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Brede JR, Rehn M. The end of balloons? Our take on the UK-REBOA trial. Scand J Trauma Resusc Emerg Med 2023; 31:69. [PMID: 37908007 PMCID: PMC10619299 DOI: 10.1186/s13049-023-01142-5] [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: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is increasingly used. The recently published UK-REBOA trial aimed to investigate patients suffering haemorrhagic shock and randomized to standard care alone or REBOA as adjunct to standard care and concludes that REBOA may increase the mortality. MAIN BODY In this commentary we try to balance the discussion on use of REBOA and address limitations in the UK-REBOA trial that may have influenced the outcome of the study. CONCLUSION The situation is complex, and the patients are in extremis. In summary, we do not think this is the end of balloons.
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Affiliation(s)
- Jostein Rødseth Brede
- Department of Emergency Medicine and Pre-Hospital Services, St. Olav's University Hospital, Prinsesse Kristinas Gate 3, 7006, Trondheim, Norway.
- Department of Research and Development, Norwegian Air Ambulance Foundation, Oslo, Norway.
- Department of Anaesthesiology and Intensive Care Medicine, St. Olav's University Hospital, Trondheim, Norway.
| | - Marius Rehn
- Department of Research and Development, Norwegian Air Ambulance Foundation, Oslo, Norway
- Division of Prehospital Services, Air Ambulance Department, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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REBOARREST, resuscitative endovascular balloon occlusion of the aorta in non-traumatic out-of-hospital cardiac arrest: a study protocol for a randomised, parallel group, clinical multicentre trial. Trials 2021; 22:511. [PMID: 34332617 PMCID: PMC8325811 DOI: 10.1186/s13063-021-05477-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 07/20/2021] [Indexed: 11/24/2022] Open
Abstract
Background Survival after out-of-hospital cardiac arrest (OHCA) is poor and dependent on high-quality cardiopulmonary resuscitation. Resuscitative endovascular balloon occlusion of the aorta (REBOA) may be advantageous in non-traumatic OHCA due to the potential benefit of redistributing the cardiac output to organs proximal to the aortic occlusion. This theory is supported by data from both preclinical studies and human case reports. Methods This multicentre trial will enrol 200 adult patients, who will be randomised in a 1:1 ratio to either a control group that receives advanced cardiovascular life support (ACLS) or an intervention group that receives ACLS and REBOA. The primary endpoint will be the proportion of patients who achieve return of spontaneous circulation with a duration of at least 20 min. The secondary objectives of this trial are to measure the proportion of patients surviving to 30 days with good neurological status, to describe the haemodynamic physiology of aortic occlusion during ACLS, and to document adverse events. Discussion Results from this study will assess the efficacy and safety of REBOA as an adjunctive treatment for non-traumatic OHCA. This novel use of REBOA may contribute to improve treatment for this patient cohort. Trial registration The trial is approved by the Regional Committee for Medical and Health Research Ethics in Norway (reference 152504) and is registered at ClinicalTrials.gov (reference NCT04596514) and as Universal Trial Number WHO: U1111-1253-0322. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05477-1.
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Resuscitative Endovascular Balloon Occlusion of the Aorta in Experimental Cardiopulmonary Resuscitation: Aortic Occlusion Level Matters. Shock 2020; 52:67-74. [PMID: 30067564 PMCID: PMC6587222 DOI: 10.1097/shk.0000000000001236] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Introduction: Aortic occlusion during cardiopulmonary resuscitation (CPR) increases systemic arterial pressures. Correct thoracic placement during the resuscitative endovascular balloon occlusion of the aorta (REBOA) may be important for achieving effective CPR. Hypothesis: The positioning of the REBOA in the thoracic aorta during CPR will affect systemic arterial pressures. Methods: Cardiac arrest was induced in 27 anesthetized pigs. After 7 min of CPR with a mechanical compression device, REBOA in the thoracic descending aorta at heart level (zone Ib, REBOA-Ib, n = 9), at diaphragmatic level (zone Ic, REBOA-Ic, n = 9) or no occlusion (control, n = 9) was initiated. The primary outcome was systemic arterial pressures during CPR. Results: During CPR, REBOA-Ic increased systolic blood pressure from 86 mmHg (confidence interval [CI] 71–101) to 128 mmHg (CI 107–150, P < 0.001). Simultaneously, mean and diastolic blood pressures increased significantly in REBOA-Ic (P < 0.001 and P = 0.006, respectively), and were higher than in REBOA-Ib (P = 0.04 and P = 0.02, respectively) and control (P = 0.005 and P = 0.003, respectively). REBOA-Ib did not significantly affect systemic blood pressures. Arterial pH decreased more in control than in REBOA-Ib and REBOA-Ic after occlusion (P = 0.004 and P = 0.005, respectively). Arterial lactate concentrations were lower in REBOA-Ic compared with control and REBOA-Ib (P = 0.04 and P < 0.001, respectively). Conclusions: Thoracic aortic occlusion in zone Ic during CPR may be more effective in increasing systemic arterial pressures than occlusion in zone Ib. REBOA during CPR was found to be associated with a more favorable acid–base status of circulating blood. If REBOA is used as an adjunct in CPR, it may be of importance to carefully determine the aortic occlusion level. The study was performed following approval of the Regional Animal Ethics Committee in Linköping, Sweden (application ID 418).
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Dogan EM, Hörer TM, Edström M, Martell EA, Sandblom I, Marttala J, Krantz J, Axelsson B, Nilsson KF. Resuscitative endovascular balloon occlusion of the aorta in zone I versus zone III in a porcine model of non-traumatic cardiac arrest and cardiopulmonary resuscitation: A randomized study. Resuscitation 2020; 151:150-156. [DOI: 10.1016/j.resuscitation.2020.04.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 03/24/2020] [Accepted: 04/03/2020] [Indexed: 10/24/2022]
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Brede JR, Kramer-Johansen J, Rehn M. A needs assessment of resuscitative endovascular balloon occlusion of the aorta (REBOA) in non-traumatic out-of-hospital cardiac arrest in Norway. BMC Emerg Med 2020; 20:28. [PMID: 32316924 PMCID: PMC7175537 DOI: 10.1186/s12873-020-00324-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 04/13/2020] [Indexed: 11/10/2022] Open
Abstract
Introduction Out of hospital cardiac arrest (OHCA) carries an 86% mortality rate in Norway. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a potential adjunct in management of non-traumatic cardiac arrest and is feasible in pre-hospital setting without compromising standard cardiopulmonary resuscitation (CPR). However, number of patients potentially eligible for REBOA remain unknown. In preparation for a clinical trial to investigate any benefit of pre-hospital REBOA, we sought to assess the need for REBOA in Norway as an adjunct treatment in OHCA. Methods Retrospective observational cohort study of data from the Norwegian Cardiac Arrest Registry in the 3-year period 2016–2018. We identified number of patients potentially eligible for pre-hospital REBOA during CPR, defined by suspected non-traumatic origin, age 18–75 years, witnessed arrest, ambulance response time less than 15 min, treated by ambulance personnel and resuscitation effort over 30 min. Results In the 3-year period, ambulance personnel resuscitated 8339 cases. Of these, a group of 720 patients (8.6%) were eligible for REBOA. Only 18% in this group achieved return of spontaneous circulation and 7% survived for 30 days or more. Conclusion This national registry data analysis constitutes a needs assessment of REBOA in OHCA. We found that each year approximately 240 patients, or nearly 9% of ambulance treated OHCA, in Norway is potentially eligible for pre-hospital REBOA as an adjunct treatment to standard resuscitation. This needs assessment suggests that there is sufficient patient population in Norway to study REBOA as an adjunct treatment in OHCA.
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Affiliation(s)
- Jostein Rødseth Brede
- Department of Emergency Medicine and Pre-Hospital Services, St. Olav University Hospital, Trondheim, Norway. .,Norwegian Air Ambulance Foundation, Department of Research and Development, Oslo, Norway. .,Department of Anesthesiology and Intensive Care Medicine, St. Olav's University Hospital, Prinsesse Kristinas Gate 3, 7030, Trondheim, Norway. .,Department of Circulation and MedicalImaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
| | - Jo Kramer-Johansen
- Division of Prehospital Services, Air Ambulance Department, Oslo University Hospital, Oslo, Norway.,Norwegian National Advisory Unit for Prehospital Emergency Care (NAKOS), Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Marius Rehn
- Norwegian Air Ambulance Foundation, Department of Research and Development, Oslo, Norway.,Division of Prehospital Services, Air Ambulance Department, Oslo University Hospital, Oslo, Norway.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
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Brede JR, Lafrenz T, Klepstad P, Skjærseth EA, Nordseth T, Søvik E, Krüger AJ. Feasibility of Pre-Hospital Resuscitative Endovascular Balloon Occlusion of the Aorta in Non-Traumatic Out-of-Hospital Cardiac Arrest. J Am Heart Assoc 2019; 8:e014394. [PMID: 31707942 PMCID: PMC6915259 DOI: 10.1161/jaha.119.014394] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Few patients survive after out‐of‐hospital cardiac arrest and any measure that improve circulation during cardiopulmonary resuscitation is beneficial. Animal studies support that resuscitative endovascular balloon occlusion of the aorta (REBOA) during cardiopulmonary resuscitation might benefit patients suffering from out‐of‐hospital cardiac arrest, but human data are scarce. Methods and Results We performed an observational study at the helicopter emergency medical service in Trondheim (Norway) to assess the feasibility and safety of establishing REBOA in patients with out‐of‐hospital cardiac arrest. All patients received advanced cardiac life support during the procedure. End‐tidal CO2 was measured before and after REBOA placement as a proxy measure of central circulation. A safety‐monitoring program assessed if the procedure interfered with the quality of advanced cardiac life support. REBOA was initiated in 10 patients. The mean age was 63 years (range 50–74 years) and 7 patients were men. The REBOA procedure was successful in all cases, with 80% success rate on first cannulation attempt. Mean procedural time was 11.7 minutes (SD 3.2, range 8–16). Mean end‐tidal CO2 increased by 1.75 kPa after 60 seconds compared with baseline (P<0.001). Six patients achieved return of spontaneous circulation (60%), 3 patients were admitted to hospital, and 1 patient survived past 30 days. The safety‐monitoring program identified no negative influence on the advanced cardiac life support quality. Conclusions To our knowledge, this is the first study to demonstrate that REBOA is feasible during non‐traumatic out‐of‐hospital cardiac arrest. The REBOA procedure did not interfere with the quality of the advanced cardiac life support. The significant increase in end‐tidal CO2 after occlusion suggests improved organ circulation during cardiopulmonary resuscitation. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT03534011.
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Affiliation(s)
- Jostein Rødseth Brede
- Department of Emergency Medicine and Pre-Hospital Services St. Olav's University Hospital Trondheim Norway.,Department of Anesthesiology and Intensive Care Medicine St. Olav's University Hospital Trondheim Norway.,Department of Research and Development Norwegian Air Ambulance Foundation Oslo Norway
| | - Thomas Lafrenz
- Department of Thoracic Anesthesiology and Intensive Care Medicine St. Olav's University Hospital Trondheim Norway.,Medical Simulation Center St. Olav's University Hospital Trondheim Norway
| | - Pål Klepstad
- Department of Anesthesiology and Intensive Care Medicine St. Olav's University Hospital Trondheim Norway.,Department of Circulation and Medical Imaging Faculty of Medicine and Health Sciences Norwegian University of Science and Technology (NTNU) Trondheim Norway
| | - Eivinn Aardal Skjærseth
- Department of Emergency Medicine and Pre-Hospital Services St. Olav's University Hospital Trondheim Norway
| | - Trond Nordseth
- Department of Emergency Medicine and Pre-Hospital Services St. Olav's University Hospital Trondheim Norway.,Department of Circulation and Medical Imaging Faculty of Medicine and Health Sciences Norwegian University of Science and Technology (NTNU) Trondheim Norway.,Department of Anesthesiology Molde Hospital Molde Norway
| | - Edmund Søvik
- Medical Simulation Center St. Olav's University Hospital Trondheim Norway.,Department of Radiology and Nuclear Medicine St. Olav's University Hospital Trondheim Norway
| | - Andreas J Krüger
- Department of Emergency Medicine and Pre-Hospital Services St. Olav's University Hospital Trondheim Norway.,Department of Research and Development Norwegian Air Ambulance Foundation Oslo Norway.,Department of Circulation and Medical Imaging Faculty of Medicine and Health Sciences Norwegian University of Science and Technology (NTNU) Trondheim Norway
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Brede JR, Lafrenz T, Krüger AJ, Søvik E, Steffensen T, Kriesi C, Steinert M, Klepstad P. Resuscitative endovascular balloon occlusion of the aorta (REBOA) in non-traumatic out-of-hospital cardiac arrest: evaluation of an educational programme. BMJ Open 2019; 9:e027980. [PMID: 31076474 PMCID: PMC6528011 DOI: 10.1136/bmjopen-2018-027980] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Out-of-hospital cardiac arrest (OHCA) is a critical incident with a high mortality rate. Augmentation of the circulation during cardiopulmonary resuscitation (CPR) might be beneficial. Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) redistribute cardiac output to the organs proximal to the occlusion. Preclinical data support that patients in non-traumatic cardiac arrest might benefit from REBOA in the thoracic level during CPR. This study describes a training programme to implement the REBOA procedure to a prehospital working team, in preparation to a planned clinical study. METHODS We developed a team-based REBOA training programme involving the physicians and paramedics working on the National Air Ambulance helicopter base in Trondheim, Norway. The programme consists of a four-step approach to educate, train and implement the REBOA procedure in a simulated prehospital setting. An objective structured assessment of prehospital REBOA application scoring chart and a special designed simulation mannequin was made for this study. RESULTS Seven physicians and 3 paramedics participated. The time needed to perform the REBOA procedure was 8.5 (6.3-12.7) min. The corresponding time from arrival at scene to balloon inflation was 12.0 (8.8-15) min. The total objective assessment scores of the candidates' competency was 41.8 (39-43.5) points out of 48. The advanced cardiovascular life support (ACLS) remained at standard quality, regardless of the simultaneous REBOA procedure. CONCLUSION This four-step approach to educate, train and implement the REBOA procedure to a prehospital working team ensures adequate competence in a simulated OHCA setting. The use of a structured training programme and objective assessment of skills is recommended before utilising the procedure in a clinical setting. In a simulated setting, the procedure does not add significant time to the prehospital resuscitation time nor does the procedure interfere with the quality of the ACLS. TRIAL REGISTRATION NUMBER NCT03534011.
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Affiliation(s)
- Jostein Rødseth Brede
- Department of emergency medicine and pre-hospital services, St. Olavs Hospital, Trondheim, Norway
- Departmentof research and development, Norwegian Air Ambulance Foundation, Oslo, Norway
- Department of circulation and medical imaging, NTNU, Trondheim, Norway
| | - Thomas Lafrenz
- Department of thoracic anesthesiology and intensive care medicine, St. Olavs Hospital, Trondheim, Norway
| | - Andreas J Krüger
- Department of emergency medicine and pre-hospital services, St. Olavs Hospital, Trondheim, Norway
- Departmentof research and development, Norwegian Air Ambulance Foundation, Oslo, Norway
- Department of circulation and medical imaging, NTNU, Trondheim, Norway
| | - Edmund Søvik
- Department of radiology and nuclear medicine, St. Olavs Hospital, Trondheim, Norway
| | - Torjus Steffensen
- Department of mechanical and industrial engineering, NTNU, Trondheim, Norway
| | - Carlo Kriesi
- Department of mechanical and industrial engineering, NTNU, Trondheim, Norway
| | - Martin Steinert
- Department of mechanical and industrial engineering, NTNU, Trondheim, Norway
| | - Pål Klepstad
- Department of circulation and medical imaging, NTNU, Trondheim, Norway
- Department of anesthesiology and intensive care medicine, St. Olavs Hospital, Trondheim, Norway
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Daley J, Morrison JJ, Sather J, Hile L. The role of resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct to ACLS in non-traumatic cardiac arrest. Am J Emerg Med 2017; 35:731-736. [PMID: 28117180 DOI: 10.1016/j.ajem.2017.01.010] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 01/08/2017] [Accepted: 01/10/2017] [Indexed: 11/19/2022] Open
Abstract
Non-traumatic cardiac arrest is a major public health problem that carries an extremely high mortality rate. If we hope to increase the survivability of this condition, it is imperative that alternative methods of treatment are given due consideration. Balloon occlusion of the aorta can be used as a method of circulatory support in the critically ill patient. Intra-aortic balloon pumps have been used to temporize patients in cardiogenic shock for decades. More recently, resuscitative endovascular balloon occlusion of the aorta (REBOA) has been utilized in the patient in hemorrhagic shock or cardiac arrest secondary to trauma. Aortic occlusion in non-traumatic cardiac arrest has the effect of reducing the vascular volume that the generated cardiac output is distributed across. This augments myocardial and cerebral perfusion, increasing the probability of a return to a good quality of life for the patient. This phenomenon has been the subject of numerous animal studies dating back to the early 1980s; however, the human evidence is limited to several small case series. Animal research has demonstrated improvements in cerebral and coronary perfusion pressure during ACLS that lead to statistically significant differences in mortality. Several case series in humans have replicated these findings, suggesting the efficacy of this procedure. The objectives of this review are to: 1) introduce the reader to REBOA 2) review the physiology of NTCA and examine the current limitations of traditional ACLS 3) summarize the literature regarding the efficacy and feasibility of aortic balloon occlusion to support traditional ACLS.
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Affiliation(s)
- James Daley
- Yale New Haven Hospital, Department of Emergency Medicine, New Haven, CT, United States.
| | - Jonathan James Morrison
- Queen Elizabeth University Hospital, Department of Vascular Surgery, Glasgow, United Kingdom
| | - John Sather
- Yale New Haven Hospital, Department of Emergency Medicine, New Haven, CT, United States
| | - Lisa Hile
- Johns Hopkins Medicine, Department of Emergency Medicine, Baltimore, MD, United States
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Li YQ, Liao XX, Lu JH, Liu R, Hu CL, Dai G, Zhang XS, Shi XC, Li X. Assessing the early changes of cerebral glucose metabolism via dynamic (18)FDG-PET/CT during cardiac arrest. Metab Brain Dis 2015; 30:969-77. [PMID: 25703241 DOI: 10.1007/s11011-015-9658-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 02/10/2015] [Indexed: 12/31/2022]
Abstract
To study the changes of cerebral glucose metabolism (CGM) during the phase of return of spontaneous circulation (ROSC) after cardiac arrest (CA), we used 18-fluorodeoxyglucose-positron emission tomography/computed tomography ((18)FDG-PET/CT) to measure the CGM changes in six beagle canine models. After the baseline (18)FDG-PET/CT was recorded, ventricular fibrillation (VF) was induced for 6 min, followed by close-chest cardiopulmonary resuscitation (CPR) in conjunction with intravenous (IV) administration of epinephrine and external defibrillator shocks until ROSC was achieved, within 30 min. The (18)FDG was recorded prior to intravenous administration at 0 h (baseline), and at 4, 24, and 48 h after CA with ROSC. We evaluated the expression of two key control factors in canine CGM, hexokinase I (HXK I) and HXK II, by immunohistochemistry at the four above mentioned time points. Electrically induced VF of 6 min duration was successfully induced in the dogs. Resuscitation was then performed to maintain blood pressure stability. Serial (18)FDG-PET/CT scans found that the CGM decreased at 4 h after ROSC and remained lower than the baseline even at 48 h. The expression of HXK I and II levels were consistent with the changes in CGM. These data from our present work showed that (18)FDG-PET/CT imaging can be used to detect decreased CGM during CA and was consistent with the results of CMRgl. Furthermore, there were also concomitant changes in the expression of HXK I and HXK II. The decrease in CGM may be an early sign of hyperacute global cerebral ischemia.
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Affiliation(s)
- Ying-Qing Li
- Emergency Department of Guangzhou First People's Hospital, Guangzhou Medical University, Panfu Road 1, Guangzhou, People's Republic of China
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Bakhsheshi MF, Diop M, Morrison LB, St. Lawrence K, Lee TY. Coupling of cerebral blood flow and oxygen consumption during hypothermia in newborn piglets as measured by time-resolved near-infrared spectroscopy: a pilot study. NEUROPHOTONICS 2015; 2:035006. [PMID: 26835481 PMCID: PMC4718069 DOI: 10.1117/1.nph.2.3.035006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 08/18/2015] [Indexed: 06/05/2023]
Abstract
Hypothermia (HT) is a potent neuroprotective therapy that is now widely used in following neurological emergencies, such as neonatal asphyxia. An important mechanism of HT-induced neuroprotection is attributed to the associated reduction in the cerebral metabolic rate of oxygen ([Formula: see text]). Since cerebral circulation and metabolism are tightly regulated, reduction in [Formula: see text] typically results in decreased cerebral blood flow (CBF); it is only under oxidative stress, e.g., hypoxia-ischemia, that oxygen extraction fraction (OEF) deviates from its basal value, which can lead to cerebral dysfunction. As such, it is critical to measure these key physiological parameters during therapeutic HT. This report investigates a noninvasive method of measuring the coupling of [Formula: see text] and CBF under HT and different anesthetic combinations of propofol/nitrous-oxide ([Formula: see text]) that may be used in clinical practice. Both CBF and [Formula: see text] decreased with decreasing temperature, but the OEF remained unchanged, which indicates a tight coupling of flow and metabolism under different anesthetics and over the mild HT temperature range (38°C to 33°C).
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Affiliation(s)
- Mohammad Fazel Bakhsheshi
- Lawson Health Research Institute, Imaging Program, 268 Grosvenor Street, London, Ontario N6A 4V2, Canada
- Robarts Research Institute, Imaging Research Laboratories, 1151 Richmond Street North, London, Ontario N6A 5B7, Canada
| | - Mamadou Diop
- Lawson Health Research Institute, Imaging Program, 268 Grosvenor Street, London, Ontario N6A 4V2, Canada
- Western University, Department of Medical Biophysics, London, Ontario N6A 5C1, Canada
| | - Laura B. Morrison
- Lawson Health Research Institute, Imaging Program, 268 Grosvenor Street, London, Ontario N6A 4V2, Canada
| | - Keith St. Lawrence
- Lawson Health Research Institute, Imaging Program, 268 Grosvenor Street, London, Ontario N6A 4V2, Canada
- Robarts Research Institute, Imaging Research Laboratories, 1151 Richmond Street North, London, Ontario N6A 5B7, Canada
- Western University, Department of Medical Biophysics, London, Ontario N6A 5C1, Canada
| | - Ting-Yim Lee
- Lawson Health Research Institute, Imaging Program, 268 Grosvenor Street, London, Ontario N6A 4V2, Canada
- Robarts Research Institute, Imaging Research Laboratories, 1151 Richmond Street North, London, Ontario N6A 5B7, Canada
- Western University, Department of Medical Biophysics, London, Ontario N6A 5C1, Canada
- Western University, Department of Medical Imaging, London, Ontario N6A 5W9, Canada
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Effects of a single-dose hypertonic saline hydroxyethyl starch on cerebral blood flow, long-term outcome, neurogenesis, and neuronal survival after cardiac arrest and cardiopulmonary resuscitation in rats*. Crit Care Med 2012; 40:2149-56. [DOI: 10.1097/ccm.0b013e31824e6750] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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12
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Mörtberg E, Cumming P, Wiklund L, Rubertsson S. Cerebral metabolic rate of oxygen (CMRO2) in pig brain determined by PET after resuscitation from cardiac arrest. Resuscitation 2009; 80:701-6. [DOI: 10.1016/j.resuscitation.2009.03.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2008] [Revised: 02/18/2009] [Accepted: 03/05/2009] [Indexed: 11/25/2022]
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WIKLUND LARS, SHARMA HARISHANKER, BASU SAMAR. Circulatory Arrest as a Model for Studies of Global Ischemic Injury and Neuroprotection. Ann N Y Acad Sci 2008. [DOI: 10.1111/j.1749-6632.2005.tb00027.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Mörtberg E, Cumming P, Wiklund L, Wall A, Rubertsson S. A PET study of regional cerebral blood flow after experimental cardiopulmonary resuscitation. Resuscitation 2007; 75:98-104. [PMID: 17499906 DOI: 10.1016/j.resuscitation.2007.03.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2006] [Revised: 03/26/2007] [Accepted: 03/30/2007] [Indexed: 10/23/2022]
Abstract
Cerebral blood flow (CBF) during cardiopulmonary resuscitation and after restoration of spontaneous circulation (ROSC) from cardiac arrest has previously been measured with the microspheres and laser Doppler techniques. We used positron emission tomography (PET) with [15O]--water to map the haemodynamic changes after ROSC in nine young pigs. After the baseline PET recording, ventricular fibrillation of 5 min duration was induced, followed by closed-chest cardiopulmonary resuscitation (CPR) in conjunction with IV administration of three bolus doses of adrenaline (epinephrine). After CPR, external defibrillatory shocks were applied to achieve ROSC. CBF was measured at intervals during 4h after ROSC. Relative to the mean global CBF at baseline (32+/-5 ml hg(-1)min(-1)), there was a substantial global increase in CBF at 10 min, especially in the diencephalon. This was followed by an interval of cortical hypoperfusion and a subsequent gradual return to baseline values.
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Affiliation(s)
- Erik Mörtberg
- Department of Surgical Sciences-Anesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden.
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Miclescu A, Basu S, Wiklund L. Methylene blue added to a hypertonic–hyperoncotic solution increases short-term survival in experimental cardiac arrest*. Crit Care Med 2006; 34:2806-13. [PMID: 16957637 DOI: 10.1097/01.ccm.0000242517.23324.27] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Methylene blue (MB), a free-radical scavenger inhibiting the production and actions of nitric oxide, may counteract excessive vasodilatation induced by nitric oxide during cardiac arrest. Effects of MB in cardiac arrest and cardiopulmonary resuscitation were investigated. DESIGN Randomized, prospective, laboratory animal study. SETTING University animal research laboratory. SUBJECTS A total of 63 piglets of both sexes. INTERVENTIONS A pig model of extended cardiac arrest (12 mins of untreated cardiac arrest and 8 mins of cardiopulmonary resuscitation) was employed to assess the addition or no addition of MB to a hypertonic saline-dextran solution. These two groups (MB and hypertonic saline-dextran group [MB group] and hypertonic saline-dextran-only group) of 21 animals were each compared with a group receiving isotonic saline (n = 21). MEASUREMENTS AND MAIN RESULTS Although the groups were similar in baseline values, 4-hr survival in the MB group was increased (p = .02) in comparison with the isotonic saline group. Hemodynamic variables were somewhat improved at 15 mins after restoration of spontaneous circulation in the MB group compared with the other two groups. The jugular bulb levels of 8-isoprostane-prostaglandin F2alpha and 15-keto-dihydro-prostaglandin F2alpha (indicators of peroxidation and inflammation) were significantly decreased in the MB group compared with the isotonic saline group. Significant differences were recorded between the three groups in levels of protein S-100beta (indicator of neurologic injury), with lower levels in the MB group compared with the isotonic saline and hypertonic saline-dextran-only groups. Troponin I and myocardial muscle creatine kinase isoenzyme arterial concentrations (indicators of myocardial damage) were also significantly lower in the MB group. CONCLUSIONS MB co-administered with a hypertonic-hyperoncotic solution increased 4-hr survival vs. saline in an experimental porcine model of cardiac arrest and reduced oxidative, inflammatory, myocardial, and neurologic injury.
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Affiliation(s)
- Adriana Miclescu
- Department of Surgical Sciences/Anesthesiology and Intensive Care, Uppsala University Hospital, Uppsala, Sweden
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Nozari A, Safar P, Stezoski SW, Wu X, Kostelnik S, Radovsky A, Tisherman S, Kochanek PM. Critical time window for intra-arrest cooling with cold saline flush in a dog model of cardiopulmonary resuscitation. Circulation 2006; 113:2690-6. [PMID: 16769925 DOI: 10.1161/circulationaha.106.613349] [Citation(s) in RCA: 154] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Mild hypothermia improves outcome when induced after cardiac arrest in humans. Recent studies in both dogs and mice suggest that induction of mild hypothermia during cardiopulmonary resuscitation (CPR) greatly enhances its efficacy. In this study, we evaluate the time window for the beneficial effect of intra-arrest cooling in the setting of prolonged CPR in a clinically relevant large-animal model. METHODS AND RESULTS Seventeen dogs had ventricular fibrillation cardiac arrest no flow of 3 minutes, followed by 7 minutes of CPR basic life support and 50 minutes of advanced life support. In the early hypothermia group (n=9), mild hypothermia (34 degrees C) was induced with an intravenous fluid bolus flush and venovenous blood shunt cooling after 10 minutes of ventricular fibrillation. In the delayed hypothermia group (n=8), hypothermia was induced at ventricular fibrillation 20 minutes. After 60 minutes of ventricular fibrillation, restoration of spontaneous circulation was achieved with cardiopulmonary bypass for 4 hours, and intensive care was given for 96 hours. In the early hypothermia group, 7 of 9 dogs survived to 96 hours, 5 with good neurological outcome. In contrast, 7 of 8 dogs in the delayed hypothermia group died within 37 hours with multiple organ failure (P=0.012). CONCLUSIONS Early application of mild hypothermia with cold saline during prolonged CPR enables intact survival. Delay in the induction of mild hypothermia in this setting markedly reduces its efficacy. Our data suggest that if mild hypothermia is used during CPR, it should be applied as early as possible.
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Affiliation(s)
- Ala Nozari
- Department of Anesthesia and Critical Care, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114-2696.
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Nozari A, Alston TA. Tuning up the compression and applying the choke for better horsepower in resuscitation*. Crit Care Med 2006; 34:1563-4. [PMID: 16633262 DOI: 10.1097/01.ccm.0000216180.02461.a8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Krep H, Breil M, Sinn D, Hagendorff A, Hoeft A, Fischer M. Effects of hypertonic versus isotonic infusion therapy on regional cerebral blood flow after experimental cardiac arrest cardiopulmonary resuscitation in pigs. Resuscitation 2004; 63:73-83. [PMID: 15451589 DOI: 10.1016/j.resuscitation.2004.03.023] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2004] [Revised: 03/18/2004] [Accepted: 03/26/2004] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate the effects of hypertonic, isooncotic, and isotonic infusion therapy on cerebral blood flow (CBF) during and after cardiopulmonary resuscitation (CPR) from experimental cardiac arrest (CA). METHODS In 32 domestic swine (13-23 kg) open chest CPR was initiated after 8 min of ventricular fibrillation. With the onset of CPR animals randomly received 2 ml/kg per 10 min of either hypertonic saline (HS: 7.2% NaCl), hypertonic-isooncotic HES-saline (HHS: 7.2% NaCl in 6% HES 200,000/0.5), isooncotic HES (6% HES 200,000/0.5), or isotonic (normal) saline (NS: 0.9% NaCl). Haemodynamic variables were monitored continuously, and coloured microspheres were used to measure CBF quantitatively before CA, during CPR, and 20, 90 and 240 min after restoration of spontaneous circulation (ROSC). RESULTS In HES/NaCl treated animals, CBF significantly decreased during CPR compared to the prearrest level (P < 0.01, respectively; MANOVA). In contrast, CBF was sustained during CPR in HS/HHS treated animals and significantly higher compared to animals receiving NS (P < 0.05, respectively). During recirculation severe postischaemic hypoperfusion as indicated by a decrease of CBF below the prearrest level, was present only in animals receiving HES and NS. CONCLUSIONS Hypertonic solutions (HS/HHS) applied during internal cardiac massage enhanced CBF during CPR and after ROSC.
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Affiliation(s)
- Henning Krep
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Sigmund-Freud Street 25, D-53105 Bonn, Germany.
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Krep H, Böttiger BW, Bock C, Kerskens CM, Radermacher B, Fischer M, Hoehn M, Hossmann KA. Time course of circulatory and metabolic recovery of cat brain after cardiac arrest assessed by perfusion- and diffusion-weighted imaging and MR-spectroscopy. Resuscitation 2003; 58:337-48. [PMID: 12969612 DOI: 10.1016/s0300-9572(03)00151-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Brain recovery after cardiac arrest (CA) was assessed in cats using arterial spin tagging perfusion-weighted imaging (PWI), diffusion-weighted imaging (DWI), and 1H-spectroscopy (1H-MRS). Cerebral reperfusion and metabolic recovery was monitored in the cortex and in basal ganglia for 6 h after cardiopulmonary resuscitation (CPR). Furthermore, the effects of an hypertonic/hyperoncotic solution (7.5% NaCl/6% hydroxyl ethyl starch, HES) and a tissue-type plasminogen activator (TPA), applied during CPR, were assessed on brain recovery. CA and CPR were carried out in the MR scanner by remote control. CA for 15-20 min was induced by electrical fibrillation of the heart, followed by CPR using a pneumatic vest. PWI after successful CPR revealed initial cerebral hyperperfusion followed by delayed hypoperfusion. Initial cerebral recirculation was improved after osmotic treatment. Osmotic and thrombolytic therapy were ineffective in ameliorating delayed hypoperfusion. Calculation of the apparent diffusion coefficient (ADC) from DWI demonstrated complete recovery of ion and water homeostasis in all animals. 1H-MRS measurements of lactate suggested an extended preservation of post-ischaemic anaerobic metabolism after TPA treatment. The combination of noninvasive MR techniques is a powerful tool for the evaluation of therapeutical strategies on circulatory and metabolic cerebral recovery after experimental cerebral ischaemia.
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Affiliation(s)
- Henning Krep
- Department of Anesthesia and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany.
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Imberti R, Bellinzona G, Riccardi F, Pagani M, Langer M. Cerebral perfusion pressure and cerebral tissue oxygen tension in a patient during cardiopulmonary resuscitation. Intensive Care Med 2003; 29:1016-1019. [PMID: 12664224 DOI: 10.1007/s00134-003-1719-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2002] [Accepted: 02/18/2003] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To report on the effects of cardiopulmonary resuscitation (CPR) instituted immediately after a cardiac arrest on cerebral perfusion pressure (CPP) and cerebral tissue oxygen tension (PbrO(2)). DESIGN Case report. SETTING ICU of a university hospital. PATIENT A head-injured 17-year-old man submitted to multimodal neurological monitoring underwent sudden cardiac arrest and successful CPR. INTERVENTIONS External chest compression, 100% oxygen ventilation, volume expansion and standard ACLS protocols. MEASUREMENTS AND RESULTS Heart rate, ECG, mean arterial blood pressure (MABP), ETCO(2), PaO(2), intracranial pressure (ICP), CPP and PbrO(2) were continuously monitored during CPR and data recorded at 15-s intervals by a dedicated personal computer. At the onset of the cardiac arrest, PbrO(2) decreased to zero. The institution of CPR resulted in a progressive increase of MABP, CPP and PbrO(2). Assuming, on the basis of previous experimental and clinical reports, 8 mmHg PbrO(2) as a possible ischaemic/hypoxic threshold value, during the first 6.5 min of CPR, PbrO(2) values were below this threshold (range 0-7 mmHg) and CPP values were <25 mmHg for 81.5% of the time. In the following 5.5 min, more efficient CPR generated CPP values >25 mmHg for 77.3% of the time. These values were associated with a PbrO(2) >8 mmHg (range 8-28 mmHg) at all times. CONCLUSIONS In the clinical setting of a witnessed cardiac arrest, immediate institution of CPR can be effective in generating PbrO(2) values above a supposed ischaemic/hypoxic threshold when CPP is >25 mmHg. PbrO(2) monitoring by the Licox system is sensitive and reliable, even at low values, and can be suitable for evaluating cerebral oxygenation during experimental CPR.
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Affiliation(s)
- Roberto Imberti
- Servizio di Anestesia e Rianimazione II, IRCCS Policlinico S. Matteo, 27100, Pavia, Italy.
| | - Guido Bellinzona
- Servizio di Anestesia e Rianimazione II, IRCCS Policlinico S. Matteo, 27100, Pavia, Italy
| | - Francesca Riccardi
- Servizio di Anestesia e Rianimazione II, IRCCS Policlinico S. Matteo, 27100, Pavia, Italy
| | - Michele Pagani
- Servizio di Anestesia e Rianimazione II, IRCCS Policlinico S. Matteo, 27100, Pavia, Italy
| | - Martin Langer
- Servizio di Anestesia e Rianimazione II, IRCCS Policlinico S. Matteo, 27100, Pavia, Italy
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Liu XL, Nozari A, Basu S, Ronquist G, Rubertsson S, Wiklund L. Neurological outcome after experimental cardiopulmonary resuscitation: a result of delayed and potentially treatable neuronal injury? Acta Anaesthesiol Scand 2002; 46:537-46. [PMID: 12027848 DOI: 10.1034/j.1399-6576.2002.460511.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND In experimental cardiopulmonary resuscitation (CPR) aortic balloon occlusion, vasopressin, and hypertonic saline dextran administration improve cerebral blood flow. Free radical scavenger alpha-phenyl-N-tert-butyl-nitrone (PBN) and cyclosporine-A (CsA) alleviate neuronal damage after global ischemia. Combining these treatments, we investigated neurological outcome after experimental cardiac arrest. METHODS : Thirty anesthetized piglets, randomly allocated into three groups, were subjected to 8 min of ventricular fibrillation followed by 5 min of closed-chest CPR. The combined treatment (CT) group received all the above-mentioned modalities; group B was treated with balloon occlusion and epinephrine; and group C had sham balloon occlusion with epinephrine. Indicators of oxidative stress (8-iso-PGF(2 alpha)), inflammation (15-keto-dihydro-PGF(2 alpha)), energy crisis (hypoxanthine and xanthine), and anoxia/hypoxia (lactate) were monitored in jugular bulb venous blood. Neurological outcome was evaluated 24 h after CPR. RESULTS : Restoration of spontaneous circulation (ROSC) was more rapidly achieved and neurological outcome was significantly better in the CT group, although there was no difference in coronary perfusion pressure between groups. The jugular venous PCO2 and cerebral oxygen extraction ratio were lower in the CT group at 5-15 min after ROSC. Jugular venous 8-iso-PGF(2 alpha) and hypoxanthine after ROSC were correlated to 24 h neurological outcome CONCLUSIONS : A combination of cerebral blood flow promoting measures and administration of alpha-phenyl-N-tert-butyl-nitrone and cyclosporine-A improved 24 h neurological outcome after 8 min of experimental normothermic cardiac arrest, indicating an ongoing neuronal injury in the reperfusion phase.
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Affiliation(s)
- X L Liu
- Department of Surgical Sciences/Anaesthesiology and Intensive Care, Uppsala University Hospital, Uppsala, Sweden.
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Nozari A, Rubertsson S, Wiklund L. Improved cerebral blood supply and oxygenation by aortic balloon occlusion combined with intra-aortic vasopressin administration during experimental cardiopulmonary resuscitation. Acta Anaesthesiol Scand 2000; 44:1209-19. [PMID: 11065200 DOI: 10.1034/j.1399-6576.2000.441005.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Intravenous administration of vasopressin during cardiopulmonary resuscitation (CPR) has been shown to improve myocardial and cerebral blood flow. Aortic balloon occlusion during CPR may also augment myocardial and cerebral blood flow and can be used as a central route for the administration of resuscitative drugs. We hypothesized that, as compared with intravenously administered vasopressin, the administration of this drug above the site of an aortic balloon occlusion would result in a greater increase in cerebral perfusion and oxygenation during CPR and after restoration of spontaneous circulation (ROSC). METHODS Twenty piglets were subjected to 5 min of ventricular fibrillation followed by 8 min of closed-chest CPR and were treated with 0.4 U kg(-1) boluses of vasopressin intravenously (the IV-vasopressin group with sham aortic balloon) or above the site for an aortic balloon occlusion (the balloon-vasopressin group). The aortic balloon catheter was inflated in the latter group 1 min after commencement of CPR and was deflated within 1 min after ROSC. Systemic blood pressures, cerebral cortical blood flow, cerebral tissue pH and PCO2 were monitored continuously and the cerebral oxygen extraction ratio was calculated. RESULTS During CPR, arterial blood pressure and cerebral perfusion pressure were greater in the balloon-vasopressin group, as compared with the IV-vasopressin group. These pressures did not differ between the groups after ROSC. Cerebral cortical blood flow was not significantly greater in the balloon-vasopressin group during CPR, whereas significantly higher cortical blood flow levels were recorded after ROSC. Cerebral tissue pH decreased in the IV-vasopressin group during the post-resuscitation hypoperfusion period. In contrast, decreasing pressures during the hypoperfusion period did not result in increasing tissue acidosis in the balloon-vasopressin group. CONCLUSIONS During CPR, intra-aortic vasopressin combined with aortic balloon occlusion resulted in significantly greater perfusion pressures but not in greater cerebral cortical blood flow. After ROSC, however, a greater increase in cortical blood flow was recorded in the balloon-vasopressin group, even though the aortic balloon was deflated and perfusion pressures did not differ between the groups. This suggests that vasopressin predominantly gives vasoconstrictive effects on cerebral cortical vessels during CPR, but results in cerebral cortical vasodilatation after ROSC.
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Affiliation(s)
- A Nozari
- Department of Anesthesiology and Intensive Care, Uppsala University Hospital, Sweden.
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Basu S, Nozari A, Liu XL, Rubertsson S, Wiklund L. Development of a novel biomarker of free radical damage in reperfusion injury after cardiac arrest. FEBS Lett 2000; 470:1-6. [PMID: 10722834 DOI: 10.1016/s0014-5793(00)01279-5] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In a porcine model of cardiopulmonary resuscitation (CPR), we investigated changes in the plasma levels of 8-iso-PGF(2alpha), a marker for oxidative injury, and 15-keto-dihydro-PGF(2alpha), an inflammatory response indicator during the post-resuscitation period after cardiac arrest. Twelve piglets were subjected to either 2 or 5 min (VF2 and VF5 group) of ventricular fibrillation (VF) followed by 5 min of closed-chest CPR. Six piglets without cardiac arrest were used as controls. In VF5 group, 8-iso-PGF(2alpha) in the jugular bulb plasma (draining the brain) increased four-fold. Jugular bulb 8-iso-PGF(2alpha) in the control group remained unchanged. The 15-keto-dihydro-PGF(2alpha) also increased four-fold in the VF5 group. Thus, 8-iso-PGF(2alpha) and 15-keto-dihydro-PGF(2alpha) measurements in jugular bulb plasma may be used as biomarkers for quantification of free radical catalyzed oxidative brain injury and inflammatory response in reperfusion injury.
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Affiliation(s)
- S Basu
- Department of Geriatrics, Faculty of Medicine, Uppsala University, P. O. Box 609, SE-751 25, Uppsala, Sweden.
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