereb Blood Flow Metab 2024; 44:155-168. [PMID: 37728791 PMCID: PMC10993878 DOI: 10.1177/0271678x231201241] [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: 02/13/2023] [Revised: 07/12/2023] [Accepted: 08/15/2023] [Indexed: 09/21/2023]
Abstract
Hypoglycemia is a serious complication of insulin treatment of diabetes that can lead to coma and death. Neurovascular coupling, which mediates increased local blood flow in response to neuronal activity, increases glucose availability to active neurons. This mechanism could be essential for neuronal health during hypoglycemia, when total glucose supplies are low. Previous studies suggest, however, that neurovascular coupling (a transient blood flow increase in response to an increase in neuronal activity) may be reduced during hypoglycemia. Such a reduction in blood flow increase would exacerbate the effects of hypoglycemia, depriving active neurons of glucose. We have reexamined the effects of hypoglycemia on neurovascular coupling by simultaneously monitoring neuronal and vascular responses to whisker stimulation in the awake mouse somatosensory cortex. We find that neurovascular coupling at both penetrating arterioles and at 2nd order capillaries did not change significantly during insulin-induced hypoglycemia compared to euglycemia. In addition, we show that the basal diameter of both arterioles and capillaries increases during hypoglycemia (10.3 and 9.7% increases, respectively). Our results demonstrate that both neurovascular coupling and basal increases in vessel diameter are active mechanisms which help to maintain an adequate supply of glucose to the brain during hypoglycemia.
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Affiliation(s)
| | | | - Eric A Newman
- Department of Neuroscience, University of Minnesota, Minneapolis, Minnesota, USA
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Battaglini D, Bogossian EG, Anania P, Premraj L, Cho SM, Taccone FS, Sekhon M, Robba C. Monitoring of Brain Tissue Oxygen Tension in Cardiac Arrest: a Translational Systematic Review from Experimental to Clinical Evidence. Neurocrit Care 2024; 40:349-363. [PMID: 37081276 DOI: 10.1007/s12028-023-01721-5] [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: 12/05/2022] [Accepted: 03/24/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Cardiac arrest (CA) is a sudden event that is often characterized by hypoxic-ischemic brain injury (HIBI), leading to significant mortality and long-term disability. Brain tissue oxygenation (PbtO2) is an invasive tool for monitoring brain oxygen tension, but it is not routinely used in patients with CA because of the invasiveness and the absence of high-quality data on its effect on outcome. We conducted a systematic review of experimental and clinical evidence to understand the role of PbtO2 in monitoring brain oxygenation in HIBI after CA and the effect of targeted PbtO2 therapy on outcomes. METHODS The search was conducted using four search engines (PubMed, Scopus, Embase, and Cochrane), using the Boolean operator to combine mesh terms such as PbtO2, CA, and HIBI. RESULTS Among 1,077 records, 22 studies were included (16 experimental studies and six clinical studies). In experimental studies, PbtO2 was mainly adopted to assess the impact of gas exchanges, drugs, or systemic maneuvers on brain oxygenation. In human studies, PbtO2 was rarely used to monitor the brain oxygen tension in patients with CA and HIBI. PbtO2 values had no clear association with patients' outcomes, but in the experimental studies, brain tissue hypoxia was associated with increased inflammation and neuronal damage. CONCLUSIONS Further studies are needed to validate the effect and the threshold of PbtO2 associated with outcome in patients with CA, as well as to understand the physiological mechanisms influencing PbtO2 induced by gas exchanges, drug administration, and changes in body positioning after CA.
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Affiliation(s)
- Denise Battaglini
- Anesthesiology and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Elisa Gouvea Bogossian
- Department of Intensive Care, Hospital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Pasquale Anania
- Department of Neurosurgery, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.
| | - Lavienraj Premraj
- Griffith University School of Medicine, Gold Coast, QLD, Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Sung-Min Cho
- Departments of Neurology, Surgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hospital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Mypinder Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Chiara Robba
- Anesthesiology and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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Kook Kang J, Kalra A, Ameen Ahmad S, Kumar Menta A, Rando HJ, Chinedozi I, Darby Z, Spann M, Keller SP, J. R. Whitman G, Cho SM. A recommended preclinical extracorporeal cardiopulmonary resuscitation model for neurological outcomes: A scoping review. Resusc Plus 2023; 15:100424. [PMID: 37719942 PMCID: PMC10500026 DOI: 10.1016/j.resplu.2023.100424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/14/2023] [Accepted: 06/19/2023] [Indexed: 09/19/2023] Open
Abstract
Background Despite the high prevalence of neurological complications and mortality associated with extracorporeal cardiopulmonary resuscitation (ECPR), neurologically-focused animal models are scarce. Our objective is to review current ECPR models investigating neurological outcomes and identify key elements for a recommended model. Methods We searched PubMed and four other engines for animal ECPR studies examining neurological outcomes. Inclusion criteria were: animals experiencing cardiac arrest, ECPR/ECMO interventions, comparisons of short versus long cardiac arrest times, and neurological outcomes. Results Among 20 identified ECPR animal studies (n = 442), 13 pigs, 4 dogs, and 3 rats were used. Only 10% (2/20) included both sexes. Significant heterogeneity was observed in experimental protocols. 90% (18/20) employed peripheral VA-ECMO cannulation and 55% (11/20) were survival models (median survival = 168 hours; ECMO duration = 60 minutes). Ventricular fibrillation (18/20, 90%) was the most common method for inducing cardiac arrest with a median duration of 15 minutes (IQR = 6-20). In two studies, cardiac arrests exceeding 15 minutes led to considerable mortality and neurological impairment. Among seven studies utilizing neuromonitoring tools, only four employed multimodal devices to evaluate cerebral blood flow using Transcranial Doppler ultrasound and near-infrared spectroscopy, brain tissue oxygenation, and intracranial pressure. None examined cerebral autoregulation or neurovascular coupling. Conclusions The substantial heterogeneity in ECPR preclinical model protocols leads to limited reproducibility and multiple challenges. The recommended model includes large animals with both sexes, standardized pre-operative protocols, a cardiac arrest time between 10-15 minutes, use of multimodal methods to evaluate neurological outcomes, and the ability to survive animals after conducting experiments.
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Affiliation(s)
- Jin Kook Kang
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, USA
| | - Andrew Kalra
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, USA
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Syed Ameen Ahmad
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, USA
| | - Arjun Kumar Menta
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, USA
| | - Hannah J. Rando
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, USA
| | - Ifeanyi Chinedozi
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, USA
| | - Zachary Darby
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, USA
| | - Marcus Spann
- Informationist Services, Johns Hopkins School of Medicine, Baltimore, USA
| | - Steven P. Keller
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, USA
| | - Glenn J. R. Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, USA
| | - Sung-Min Cho
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, USA
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, USA
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, USA
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Ortmann LA, Reeder RW, Raymond TT, Brunetti MA, Himebauch A, Bhakta R, Kempka J, di Bari S, Lasa JJ. Epinephrine dosing strategies during pediatric extracorporeal cardiopulmonary resuscitation reveal novel impacts on survival: A multicenter study utilizing time-stamped epinephrine dosing records. Resuscitation 2023; 188:109855. [PMID: 37257678 PMCID: PMC10890910 DOI: 10.1016/j.resuscitation.2023.109855] [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: 03/26/2023] [Revised: 05/11/2023] [Accepted: 05/22/2023] [Indexed: 06/02/2023]
Abstract
OBJECTIVES To describe epinephrine dosing distribution using time-stamped data and assess the impact of dosing strategy on survival after ECPR in children. METHODS This was a retrospective study at five pediatric hospitals of children <18 years with an in-hospital ECPR event. Mean number of epinephrine doses was calculated for each 10-minute CPR interval and compared between survivors and non-survivors. Patients were also divided by dosing strategy into a frequent epinephrine group (dosing interval of ≤5 min/dose throughout the first 30 minutes of the event), and a limited epinephrine group (dosing interval of ≤5 min/dose for the first 10 minutes then >5 min/dose for the time between 10 and 30 minutes). RESULTS A total of 191 patients were included. Epinephrine was not evenly distributed throughout ECPR, with 66% of doses being given during the first half of the event. Mean number of epinephrine doses was similar between survivors and non-survivors the first 10 minutes (2.7 doses). After 10 minutes, survivors received fewer doses than non-survivors during each subsequent 10-minute interval. Adjusted survival was not different between strategy groups [OR of survival for frequent epinephrine strategy: 0.78 (95% CI 0.36-1.69), p = 0.53]. CONCLUSIONS Survivors received fewer doses than non-survivors after the first 10 minutes of CPR and although there was no statistical difference in survival based on dosing strategy, the findings of this study question the conventional approach to EPCR analysis that assumes dosing is evenly distributed.
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Affiliation(s)
- Laura A Ortmann
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Tia T Raymond
- Department of Pediatrics, Cardiac Critical Care, Medical City Children's Hospital, Dallas, TX, USA
| | - Marissa A Brunetti
- Division of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Adam Himebauch
- Division of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Rupal Bhakta
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jessica Kempka
- Division of Critical Care Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Shauna di Bari
- Division of Critical Care Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Javier J Lasa
- Division of Cardiology, Children's Medical Center, UT Southwestern Medical Center, Dallas, TX, USA; Division of Critical Care, Children's Medical Center, UT Southwestern Medical Center, Dallas, TX, USA.
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5
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Khanduja S, Kim J, Kang JK, Feng CY, Vogelsong MA, Geocadin RG, Whitman G, Cho SM. Hypoxic-Ischemic Brain Injury in ECMO: Pathophysiology, Neuromonitoring, and Therapeutic Opportunities. Cells 2023; 12:1546. [PMID: 37296666 PMCID: PMC10252448 DOI: 10.3390/cells12111546] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/02/2023] [Accepted: 06/03/2023] [Indexed: 06/12/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO), in conjunction with its life-saving benefits, carries a significant risk of acute brain injury (ABI). Hypoxic-ischemic brain injury (HIBI) is one of the most common types of ABI in ECMO patients. Various risk factors, such as history of hypertension, high day 1 lactate level, low pH, cannulation technique, large peri-cannulation PaCO2 drop (∆PaCO2), and early low pulse pressure, have been associated with the development of HIBI in ECMO patients. The pathogenic mechanisms of HIBI in ECMO are complex and multifactorial, attributing to the underlying pathology requiring initiation of ECMO and the risk of HIBI associated with ECMO itself. HIBI is likely to occur in the peri-cannulation or peri-decannulation time secondary to underlying refractory cardiopulmonary failure before or after ECMO. Current therapeutics target pathological mechanisms, cerebral hypoxia and ischemia, by employing targeted temperature management in the case of extracorporeal cardiopulmonary resuscitation (eCPR), and optimizing cerebral O2 saturations and cerebral perfusion. This review describes the pathophysiology, neuromonitoring, and therapeutic techniques to improve neurological outcomes in ECMO patients in order to prevent and minimize the morbidity of HIBI. Further studies aimed at standardizing the most relevant neuromonitoring techniques, optimizing cerebral perfusion, and minimizing the severity of HIBI once it occurs will improve long-term neurological outcomes in ECMO patients.
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Affiliation(s)
- Shivalika Khanduja
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (S.K.); (J.K.K.); (G.W.)
| | - Jiah Kim
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (J.K.); (C.-Y.F.)
| | - Jin Kook Kang
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (S.K.); (J.K.K.); (G.W.)
| | - Cheng-Yuan Feng
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (J.K.); (C.-Y.F.)
| | - Melissa Ann Vogelsong
- Department of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA;
| | - Romergryko G. Geocadin
- Divisions of Neurosciences Critical Care, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA;
| | - Glenn Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (S.K.); (J.K.K.); (G.W.)
| | - Sung-Min Cho
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (S.K.); (J.K.K.); (G.W.)
- Divisions of Neurosciences Critical Care, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA;
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Cai J, Abudou H, Chen Y, Wang H, Wang Y, Li W, Li D, Niu Y, Chen X, Liu Y, Li Y, Liu Z, Meng X, Fan H. The effects of ECMO on neurological function recovery of critical patients: A double-edged sword. Front Med (Lausanne) 2023; 10:1117214. [PMID: 37064022 PMCID: PMC10098123 DOI: 10.3389/fmed.2023.1117214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 03/16/2023] [Indexed: 04/01/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) played an important role in the treatment of patients with critical care such as cardiac arrest (CA) and acute respiratory distress syndrome. ECMO is gradually showing its advantages in terms of speed and effectiveness of circulatory support, as it provides adequate cerebral blood flow (CBF) to the patient and ensures the perfusion of organs. ECMO enhances patient survival and improves their neurological prognosis. However, ECMO-related brain complications are also important because of the high risk of death and the associated poor outcomes. We summarized the reported complications related to ECMO for patients with CA, such as north–south syndrome, hypoxic–ischemic brain injury, cerebral ischemia–reperfusion injury, impaired intracranial vascular autoregulation, embolic stroke, intracranial hemorrhage, and brain death. The exact mechanism of ECMO on the role of brain function is unclear. Here we review the pathophysiological mechanisms associated with ECMO in the protection of neurologic function in recent years, as well as the ECMO-related complications in brain and the means to improve it, to provide ideas for the treatment of brain function protection in CA patients.
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Affiliation(s)
- Jinxia Cai
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Halidan Abudou
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Yuansen Chen
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Haiwang Wang
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Yiping Wang
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Wenli Li
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Duo Li
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Yanxiang Niu
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Xin Chen
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Yanqing Liu
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Yongmao Li
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Ziquan Liu
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
- *Correspondence: Ziquan Liu,
| | - Xiangyan Meng
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
- Xiangyan Meng,
| | - Haojun Fan
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
- Haojun Fan,
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7
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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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8
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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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9
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Justice CN, Halperin HR, Vanden Hoek TL, Geocadin RG. Extracorporeal cardiopulmonary resuscitation (eCPR) and cerebral perfusion: A narrative review. Resuscitation 2023; 182:109671. [PMID: 36549433 PMCID: PMC9877198 DOI: 10.1016/j.resuscitation.2022.12.009] [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: 10/09/2022] [Revised: 12/12/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
Extracorporeal cardiopulmonary resuscitation (eCPR) is emerging as an effective, lifesaving resuscitation strategy for select patients with prolonged or refractory cardiac arrest. Currently, a paucity of evidence-based recommendations is available to guide clinical management of eCPR patients. Despite promising results from initial clinical trials, neurological injury remains a significant cause of morbidity and mortality. Neuropathology associated with utilization of an extracorporeal circuit may interact significantly with the consequences of a prolonged low-flow state that typically precedes eCPR. In this narrative review, we explore current gaps in knowledge about cerebral perfusion over the course of cardiac arrest and resuscitation with a focus on patients treated with eCPR. We found no studies which investigated regional cerebral blood flow or cerebral autoregulation in human cohorts specific to eCPR. Studies which assessed cerebral perfusion in clinical eCPR were small and limited to near-infrared spectroscopy. Furthermore, no studies prospectively or retrospectively evaluated the relationship between epinephrine and neurological outcomes in eCPR patients. In summary, the field currently lacks a comprehensive understanding of how regional cerebral perfusion and cerebral autoregulation are temporally modified by factors such as pre-eCPR low-flow duration, vasopressors, and circuit flow rate. Elucidating these critical relationships may inform future strategies aimed at improving neurological outcomes in patients treated with lifesaving eCPR.
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Affiliation(s)
- Cody N Justice
- Center for Advanced Resuscitation Medicine, Department of Emergency Medicine, Center for Cardiovascular Research, University of Illinois at Chicago, Chicago, IL USA
| | - Henry R Halperin
- Departments of Medicine, Radiology and Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Terry L Vanden Hoek
- Center for Advanced Resuscitation Medicine, Department of Emergency Medicine, Center for Cardiovascular Research, University of Illinois at Chicago, Chicago, IL USA
| | - Romergryko G Geocadin
- Departments of Neurology, Anesthesiology-Critical Care Medicine, and Neurosurgery, Johns Hopkins University, Baltimore, MD, USA.
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10
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Thomas R, Pooventhiran T, Bakht MA, Alzahrani AY, Salem MA. Study of interaction between different solvents and neurotransmitters dopamine, l-adrenaline, and l-noradrenaline using LED, QTAIM and AIMD. J Mol Liq 2022. [DOI: 10.1016/j.molliq.2022.120708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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11
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Spraider P, Martini J, Abram J, Putzer G, Ranalter M, Mathis S, Hell T, Barnes T, Enk D. Individualised flow-controlled ventilation versus pressure-controlled ventilation in a porcine model of thoracic surgery requiring one-lung ventilation: A laboratory study. Eur J Anaesthesiol 2022; 39:885-894. [PMID: 36125005 DOI: 10.1097/eja.0000000000001745] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Flow-controlled ventilation (FCV) enables precise determination of dynamic compliance due to a continuous flow coupled with direct tracheal pressure measurement. Thus, pressure settings can be adjusted accordingly in an individualised approach. OBJECTIVE The aim of this study was to compare gas exchange of individualised FCV to pressure-controlled ventilation (PCV) in a porcine model of simulated thoracic surgery requiring one-lung ventilation (OLV). DESIGN Controlled interventional trial conducted on 16 domestic pigs. SETTING Animal operating facility at the Medical University of Innsbruck. INTERVENTIONS Thoracic surgery was simulated with left-sided thoracotomy and subsequent collapse of the lung over a period of three hours. When using FCV, ventilation was performed with compliance-guided pressure settings. When using PCV, end-expiratory pressure was adapted to achieve best compliance with peak pressure adjusted to achieve a tidal volume of 6 ml kg -1 during OLV. MAIN OUTCOME MEASURES Gas exchange was assessed by the Horowitz index (= P aO 2 /FIO 2 ) and CO 2 removal by the P aCO 2 value in relation to required respiratory minute volume. RESULTS In the FCV group ( n = 8) normocapnia could be maintained throughout the OLV trial despite a significantly lower respiratory minute volume compared to the PCV group ( n = 8) (8.0 vs. 11.6, 95% confidence interval, CI -4.5 to -2.7 l min -1 ; P < 0.001), whereas permissive hypercapnia had to be accepted in PCV ( P aCO 2 5.68 vs. 6.89, 95% CI -1.7 to -0.7 kPa; P < 0.001). The Horowitz index was comparable in both groups but calculated mechanical power was significantly lower in FCV (7.5 vs. 22.0, 95% CI -17.2 to -11.8 J min -1 ; P < 0.001). CONCLUSIONS In this porcine study FCV maintained normocapnia during OLV, whereas permissive hypercapnia had to be accepted in PCV despite a substantially higher minute volume. Reducing exposure of the lungs to mechanical power applied by the ventilator in FCV offers a possible advantage for this mode of ventilation in terms of lung protection.
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Affiliation(s)
- Patrick Spraider
- From the Department of Anaesthesia and Intensive Care Medicine, Medical University Innsbruck, Austria (PS, JM, JA, GP, MR, SM), Department of Mathematics, Faculty of Mathematics, Computer Science and Physics, University of Innsbruck, Austria (TH), University of Greenwich, UK (TB), Faculty of Medicine, University of Münster, Germany (DE)
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12
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Nordström CH, Forsse A, Jakobsen RP, Mölström S, Nielsen TH, Toft P, Ungerstedt U. Bedside interpretation of cerebral energy metabolism utilizing microdialysis in neurosurgical and general intensive care. Front Neurol 2022; 13:968288. [PMID: 36034291 PMCID: PMC9399721 DOI: 10.3389/fneur.2022.968288] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/11/2022] [Indexed: 12/02/2022] Open
Abstract
The microdialysis technique was initially developed for monitoring neurotransmitters in animals. In 1995 the technique was adopted to clinical use and bedside enzymatic analysis of glucose, pyruvate, lactate, glutamate and glycerol. Under clinical conditions microdialysis has also been used for studying cytokines, protein biomarkers, multiplex proteomic and metabolomic analyses as well as for pharmacokinetic studies and evaluation of blood-brain barrier function. This review focuses on the variables directly related to cerebral energy metabolism and the possibilities and limitations of microdialysis during routine neurosurgical and general intensive care. Our knowledge of cerebral energy metabolism is to a large extent based on animal experiments performed more than 40 years ago. However, the different biochemical information obtained from various techniques should be recognized. The basic animal studies analyzed brain tissue homogenates while the microdialysis technique reflects the variables in a narrow zone of interstitial fluid surrounding the probe. Besides the difference of the volume investigated, the levels of the biochemical variables differ in different compartments. During bedside microdialysis cerebral energy metabolism is primarily reflected in measured levels of glucose, lactate and pyruvate and the lactate to pyruvate (LP) ratio. The LP ratio reflects cytoplasmatic redox-state which increases instantaneously during insufficient aerobic energy metabolism. Cerebral ischemia is characterized by a marked increase in intracerebral LP ratio at simultaneous decreases in intracerebral levels of pyruvate and glucose. Mitochondrial dysfunction is characterized by a moderate increase in LP ratio at a very marked increase in cerebral lactate and normal or elevated levels of pyruvate and glucose. The patterns are of importance in particular for interpretations in transient cerebral ischemia. A new technique for evaluating global cerebral energy metabolism by microdialysis of the draining cerebral venous blood is discussed. In experimental studies it has been shown that pronounced global cerebral ischemia is reflected in venous cerebral blood. Jugular bulb microdialysis has been investigated in patients suffering from subarachnoid hemorrhage, during cardiopulmonary bypass and resuscitation after out of hospital cardiac arrest. Preliminary results indicate that the new technique may give valuable information of cerebral energy metabolism in clinical conditions when insertion of an intracerebral catheter is contraindicated.
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Affiliation(s)
- Carl-Henrik Nordström
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
- *Correspondence: Carl-Henrik Nordström
| | - Axel Forsse
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
| | - Rasmus Peter Jakobsen
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Simon Mölström
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | | | - Palle Toft
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Urban Ungerstedt
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
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13
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Jakobsen RP, Hansen EC, Nielsen TH, Nordström CH, Toft P. Effects of norepinephrine infusion on cerebral energy metabolism during experimental haemorrhagic shock. Intensive Care Med Exp 2022; 10:4. [PMID: 35118520 PMCID: PMC8814229 DOI: 10.1186/s40635-022-00432-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 01/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The use of norepinephrine in the case of life-threatening haemorrhagic shock is well established but widely discussed. The present study was designed to compare the effects of early norepinephrine treatment vs. no treatment on cerebral energy metabolism during haemorrhagic shock. METHODS Twelve pigs were subjected to haemorrhagic shock, 4 in the control group and 8 in the norepinephrine (NE) group. Following a 60 min baseline period haemorrhagic shock was achieved by bleeding all animals to a pre-defined mean arterial blood pressure (MAP) of approximately 40 mm Hg. When mean arterial pressure had decreased to 40 mmHg NE infusion started in the treatment group. After 90 min, NE infusion stopped, and all pigs were resuscitated with autologous blood and observed for 2.5 h. During the experiment cerebral tissue oxygenation (PbtO2) was monitored continuously and variables reflecting cerebral energy metabolism (glucose, lactate, pyruvate, glutamate, glycerol) were measured by utilizing intracerebral microdialysis. RESULTS All 12 pigs completed the protocol. NE infusion resulted in significantly higher MAP (p < 0.001). During the shock period lactate/pyruvate (LP) ratio group increased from 20 (15-29) to 66 (38-82) (median (IQR)) in the control group but remained within normal limits in the NE group. The significant increase in LP ratio in the control group remained after resuscitation. After induction of shock PbtO2 decreased markedly in the control group and was significantly lower than in the NE group during the resuscitation phase. CONCLUSION NE infusion during haemorrhagic shock improved cerebral energy metabolism compared with no treatment.
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Affiliation(s)
- Rasmus Peter Jakobsen
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, J.B. Winsløws Vej 4, indgang 8, indgang 5, Penthouse/2, 20, 201, 5000, Odense C, Denmark. .,Faculty of Health Sciences, University of Southern Denmark, J.B. Winsløws Vej 19 3, 5000, Odense C, Denmark.
| | - Elisabeth Charlotte Hansen
- Faculty of Health Sciences, University of Southern Denmark, J.B. Winsløws Vej 19 3, 5000, Odense C, Denmark
| | - Troels Halfeld Nielsen
- Department of Neurosurgery, Odense University Hospital, Kløvervænget 47, indgang 44, 1. etage, 5000, Odense C, Denmark
| | - Carl-Henrik Nordström
- Department of Neurosurgery, Odense University Hospital, Kløvervænget 47, indgang 44, 1. etage, 5000, Odense C, Denmark.,Faculty of Medicine, Lund University, P.O. Box 117, 221 00, Lund, Sweden
| | - Palle Toft
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, J.B. Winsløws Vej 4, indgang 8, indgang 5, Penthouse/2, 20, 201, 5000, Odense C, Denmark.,Faculty of Health Sciences, University of Southern Denmark, J.B. Winsløws Vej 19 3, 5000, Odense C, Denmark
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14
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Putzer G, Martini J, Mair P, Helbok R. Reply to: Cerebral microdialysis after cardiac arrest - Misinterpretations based on a misconception. Resuscitation 2021; 171:71-72. [PMID: 34979162 DOI: 10.1016/j.resuscitation.2021.12.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 12/24/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Gabriel Putzer
- Department of Anaesthesiology and Critical Care Medicine, Medical University Innsbruck, Austria.
| | - Judith Martini
- Department of Anaesthesiology and Critical Care Medicine, Medical University Innsbruck, Austria
| | - Peter Mair
- Department of Anaesthesiology and Critical Care Medicine, Medical University Innsbruck, Austria
| | - Raimund Helbok
- Department of Neurology, Medical University Innsbruck, Austria
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15
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Cerebral microdialysis after cardiac arrest - Misinterpretations based on a misconception. Resuscitation 2021; 169:227-228. [PMID: 34800591 DOI: 10.1016/j.resuscitation.2021.10.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 10/07/2021] [Indexed: 11/22/2022]
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16
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Genbrugge C, Salcido DD. Is the writing on the skull? Resuscitation 2021; 169:154-155. [PMID: 34655715 DOI: 10.1016/j.resuscitation.2021.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/05/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Cornelia Genbrugge
- Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium; Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC) Université Catholique de Louvain, Belgium.
| | - David D Salcido
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
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17
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Slovis JC, Morgan RW, Kilbaugh TJ, Berg RA. Adrenaline effects on cerebral physiology during cardiac arrest: More to this story. Resuscitation 2021; 168:216-218. [PMID: 34560235 DOI: 10.1016/j.resuscitation.2021.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 09/12/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Julia C Slovis
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, United States
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, United States
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, United States
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, United States.
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