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Ferrada P, Cannon JW, Kozar RA, Bulger EM, Sugrue M, Napolitano LM, Tisherman SA, Coopersmith CM, Efron PA, Dries DJ, Dunn TB, Kaplan LJ. Surgical Science and the Evolution of Critical Care Medicine. Crit Care Med 2023; 51:182-211. [PMID: 36661448 DOI: 10.1097/ccm.0000000000005708] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Surgical science has driven innovation and inquiry across adult and pediatric disciplines that provide critical care regardless of location. Surgically originated but broadly applicable knowledge has been globally shared within the pages Critical Care Medicine over the last 50 years.
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Affiliation(s)
- Paula Ferrada
- Division of Trauma and Acute Care Surgery, Department of Surgery, Inova Fairfax Hospital, Falls Church, VA
| | - Jeremy W Cannon
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rosemary A Kozar
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Eileen M Bulger
- Division of Trauma, Burn and Critical Care Surgery, Department of Surgery, University of Washington at Seattle, Harborview, Seattle, WA
| | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital, County of Donegal, Ireland
| | - Lena M Napolitano
- Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Samuel A Tisherman
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Craig M Coopersmith
- Division of General Surgery, Department of Surgery, Emory University, Emory Critical Care Center, Atlanta, GA
| | - Phil A Efron
- Department of Surgery, Division of Critical Care, University of Florida, Gainesville, FL
| | - David J Dries
- Department of Surgery, University of Minnesota, Regions Healthcare, St. Paul, MN
| | - Ty B Dunn
- Division of Transplant Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lewis J Kaplan
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Corporal Michael J. Crescenz VA Medical Center, Section of Surgical Critical Care, Surgical Services, Philadelphia, PA
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Tisherman SA. Emergency preservation and resuscitation for cardiac arrest from trauma. Ann N Y Acad Sci 2021; 1509:5-11. [PMID: 34859446 DOI: 10.1111/nyas.14725] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/19/2021] [Accepted: 10/22/2021] [Indexed: 01/01/2023]
Abstract
Patients who suffer a cardiac arrest from trauma rarely survive. Surgical control of hemorrhage cannot be obtained in time to prevent irreversible organ damage. Emergency preservation and resuscitation (EPR) was developed to utilize hypothermia to buy time to achieve hemostasis and allow delayed resuscitation. Large animal studies have demonstrated that cooling to tympanic membrane temperature 10 °C during exsanguination cardiac arrest can allow up to 2 h of circulatory arrest and repair of simulated injuries with normal neurologic recovery. The Emergency Preservation and Resuscitation for Cardiac Arrest from Trauma (EPR-CAT) trial is testing the feasibility and safety of initiating EPR. Study subjects include patients with penetrating trauma who lose a pulse within 5 minutes of hospital arrival and remain pulseless despite standard care. EPR is initiated via an intra-aortic flush of ice-cold saline solution. Following hemostasis, delayed resuscitation and rewarming are accomplished with cardiopulmonary bypass. The primary outcome is survival to hospital discharge without significant neurologic deficits. If trained team members are available, subjects can undergo EPR. If not, subjects can be enrolled as concurrent controls. Ten EPR and 10 control subjects will be enrolled. If successful, EPR could save the lives of trauma patients who are currently dying from exsanguinating hemorrhage.
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Affiliation(s)
- Samuel A Tisherman
- Department of Surgery and the Program in Trauma, University of Maryland School of Medicine, RA Cowley Shock Trauma Center, Baltimore, Maryland
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Liu C, Yuan D, Crawford R, Sarkar R, Hu B. Directly Cooling Gut Prevents Mortality in the Rat Model of Reboa Management of Lethal Hemorrhage. Shock 2021; 56:813-823. [PMID: 33555843 PMCID: PMC8329109 DOI: 10.1097/shk.0000000000001744] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a lifesaving technique for the management of lethal torso hemorrhage. Its benefit, however, must be weighed against the lethal distal organ ischemia-reperfusion injury (IRI). This study uses a novel direct gut cooling technique to manage the distal organ IRI. METHODS A rat lethal hemorrhage model was established by bleeding of 50% of the estimated total blood volume via inferior vena cava. A novel TransRectal Intra-Colon (TRIC) temperature management device was positioned in the descending colon either to maintain intra-colon temperature at 37°C or 12°C. The upper body temperature was maintained at as close to 37°C as possible in both groups. A 2F Fogarty balloon catheter was inserted via the femoral artery into the descending thoracic aorta for the implementation of REBOA. After REBOA, the balloon was deflated, and the shed blood was returned. The temperature managements were continued for additional 180 to 270 min during the post-REBOA period. RESULTS All rats subjected to REBOA management of lethal hemorrhage at 37°C had severe histopathological gut and abdominal organ IRI, severe functional deficits, and died within 24 h with 100% mortality. By contrast, directly cooling the colon to 10°C to 12°C with the novel TRIC device abolished mortality, and dramatically improved ABG parameters, prevented the abdominal organ injury, and reduced the functional deficits during the 7-day post-REBOA period. CONCLUSIONS Direct trans-rectal colon cooling during REBOA management of lethal hemorrhage offers extraordinary functional improvement and amazing tissue protection, and abolishes mortality.
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Affiliation(s)
- Chunli Liu
- Veterans Affairs Maryland Health Center System,10 North Greene Street, Baltimore, MD 21201
| | - Dong Yuan
- Departments of Anesthesiology and Surgery, Shock Trauma and Anesthesiology Research Center University of Maryland School of Medicine, Baltimore, MD
| | - Robert Crawford
- Departments of Anesthesiology and Surgery, Shock Trauma and Anesthesiology Research Center University of Maryland School of Medicine, Baltimore, MD
| | - Rajabrata Sarkar
- Departments of Anesthesiology and Surgery, Shock Trauma and Anesthesiology Research Center University of Maryland School of Medicine, Baltimore, MD
| | - Bingren Hu
- Departments of Anesthesiology and Surgery, Shock Trauma and Anesthesiology Research Center University of Maryland School of Medicine, Baltimore, MD
- Veterans Affairs Maryland Health Center System,10 North Greene Street, Baltimore, MD 21201
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Dalton HJ, Berg RA, Nadkarni VM, Kochanek PM, Tisherman SA, Thiagarajan R, Alexander P, Bartlett RH. Cardiopulmonary Resuscitation and Rescue Therapies. Crit Care Med 2021; 49:1375-1388. [PMID: 34259654 DOI: 10.1097/ccm.0000000000005106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The history of cardiopulmonary resuscitation and the Society of Critical Care Medicine have much in common, as many of the founders of the Society of Critical Care Medicine focused on understanding and improving outcomes from cardiac arrest. We review the history, the current, and future state of cardiopulmonary resuscitation.
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Affiliation(s)
- Heidi J Dalton
- Heart and Vascular Institute and Department of Pediatrics, INOVA Fairfax Medical Center, Falls Church, VA. Department of Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA. Department of Anesthesiology/Critical Care Medicine, Peter Safer Resuscitation Center, Pittsburgh, PA. Department of Surgery, R Adams Cowley Shock Trauma Center, Baltimore, MD. Department of Cardiology, Division of Cardiovascular Critical Care, Boston Children's Hospital, Boston, MA. Department of Surgery, University of Michigan, Ann Arbor, MI
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Arya AK, Hu K, Subedi L, Li T, Hu B. Focal intra-colon cooling reduces organ injury and systemic inflammation after REBOA management of lethal hemorrhage in rats. Sci Rep 2021; 11:13696. [PMID: 34211011 PMCID: PMC8249469 DOI: 10.1038/s41598-021-93064-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 06/14/2021] [Indexed: 12/04/2022] Open
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a lifesaving maneuver for the management of lethal torso hemorrhage. However, its prolonged use leads to distal organ ischemia-reperfusion injury (IRI) and systemic inflammatory response syndrome (SIRS). The objective of this study is to investigate the blood-based biomarkers of IRI and SIRS and the efficacy of direct intestinal cooling in the prevention of IRI and SIRS. A rat lethal hemorrhage model was produced by bleeding 50% of the total blood volume. A balloon catheter was inserted into the aorta for the implementation of REBOA. A novel TransRectal Intra-Colon (TRIC) device was placed in the descending colon and activated from 10 min after the bleeding to maintain the intra-colon temperature at 37 °C (TRIC37°C group) or 12 °C (TRIC12°C group) for 270 min. The upper body temperature was maintained at as close to 37 °C as possible in both groups. Blood samples were collected before hemorrhage and after REBOA. The organ injury biomarkers and inflammatory cytokines were evaluated by ELISA method. Blood based organ injury biomarkers (endotoxin, creatinine, AST, FABP1/L-FABP, cardiac troponin I, and FABP2/I-FABP) were all drastically increased in TRIC37°C group after REBOA. TRIC12°C significantly downregulated these increased organ injury biomarkers. Plasma levels of pro-inflammatory cytokines TNF-α, IL-1b, and IL-17F were also drastically increased in TRIC37°C group after REBOA. TRIC12°C significantly downregulated the pro-inflammatory cytokines. In contrast, TRIC12°C significantly upregulated the levels of anti-inflammatory cytokines IL-4 and IL-10 after REBOA. Amazingly, the mortality rate was 100% in TRIC37°C group whereas 0% in TRIC12°C group after REBOA. Directly cooling the intestine offered exceptional protection of the abdominal organs from IRI and SIRS, switched from a harmful pro-inflammatory to a reparative anti-inflammatory response, and mitigated mortality in the rat model of REBOA management of lethal hemorrhage.
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Affiliation(s)
- Awadhesh K Arya
- Departments of Anesthesiology, Shock, Trauma and Anesthesiology Research Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kurt Hu
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Lalita Subedi
- Departments of Anesthesiology, Shock, Trauma and Anesthesiology Research Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Tieluo Li
- Departments of Anesthesiology, Shock, Trauma and Anesthesiology Research Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bingren Hu
- Departments of Anesthesiology, Shock, Trauma and Anesthesiology Research Center, University of Maryland School of Medicine, Baltimore, MD, USA.
- Veterans Affairs Maryland Health Center System, 10 North Greene Street, Baltimore, MD, USA.
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Abstract
ABSTRACT The emerging concept of endovascular resuscitation applies catheter-based techniques in the management of patients in shock to manipulate physiology, optimize hemodynamics, and bridge to definitive care. These interventions hope to address an unmet need in the care of severely injured patients, or those with refractory non-traumatic cardiac arrest, who were previously deemed non-survivable. These evolving techniques include Resuscitative Endovascular Balloon Occlusion of Aorta, Selective Aortic Arch Perfusion, and Extracorporeal Membrane Oxygenation and there is a growing literature base behind them. This review presents the up-to-date techniques and interventions, along with their application, evidence base, and controversy within the new era of endovascular resuscitation.
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Affiliation(s)
- Marta J Madurska
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - James D Ross
- Division of Trauma and Acute Care Surgery, Oregon Health and Science University, Portland, Oregon
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - Jonathan J Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
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Sultan S, Acharya Y, Barrett N, Hynes N. A pilot protocol and review of triple neuroprotection with targeted hypothermia, controlled induced hypertension, and barbiturate infusion during emergency carotid endarterectomy for acute stroke after failed tPA or beyond 24-hour window of opportunity. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1275. [PMID: 33178807 PMCID: PMC7607101 DOI: 10.21037/atm-2020-cass-14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
An alternative to tissue plasminogen activator (tPA) failure has been a daunting challenge in ischemic stroke management. As tPA is time-dependent, delays can occur in definitive treatment while passively waiting to observe a clinical response to intravenous thrombolysis. Until today, uncertainty exists in the management strategy of wake-up stroke patients or those presenting beyond the therapeutic tPA window. Clinical dilemmas in these situations can prolong the transitional period of inertia, resulting in an adverse neurological outcome. We propose and review an innovative approach called triple neuro-protection (TNP), which encompasses three technical domains-targeted hypothermia, systemic induced hypertension, and barbiturates infusion, to protect the brain during carotid endarterectomy after failed tPA and/or beyond the 24-hour therapeutic mechanical thrombectomy window. This proposal assimilates discussion on the clinical evidence of the individual domains of TNP with our own clinical experience with TNP. Our first TNP was successfully employed in a 55-year-old man in 2015 while performing emergency carotid endarterectomy after he was referred to us 72 hours post tPA failure. The patient had a successful clinical outcome despite being in therapeutic inertia with 90–99% ipsilateral carotid stenosis and contralateral occlusion on presentation. In the last five years, we have safely used TNP in 25 selected cases with favourable clinical outcomes.
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Affiliation(s)
- Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland.,Department of Vascular & Endovascular Surgery, Galway Clinic, Royal College of Surgeons of Ireland/National University of Ireland Affiliated Teaching Hospitals, Doughiska, Galway, Ireland
| | - Yogesh Acharya
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Nora Barrett
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Niamh Hynes
- Department of Vascular & Endovascular Surgery, Galway Clinic, Royal College of Surgeons of Ireland/National University of Ireland Affiliated Teaching Hospitals, Doughiska, Galway, Ireland
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Abstract
Hemorrhagic shock is the leading cause of preventable death after trauma. Hibernation-based treatment approaches have been of increasing interest for various biomedical applications. Owing to apparent similarities in tissue perfusion and metabolic activity between severe blood loss and the hibernating state, hibernation-based approaches have also emerged for the treatment of hemorrhagic shock. Research has shown that hibernators are protected from shock-induced injury and inflammation. Utilizing the adaptive mechanisms that prevent injury in these animals may help alleviate the detrimental effects of hemorrhagic shock in non-hibernating species. This review describes hibernation-based preclinical and clinical approaches for the treatment of severe blood loss. Treatments include the delta opioid receptor agonist D-Ala-Leu-enkephalin (DADLE), the gasotransmitter hydrogen sulfide, combinations of adenosine, lidocaine, and magnesium (ALM) or D-beta-hydroxybutyrate and melatonin (BHB/M), and therapeutic hypothermia. While we focus on hemorrhagic shock, many of the described treatments may be used in other situations of hypoxia or ischemia/reperfusion injury.
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Shiyam Sundar LK, Muzik O, Rischka L, Hahn A, Lanzenberger R, Hienert M, Klebermass EM, Bauer M, Rausch I, Pataraia E, Traub-Weidinger T, Beyer T. Promise of Fully Integrated PET/MRI: Noninvasive Clinical Quantification of Cerebral Glucose Metabolism. J Nucl Med 2019; 61:276-284. [PMID: 31375567 PMCID: PMC8801961 DOI: 10.2967/jnumed.119.229567] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 07/15/2019] [Indexed: 01/21/2023] Open
Abstract
We describe a fully automated processing pipeline to support the noninvasive absolute quantification of the cerebral metabolic rate for glucose (CMRGlc) in a clinical setting. This pipeline takes advantage of “anatometabolic” information associated with fully integrated PET/MRI. Methods: Ten healthy volunteers (5 men and /5 women; 27 ± 7 y old; 70 ± 10 kg) underwent a test-retest 18F-FDG PET/MRI examination of the brain. The imaging protocol consisted of a 60-min PET list-mode acquisition with parallel MRI acquisitions, including 3-dimensional time-of-flight MR angiography, MRI navigators, and a T1-weighted MRI scan. State-of-the-art MRI-based attenuation correction was derived from T1-weighted MRI (pseudo-CT [pCT]). For validation purposes, a low-dose CT scan was also performed. Arterial blood samples were collected as the reference standard (arterial input function [AIF]). The developed pipeline allows the derivation of an image-derived input function (IDIF), which is subsequently used to create CMRGlc maps by means of a Patlak analysis. The pipeline also includes motion correction using the MRI navigator sequence as well as a novel partial-volume correction that accounts for background heterogeneity. Finally, CMRGlc maps are used to generate a normative database to facilitate the detection of metabolic abnormalities in future patient scans. To assess the performance of the developed pipeline, IDIFs extracted by both CT-based attenuation correction (CT-IDIF) and MRI-based attenuation correction (pCT-IDIF) were compared with the reference standard (AIF) using the absolute percentage difference between the areas under the curves as well as the absolute percentage difference in regional CMRGlc values. Results: The absolute percentage differences between the areas under the curves for CT-IDIF and pCT-IDIF were determined to be 1.4% ± 1.0% and 3.4% ± 2.6%, respectively. The absolute percentage difference in regional CMRGlc values based on CT-IDIF and pCT-IDIF differed by less than 6% from the reference values obtained from the AIF. Conclusion: By taking advantage of the capabilities of fully integrated PET/MRI, we developed a fully automated computational pipeline that allows the noninvasive determination of regional CMRGlc values in a clinical setting. This methodology might facilitate the proliferation of fully quantitative imaging into the clinical arena and, as a result, might contribute to improved diagnostic efficacy.
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Affiliation(s)
- Lalith Kumar Shiyam Sundar
- QIMP Team, Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Otto Muzik
- Department of Pediatrics, Children's Hospital of Michigan, The Detroit Medical Center, Wayne State University School of Medicine, Detroit, Michigan
| | - Lucas Rischka
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Andreas Hahn
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Rupert Lanzenberger
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Marius Hienert
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Eva-Maria Klebermass
- Department of Clinical Pharmacology, Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria; and
| | - Martin Bauer
- Department of Clinical Pharmacology, Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria; and
| | - Ivo Rausch
- QIMP Team, Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | | | - Tatjana Traub-Weidinger
- Department of Clinical Pharmacology, Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria; and
| | - Thomas Beyer
- QIMP Team, Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
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Development of the emergency preservation and resuscitation for cardiac arrest from trauma clinical trial. J Trauma Acute Care Surg 2017; 83:803-809. [PMID: 28538639 DOI: 10.1097/ta.0000000000001585] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients who suffer a cardiac arrest from trauma rarely survive, even with aggressive resuscitation attempts, including an emergency department thoracotomy. Emergency Preservation and Resuscitation (EPR) was developed to utilize hypothermia to buy time to obtain hemostasis before irreversible organ damage occurs. Large animal studies have demonstrated that cooling to tympanic membrane temperature 10°C during exsanguination cardiac arrest can allow up to 2 hours of circulatory arrest and repair of simulated injuries with normal neurologic recovery. STUDY DESIGN The Emergency Preservation and Resuscitation for Cardiac Arrest from Trauma trial has been developed to test the feasibility and safety of initiating EPR. Select surgeons will be trained in the EPR technique. If a trained surgeon is available, the subject will undergo EPR. If not, the subject will be followed as a control subject. For this feasibility study, 10 EPR and 10 control subjects will be enrolled. STUDY PARTICIPANTS Study participants will be those with penetrating trauma who remain pulseless despite an emergency department thoracotomy. INTERVENTIONS Emergency Preservation and Resuscitation will be initiated via an intra-aortic flush of a large volume of ice-cold saline solution. Following surgical hemostasis, delayed resuscitation will be accomplished with cardiopulmonary bypass. OUTCOME MEASURES The primary outcome will be survival to hospital discharge without significant neurologic deficits. Secondary outcomes include long-term survival and functional outcome. IMPLICATIONS Once data from these 20 subjects are reviewed, revisions to the inclusion criteria and/or the EPR technique may then be tested in a second set of EPR and control subjects.
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Weiser C, Weihs W, Holzer M, Testori C, Kramer AM, Kment C, Stoiber M, Poppe M, Wallmüller C, Stratil P, Hoschitz M, Laggner A, Sterz F. Feasibility of profound hypothermia as part of extracorporeal life support in a pig model. J Thorac Cardiovasc Surg 2017; 154:867-874. [DOI: 10.1016/j.jtcvs.2017.03.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 02/02/2017] [Accepted: 03/04/2017] [Indexed: 10/19/2022]
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Moffatt SE, Mitchell SJB, Walke JL. Deep and profound hypothermia in haemorrhagic shock, friend or foe? A systematic review. J ROY ARMY MED CORPS 2017; 164:191-196. [PMID: 28495952 DOI: 10.1136/jramc-2016-000723] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 03/28/2017] [Accepted: 03/29/2017] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Survival in exsanguinating cardiac arrest patients is poor, as is neurological outcome in survivors. Hypothermia has traditionally been seen as harmful to trauma patients and associated with increased mortality; however, there has been speculation that cooling to very low temperatures (≤20°C) could be used to treat haemorrhagic trauma patients by the induction of a suspended animation period through extreme cooling, which improves survival and preserves neurological function. This has been termed emergency preservation and resuscitation (EPR). METHODS A systematic review of the literature was used to examine the evidence base behind the use of deep and profound hypothermia in haemorrhagic shock (HS). It included original research articles (human or animal) with cooling to ≤20°C after HS or an experimental model replicating it. Normovolaemic cardiac arrest, central nervous system injury and non-HS models were excluded. RESULTS Twenty articles using 456 animal subjects were included, in which 327 were cooled to ≤20°C. All studies describing good survival rates were possible using EPR and 19/20 demonstrated that EPR can preserve neurological function after prolonged periods of circulatory arrest or minimal circulatory flow. This additional period can be used for surgical intervention to arrest haemorrhage in HS that would otherwise be lethal. CONCLUSIONS The outcomes of this review have significant implications for application to human patients and the ongoing human clinical trial (EPR for Cardiac Arrest from Trauma). Current evidence suggests that hypothermia ≤20°C used in the form of EPR could be beneficial to the HS patient.
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Affiliation(s)
- Samuel E Moffatt
- University of Leicester Medical School, Centre for Medicine, Leicester, UK
| | - S J B Mitchell
- University of Leicester Medical School, Centre for Medicine, Leicester, UK
| | - J L Walke
- University of Leicester Medical School, Centre for Medicine, Leicester, UK
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Liu Y, Li S, Li Z, Zhang J, Han JS, Zhang Y, Yin ZT, Wang HS. A safety evaluation of profound hypothermia-induced suspended animation for delayed resuscitation at 90 or 120 min. Mil Med Res 2017; 4:16. [PMID: 28573043 PMCID: PMC5450360 DOI: 10.1186/s40779-017-0127-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 05/23/2017] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The successful treatment of military combat casualties with penetrating injuries is significantly dependent on the time needed to get the patient to an adequate treatment facility. Profound hypothermia-induced suspended animation for delayed resuscitation (SADR) is a novel approach for inducing cardiac arrest and buying additional time for such injuries. However, the time used to safely administer circulatory arrest (CA) is controversial. The goal of this study was to evaluate the safety of hypothermia-induced SADR over 90 and 120 min time intervals. METHODS Sixteen male BAMA minipigs were randomized into two groups: CA90 group (90 min, n = 8) and CA120 group (120 min, n = 8). Cannulation of the right common carotid arteries and internal jugular veins was performed to establish cardiopulmonary bypass for each animal. Through the perfusion of cold organ preservation solution (OPS), cardioplegia and profound hypothermia (15 °C) were induced. After CA, cardiopumonary bypass (CPB) was restarted, and the animals were gradually re-warmed and resuscitated. The animals were assisted with ventilators until spontaneous breathing was achieved. The index of hemodynamic perioperative serum chemistry values [alanine transaminase (ALT), aspartate aminotransferase (AST), creatinine (CR), lactic dehydrogenase (LDH) and troponin T (TnT)] and survival were observed from pre-operation to 7 days post-operation. RESULTS Fifteen animals were enrolled in the experiment, while 1 animal in CA120 group died from surgical error. All 8 animals in CA90 group recovered, with only 1 animal displaying mild disability. However, in CA120 group, only 2 animals survived with severe disability, and the other 5 animals died after 2 days post-operation. In CA90 group, the perioperative serum chemistry values increased at 1 day post-operation (ALT 84.43 ± 18.65 U/L; AST 88.99 ± 23.19 U/L; Cr 87.90 ± 24.49 μmol/L; LDH 1894.13 ± 322.26 U/L; TnT 0.849 ± 0.135 ng/ml) but decreased to normal or almost normal levels at 7 days post-operation (ALT 52.48 ± 9.04 U/L; AST 75.23 ± 21.46 U/L; Cr 82.69 ± 18.41 μmol/L; LDH 944.67 ± 834.32 U/L; TnT 0.336 ± 0.076 ng/ml). CONCLUSIONS Profound hypothermia-induced SADR is an effective method for inducing cardiac arrest. Our results indicate that inducing CA for 90 min (at 15 °C) is safer than doing so for 120 min. Our results indicate that 120 min of CA at 15 °C is dangerous and can result in high mortality and severe neurological complications. Further experimentation is needed to determine whether 120 min of CA at temperatures lower than 15 °C can lead to safe recovery.
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Affiliation(s)
- Yu Liu
- Department of Cardiovascular Surgery, General Hospital of Shenyang Military Command, Shenyang, 110016 China
| | - Shu Li
- Department of Forensic Medicine, National Police University of China, Liaoning, 110035 China
| | - Zhi Li
- Department of Cardiovascular Surgery, General Hospital of Shenyang Military Command, Shenyang, 110016 China
| | - Jian Zhang
- Department of Cardiovascular Surgery, General Hospital of Shenyang Military Command, Shenyang, 110016 China
| | - Jin-Song Han
- Department of Cardiovascular Surgery, General Hospital of Shenyang Military Command, Shenyang, 110016 China
| | - Yong Zhang
- Department of Cardiovascular Surgery, General Hospital of Shenyang Military Command, Shenyang, 110016 China
| | - Zong-Tao Yin
- Department of Cardiovascular Surgery, General Hospital of Shenyang Military Command, Shenyang, 110016 China
| | - Hui-Shan Wang
- Department of Cardiovascular Surgery, General Hospital of Shenyang Military Command, Shenyang, 110016 China
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Kutcher ME, Forsythe RM, Tisherman SA. Emergency preservation and resuscitation for cardiac arrest from trauma. Int J Surg 2015; 33:209-212. [PMID: 26497780 DOI: 10.1016/j.ijsu.2015.10.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 10/12/2015] [Indexed: 11/19/2022]
Abstract
The advent of cardiopulmonary resuscitation (CPR) revolutionized the care of patients with cardiac arrest, now allowing survival of up to 30% after out-of-hospital arrest due to arrhythmia; however, outcomes for cardiac arrest after trauma remain dismal, with less than 10% survival despite the most aggressive modern resuscitation techniques. The short time interval between cardiac arrest and brain ischemia, the reduced efficacy of CPR in the patient with profound hypovolemia due to hemorrhage, and the speed of exsanguination from major vascular injury all conspire to limit the effectiveness of standard CPR in the critically injured patient. Beginning in the 1980s, researchers began to harness the effects of profound hypothermia in order to extend the window of survivability after traumatic arrest, allowing the critical time needed to obtain surgical hemostasis in otherwise lethal exsanguinating injuries. These studies have culminated in the emergency preservation and resuscitation (EPR) of the trauma patient. Rapid central arterial access is obtained and profound (<10 °C) hypothermia induced with aortic infusion of cold saline. During this window of up to 1 h, damage control surgical techniques are applied to control hemorrhage and repair injuries, followed by controlled rewarming and reperfusion using cardiopulmonary bypass. In this review, we trace these techniques from their early theoretical development, through refinement in clinically relevant animal models, and into their present application in a currently-enrolling human clinical trial of EPR for cardiac arrest from trauma (EPR-CAT), as well as examine current topics, ongoing challenges, and future directions for emergency preservation and resuscitation research.
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Affiliation(s)
- Matthew E Kutcher
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Raquel M Forsythe
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Samuel A Tisherman
- Department of Surgery, RA Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
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Wordsworth M, McGuire C, Khan M. Cryoamputation: An old surgical technique to be kept on ice? TRAUMA-ENGLAND 2015. [DOI: 10.1177/1460408614557858] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Cryoamputation is a little known method of delaying a surgical amputation by rapid freezing of the affected limb to prevent further derangement of systemic physiology – hence its historical name of ‘physiologic amputation’. Rapid cryoamputation allows for a period of optimisation before surgical amputation in unstable patients. There is limited published literature on the technique and a systematic review was undertaken to identify the techniques, potential indications, complications and potential relevance to current practice and related novel developments. A literature review produced 15 relevant papers that were reviewed; all were either case reports or case series. Cryoamputation can be a lifesaving procedure in a cohort of patients at a high risk of mortality. It is a historical damage control technique and whilst it is unlikely to be used regularly, it is an effective, rapid and simple technique that should not yet be forgotten.
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Affiliation(s)
| | | | - Mansoor Khan
- Major Trauma Ward, St Mary’s Hospital, London, UK
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Neuroprotection in acute brain injury: an up-to-date review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:186. [PMID: 25896893 PMCID: PMC4404577 DOI: 10.1186/s13054-015-0887-8] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Neuroprotective strategies that limit secondary tissue loss and/or improve functional outcomes have been identified in multiple animal models of ischemic, hemorrhagic, traumatic and nontraumatic cerebral lesions. However, use of these potential interventions in human randomized controlled studies has generally given disappointing results. In this paper, we summarize the current status in terms of neuroprotective strategies, both in the immediate and later stages of acute brain injury in adults. We also review potential new strategies and highlight areas for future research.
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Akeju O, Loggia ML, Catana C, Pavone KJ, Vazquez R, Rhee J, Contreras Ramirez V, Chonde DB, Izquierdo-Garcia D, Arabasz G, Hsu S, Habeeb K, Hooker JM, Napadow V, Brown EN, Purdon PL. Disruption of thalamic functional connectivity is a neural correlate of dexmedetomidine-induced unconsciousness. eLife 2014; 3:e04499. [PMID: 25432022 PMCID: PMC4280551 DOI: 10.7554/elife.04499] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 11/26/2014] [Indexed: 12/17/2022] Open
Abstract
Understanding the neural basis of consciousness is fundamental to neuroscience research. Disruptions in cortico-cortical connectivity have been suggested as a primary mechanism of unconsciousness. By using a novel combination of positron emission tomography and functional magnetic resonance imaging, we studied anesthesia-induced unconsciousness and recovery using the α2-agonist dexmedetomidine. During unconsciousness, cerebral metabolic rate of glucose and cerebral blood flow were preferentially decreased in the thalamus, the Default Mode Network (DMN), and the bilateral Frontoparietal Networks (FPNs). Cortico-cortical functional connectivity within the DMN and FPNs was preserved. However, DMN thalamo-cortical functional connectivity was disrupted. Recovery from this state was associated with sustained reduction in cerebral blood flow and restored DMN thalamo-cortical functional connectivity. We report that loss of thalamo-cortical functional connectivity is sufficient to produce unconsciousness. DOI:http://dx.doi.org/10.7554/eLife.04499.001 Although we are all familiar with the experience of being conscious, explaining precisely what consciousness is and how it arises from activity in the brain remains extremely challenging. Indeed, explaining consciousness is so challenging that it is sometimes referred to as ‘the hard question’ of neuroscience. One way to obtain insights into the neural basis of consciousness is to compare patterns of activity in the brains of conscious subjects with patterns of brain activity in the same subjects under anesthesia. The results of some experiments of this kind suggest that loss of consciousness occurs when the communication between specific regions within the outer layer of the brain, the cortex, is disrupted. However, other studies seem to contradict these findings by showing that this communication can sometimes remain intact in unconscious subjects. Akeju, Loggia et al. have now resolved this issue by using brain imaging to examine the changes that occur as healthy volunteers enter and emerge from a light form of anesthesia roughly equivalent to non-REM sleep. An imaging technique called PET revealed that the loss of consciousness in the subjects was accompanied by reduced activity in a structure deep within the brain called the thalamus. Reduced activity was also seen in areas of cortex at the front and back of the brain. A technique called fMRI showed in turn that communication between the cortex and the thalamus was disrupted as subjects drifted into unconsciousness, whereas communication between cortical regions was spared. As subjects awakened from the anesthesia, communication between the thalamus and the cortex was restored. These results suggest that changes within distinct brain regions give rise to different depths of unconsciousness. Loss of communication between the thalamus and the cortex generates the unconsciousness of sleep or light anesthesia, while the additional loss of communication between cortical regions generates the unconsciousness of general anesthesia or coma. In addition to explaining the mixed results seen in previous experiments, this distinction could lead to advances in the diagnosis of patients with disorders of consciousness, and even to the development of therapies that target the thalamus and its connections with cortex. DOI:http://dx.doi.org/10.7554/eLife.04499.002
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Affiliation(s)
- Oluwaseun Akeju
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, United States
| | - Marco L Loggia
- MGH/MIT/HMS Athinoula A Martinos Center for Biomedical Imaging, Charlestown, United States
| | - Ciprian Catana
- MGH/MIT/HMS Athinoula A Martinos Center for Biomedical Imaging, Charlestown, United States
| | - Kara J Pavone
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, United States
| | - Rafael Vazquez
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, United States
| | - James Rhee
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, United States
| | - Violeta Contreras Ramirez
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, United States
| | - Daniel B Chonde
- MGH/MIT/HMS Athinoula A Martinos Center for Biomedical Imaging, Charlestown, United States
| | - David Izquierdo-Garcia
- MGH/MIT/HMS Athinoula A Martinos Center for Biomedical Imaging, Charlestown, United States
| | - Grae Arabasz
- MGH/MIT/HMS Athinoula A Martinos Center for Biomedical Imaging, Charlestown, United States
| | - Shirley Hsu
- MGH/MIT/HMS Athinoula A Martinos Center for Biomedical Imaging, Charlestown, United States
| | - Kathleen Habeeb
- Clinical Research Center, Massachusetts General Hospital, Boston, United States
| | - Jacob M Hooker
- MGH/MIT/HMS Athinoula A Martinos Center for Biomedical Imaging, Charlestown, United States
| | - Vitaly Napadow
- MGH/MIT/HMS Athinoula A Martinos Center for Biomedical Imaging, Charlestown, United States
| | - Emery N Brown
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, United States
| | - Patrick L Purdon
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, United States
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Salvage techniques in traumatic cardiac arrest: thoracotomy, extracorporeal life support, and therapeutic hypothermia. Curr Opin Crit Care 2014; 19:594-8. [PMID: 24240825 DOI: 10.1097/mcc.0000000000000034] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Survival from traumatic cardiac arrest is associated with a very high mortality despite aggressive resuscitation including an Emergency Department thoracotomy (EDT). Novel salvage techniques are needed to improve these outcomes. RECENT FINDINGS More aggressive out-of-hospital interventions, such as chest decompression or thoracotomy by emergency physicians or anesthesiologists, seem feasible and show some promise for improving outcomes. For trauma patients who suffer severe respiratory failure or refractory cardiac arrest, there seems to be an increasing role for the use of extracorporeal life support (ECLS), utilizing heparin-bonded systems to avoid systemic anticoagulation. The development of exposure hypothermia is associated with poor outcomes in trauma patients, but preclinical studies have consistently demonstrated that mild, therapeutic hypothermia (34 °C) improves survival from severe hemorrhagic shock. Sufficient data exist to justify a clinical trial. For patients who suffer a cardiac arrest refractory to EDT, induction of emergency preservation and resuscitation by rapid cooling to a tympanic membrane temperature of 10 °C may preserve vital organs long enough to allow surgical hemostasis, followed by resuscitation with cardiopulmonary bypass. SUMMARY Salvage techniques, such as earlier thoracotomy, ECLS, and hypothermia, may allow survival from otherwise lethal injuries.
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Drabek T, Janata A, Wilson CD, Stezoski J, Janesko-Feldman K, Tisherman SA, Foley LM, Verrier J, Kochanek PM. Minocycline attenuates brain tissue levels of TNF-α produced by neurons after prolonged hypothermic cardiac arrest in rats. Resuscitation 2014; 85:284-91. [PMID: 24513126 PMCID: PMC3952024 DOI: 10.1016/j.resuscitation.2013.10.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 09/24/2013] [Accepted: 10/15/2013] [Indexed: 12/14/2022]
Abstract
Neuro-cognitive disabilities are a well-recognized complication of hypothermic circulatory arrest. We and others have reported that prolonged cardiac arrest (CA) produces neuronal death and microglial proliferation and activation that are only partially mitigated by hypothermia. Microglia, and possibly other cells, are suggested to elaborate tumor necrosis factor alpha (TNF-α), which can trigger neuronal death cascades and exacerbate edema after CNS insults. Minocycline is neuroprotective in some brain ischemia models in part by blunting the microglial response. We tested the hypothesis that minocycline would attenuate neuroinflammation as reflected by brain tissue levels of TNF-α after hypothermic CA in rats. Rats were subjected to rapid exsanguination, followed by a 6 min normothermic CA. Hypothermia (30 °C) was then induced by an aortic saline flush. After a total of 20 min CA, resuscitation was achieved via cardiopulmonary bypass (CPB). After 5 min reperfusion, minocycline (90 mg kg−1; n = 6) or vehicle (PBS; n = 6) was given. Hypothermia (34 °C) was maintained for 6 h. Rats were sacrificed at 6 or 24 h. TNF-α was quantified (ELISA) in four brain regions (cerebellum, CEREB; cortex, CTX; hippocampus, HIP; striatum, STRI). Naïve rats (n = 6) and rats subjected to the same anesthesia and CPB but no CA served as controls (n = 6). Immunocytochemistry was used to localize TNF-α. Naïve rats and CPB controls had no detectable TNF-α in any brain region. CA markedly increased brain TNF-α. Regional differences were seen, with the highest TNF-α levels in striatum in CA groups (10-fold higher, P < 0.05 vs. all other brain regions). TNF-α was undetectable at 24 h. Minocycline attenuated TNF-α levels in CTX, HIP and STRI (P < 0.05). TNF-α showed unique co-localization with neurons. In conclusion, we report region-dependent early increases in brain TNF-α levels after prolonged hypothermic CA, with maximal increases in striatum. Surprisingly, TNF-α co-localized in neurons and not microglia. Minocycline attenuated TNF-α by approximately 50% but did not totally ablate its production. That minocycline decreased brain TNF-α levels suggests that it may represent a therapeutic adjunct to hypothermia in CA neuroprotection. University of Pittsburgh IACUC 0809278B-3.
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Affiliation(s)
- Tomas Drabek
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Andreas Janata
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Caleb D. Wilson
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jason Stezoski
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Keri Janesko-Feldman
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Samuel A. Tisherman
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lesley M. Foley
- Pittsburgh NMR Center for Biomedical Research, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Jonathan Verrier
- Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Patrick M. Kochanek
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Effect of MRI acoustic noise on cerebral fludeoxyglucose uptake in simultaneous MR-PET imaging. Invest Radiol 2013; 48:302-12. [PMID: 23462677 DOI: 10.1097/rli.0b013e3182839fbc] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED Integrated scanners capable of simultaneous positron emission tomography (PET) and magnetic resonance imaging (MRI) data acquisition are now available for human use. Although the scanners' manufacturers have made substantial efforts to understand and minimize the mutual electromagnetic interference between the 2 modalities, the potential physiological inference has not been evaluated. In this study, we have studied the influence of the acoustic noise produced by the magnetic resonance (MR) gradients on brain fludeoxyglucose (FDG) uptake in the Siemens MR-BrainPET prototype. Although particular attention was paid to the primary auditory cortex (PAC), a brain-wide analysis was also performed. METHODS The effects of the MR on the PET count rate and image quantification were first investigated in phantoms. Next, 10 healthy volunteers underwent 2 simultaneous FDG-PET/MR scans in the supine position with the FDG injection occurring inside the MR-BrainPET, alternating between a "quiet" (control) environment in which no MR sequences were run during the FDG uptake phase (the first 40 minutes after radiotracer administration) and a "noisy" (test) environment in which MR sequences were run for the entire time. Cortical and subcortical regions of interest were derived from the high-resolution morphological MR data using FreeSurfer. The changes in the FDG uptake in the FreeSurfer-derived regions of interest between the 2 conditions were analyzed from parametric and static PET images, and on a voxel-by-voxel basis using SPM8 and FreeSurfer. RESULTS Only minimal to no electromagnetic interference was observed for most of the MR sequences tested, with a maximum drop in count rate of 1.5% and a maximum change in the measured activity of 1.1% in the corresponding images. The region of interest-based analysis showed statistically significant increases in the right PAC in both the parametric (9.13% [4.73%]) and static (4.18% [2.87%]) images. The SPM8 analysis showed no statistically significant clusters in any images when a P < 0.05 (corrected) was used; however, a P < 0.001 (uncorrected) resolved bilateral statistically significant clusters of increased FDG uptake in the area of the PAC for the parametric image (left, 8.37% [1.55%]; right, 8.20% [1.17%]) but only unilateral increase in the static image (left, 8.68% [3.89%]). CONCLUSIONS Although the operation of the BrainPET prototype is virtually unaffected by the MR scanner, the acoustic noise produced by the MR gradients causes a focal increase in the FDG uptake in the PAC, which could affect the interpretation of pathological (or brain-activation-related) changes in the FDG uptake in this region if the expected effects are of comparable amplitude.
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Abstract
Setting up an extracorporeal life support program requires motivated experts, institutional commitment, and an interprofessional team of healthcare providers with dedicated time, space, and resources. This article provides guidance on the key steps involved in the process of developing a sustainable extracorporeal membrane oxygenation program, based on guidelines from the Extracorporeal Life Support Organization and from an international perspective.
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Wu D, Russano K, Kouz I, Abraham WM. NHE1 inhibition improves tissue perfusion and resuscitation outcome after severe hemorrhage. J Surg Res 2013; 181:e75-81. [DOI: 10.1016/j.jss.2012.07.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2012] [Revised: 07/05/2012] [Accepted: 07/11/2012] [Indexed: 11/25/2022]
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Lockey DJ, Weaver AE, Davies GE. Practical translation of hemorrhage control techniques to the civilian trauma scene. Transfusion 2013; 53 Suppl 1:17S-22S. [PMID: 23301967 DOI: 10.1111/trf.12031] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This article examines how established and innovative techniques in hemorrhage control can be practically applied in a civilian physician-based prehospital trauma service. A "care bundle" of measures to control hemorrhage on scene are described. Interventions discussed include the implementation of a system to achieve simple endpoints such as shorter scene times, appropriate triage, careful patient handling, use of effective splints and measures to control external hemorrhage. More complex interventions include prehospital activation of massive hemorrhage protocols and administration of on-scene tranexamic acid, prothrombin complex concentrate, and red blood cells. Radical resuscitation interventions, such as prehospital thoracotomy for cardiac tamponade, and the potential future role of other interventions are also considered.
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Affiliation(s)
- David J Lockey
- London's Air Ambulance, Royal London Hospital, London, UK.
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26
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Wu Y, Zhou Y, Bao S, Huang S, Zhao X, LI J. Using the rPatlak plot and dynamic FDG-PET to generate parametric images of relative local cerebral metabolic rate of glucose. CHINESE SCIENCE BULLETIN 2012. [DOI: 10.1007/s11434-012-5401-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Smarick SD, Haskins SC, Boller M, Fletcher DJ. RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 6: Post-cardiac arrest care. J Vet Emerg Crit Care (San Antonio) 2012; 22 Suppl 1:S85-101. [DOI: 10.1111/j.1476-4431.2012.00754.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | | | - Manuel Boller
- Department of Emergency Medicine, Center for Resuscitation Science, School of Medicine, and the Department of Clinical Studies; School of Veterinary Medicine, University of Pennsylvania; Philadelphia; PA
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Weihs W, Krizanac D, Sterz F, Hlavin G, Janata A, Sipos W, Holzer M, Losert UM, Behringer W. Rapid induction of hypothermia with a small volume aortic flush during cardiac arrest in pigs. Am J Emerg Med 2012; 30:643-50. [DOI: 10.1016/j.ajem.2011.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2011] [Revised: 02/09/2011] [Accepted: 03/06/2011] [Indexed: 10/18/2022] Open
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Abstract
The increasing popularity of mass participation endurance events necessitates that on-site medical teams be well versed in the management of both common and life-threatening conditions. Exertional heat stroke is one such condition, which if left untreated can be fatal.
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Janata A, Weihs W, Schratter A, Bayegan K, Holzer M, Frossard M, Sipos W, Springler G, Schmidt P, Sterz F, Losert UM, Laggner AN, Kochanek PM, Behringer W. Cold aortic flush and chest compressions enable good neurologic outcome after 15 mins of ventricular fibrillation in cardiac arrest in pigs*. Crit Care Med 2010; 38:1637-43. [DOI: 10.1097/ccm.0b013e3181e78b9a] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Affiliation(s)
- Samuel A. Tisherman
- Departments of Critical Care Medicine and Surgery, University of Pittsburgh, Pittsburgh, PA USA,
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Weihs W, Krizanac D, Sterz F, Sipos W, Högler S, Janata A, Holzer M, Losert UM, Behringer W. Outcome after resuscitation using controlled rapid extracorporeal cooling to a brain temperature of 30°C, 24°C and 18°C during cardiac arrest in pigs. Resuscitation 2010; 81:242-7. [DOI: 10.1016/j.resuscitation.2009.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2009] [Revised: 11/05/2009] [Accepted: 11/09/2009] [Indexed: 10/20/2022]
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Abstract
PURPOSE OF REVIEW An extensive search of the literature published in the past 2 years related to critical care organ support was undertaken. This review is limited to those that focus on extracorporeal life support modalities for adults. RECENT FINDINGS Traditional indications for extracorporeal life support such as oxygenation, carbon dioxide exchange and support of perfusion have expanded to include solute and toxin clearance for kidney, liver and potentially neurological failure. Enhanced understanding of cell-mediated mechanisms of injury may explain multiple-organ dysfunction following single-organ damage. Extracorporeal life support systems can be used safely in patients with traumatic brain, chest, and abdominal injury. 'Emergency perfusion and resuscitation' following traumatic exsanguination is entering clinical trials. SUMMARY Multiple-organ dysfunction followed by traumatic injury can be treated with multiple-organ support. A total extracorporeal organ support system may be used in the future as a portable, bedside organ support device.
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Kheirbek T, Kochanek AR, Alam HB. Hypothermia in bleeding trauma: a friend or a foe? Scand J Trauma Resusc Emerg Med 2009; 17:65. [PMID: 20030810 PMCID: PMC2806855 DOI: 10.1186/1757-7241-17-65] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2009] [Accepted: 12/23/2009] [Indexed: 11/10/2022] Open
Abstract
The induction of hypothermia for cellular protection is well established in several clinical settings. Its role in trauma patients, however, is controversial. This review discusses the benefits and complications of induced hypothermia--emphasizing the current state of knowledge and potential applications in bleeding patients. Extensive pre-clinical data suggest that in advanced stages of shock, rapid cooling can protect cells during ischemia and reperfusion, decrease organ damage, and improve survival. Yet hypothermia is a double edged sword; unless carefully managed, its induction can be associated with a number of complications. Appropriate patient selection requires a thorough understanding of the pre-clinical literature. Clinicians must also appreciate the enormous influence that temperature modulation exerts on various cellular mechanisms. This manuscript aims to provide a balanced view of the published literature on this topic. While many of the advantageous molecular and physiological effects of induced hypothermia have been outlined in animal models, rigorous clinical investigations are needed to translate these promising findings into clinical practice.
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Affiliation(s)
- Tareq Kheirbek
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
- Department of Surgery, Washington Hospital Center, Washington, DC, USA
| | - Ashley R Kochanek
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Hasan B Alam
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
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Obeid NR, Rojas A, Reoma JL, Hall CM, Cook KE, Bartlett RH, Punch JD. Organ Donation After Cardiac Determination of Death (DCD): A Swine Model. ASAIO J 2009; 55:562-8. [DOI: 10.1097/mat.0b013e3181ba133b] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Mackensen GB, McDonagh DL, Warner DS. Perioperative hypothermia: use and therapeutic implications. J Neurotrauma 2009; 26:342-58. [PMID: 19231924 DOI: 10.1089/neu.2008.0596] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Perioperative cerebral ischemic insults are common in some surgical procedures. The notion that induced hypothermia can be employed to improve outcome in surgical patients has persisted for six decades. Its principal application has been in the context of cardiothoracic and neurosurgery. Mild (32-35 degrees C) and moderate (26-31 degrees C) hypothermia have been utilized for numerous procedures involving the heart, but intensive research has found little or no benefit to outcome. This may, in part, be attributable to confounding effects associated with rewarming and lack of understanding of the mechanisms of injury. Evidence of efficacy of mild hypothermia is absent for cerebral aneurysm clipping and carotid endarterectomy. Deep hypothermia (18-25 degrees C) during circulatory arrest has been practiced in the repair of congenital heart disease, adult thoracic aortas, and giant intracranial aneurysms. There is little doubt of the protective efficacy of deep hypothermia, but continued efforts to refine its application may serve to enhance its utility. Recent evidence that mild hypothermia is efficacious in out-of-hospital cardiac arrest has implications for patients incurring anoxic or global ischemic brain insults during anesthesia and surgery, or perioperatively. Advances in preclinical models of ischemic/anoxic injury and cardiopulmonary bypass that allow definition of optimal cooling strategies and study of cellular and subcellular events during perioperative ischemia can add to our understanding of mechanisms of hypothermia efficacy and provide a rationale basis for its implementation in humans.
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Affiliation(s)
- G Burkhard Mackensen
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA
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Abstract
At the 2(nd) International Brain Hypothermia conference, in Miami, the late Dr. Peter Safar was honored for his many contributions to the field of therapeutic hypothermia. Therapeutic hypothermia played a central role in his overall vision for optimized resuscitation and neurointensive care, across a large number of potential insults. The successful use of therapeutic hypothermia in comatose patients after cardiac arrest, for example, was already included in the historic first "ABCs" of resuscitation, published by Safar in 1964. This review addresses key historical events in the development and implementation of therapeutic hypothermia across a number of central nervous system insults. A discussion of future potential uses of this therapy in a variety of applications as part of the Safar vision is also presented.
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Affiliation(s)
- Patrick M Kochanek
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15260, USA.
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38
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Protein nitration and poly-ADP-ribosylation in brain after rapid exsanguination cardiac arrest in a rat model of emergency preservation and resuscitation. Resuscitation 2008; 79:301-10. [PMID: 18640761 DOI: 10.1016/j.resuscitation.2008.06.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2007] [Revised: 05/22/2008] [Accepted: 06/04/2008] [Indexed: 11/21/2022]
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Abstract
To shorten the transplantation waiting time in the United States, federal regulations have been introduced requiring hospitals to develop policies for organ donation after cardiac (or circulatory) death (DCD). The practice of DCD is invoked based on the validity of the University of Pittsburgh Medical Center (UPMC) protocol and relies on the accuracy of the University of Wisconsin (UW) evaluation tool to appropriately identify organ donors. There is little evidence to support the position that the criteria for organ procurement adopted from the UPMC protocol complies with the dead donor rule. A high false-positive rate of the UW evaluation tool can expose many dying patients to unnecessary perimortem interventions because of donation failure. The medications and/or interventions for the sole purpose of maintaining organ viability can have unintended negative consequences on the timing and quality of end-of-life care offered to organ donors. It is essential to address and manage the evolving conflict between optimal end-of-life care and the necessary sacrifices for the procurement of transplantable organs from the terminally ill. The recipients of marginal organs recovered from DCD can also suffer higher mortality and morbidity than recipients of other types of donated organs. Finally, transparent disclosure to the public of the risks involved to both organ donors and recipients may contribute to open societal debate on the ethical acceptability of DCD.
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Drabek T, Fisk JA, Dixon CE, Garman RH, Stezoski J, Wisnewski SR, Wu X, Tisherman SA, Kochanek PM. Prolonged deep hypothermic circulatory arrest in rats can be achieved without cognitive deficits. Life Sci 2007; 81:543-52. [PMID: 17658556 DOI: 10.1016/j.lfs.2007.06.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2007] [Revised: 06/11/2007] [Accepted: 06/16/2007] [Indexed: 02/07/2023]
Abstract
Cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA) enable surgical repair of cardiovascular defects. However, neurological complications can result after both CPB and DHCA. We sought to investigate if 75 min of CPB or DHCA caused motor, cognitive or histological deficits in rats. Three groups were studied: DHCA, CPB, and sham. Rats in the DHCA group were subjected to 75 min DHCA at 15 degrees C, with a total CPB duration of 75 min. Rats in the CPB group were subjected to 75 min of normothermic CPB. Shams received the same anesthesia, cannulations and infusions. Motor function was assessed using beam testing on days 3-13. Cognitive performance was evaluated using Morris water maze tasks on days 7-13. Overall Performance Category (OPC) and Neurologic Deficit Score (NDS) were assessed daily. Histological Damage Score (HDS) was assessed in survivors on day 14. Sustained deficits on beam testing were seen only in the CPB group. Rats in the CPB and DHCA groups exhibited similar cognitive performance vs. sham. There were no differences in OPC or NDS between groups. Neuronal degeneration was present only in small foci in rats after DHCA (n=4/7). However, HDS was not different in individual brain regions or viscera between DHCA or CPB vs. sham. Surprisingly, CPB, but not DHCA was associated with motor deficits vs. sham, and no cognitive deficits were seen in either group vs. sham. Future studies with longer DHCA duration will be necessary to provide targets to assess novel preservation strategies.
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Affiliation(s)
- Tomas Drabek
- Safar Center for Resuscitation Research, University of Pittsburgh, School of Medicine, Pittsburgh PA 15260, USA.
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