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Mavridis T, Choratta T, Papadopoulou A, Sawafta A, Archontakis-Barakakis P, Laou E, Sakellakis M, Chalkias A. Protease-Activated Receptors (PARs): Biology and Therapeutic Potential in Perioperative Stroke. Transl Stroke Res 2024:10.1007/s12975-024-01233-0. [PMID: 38326662 DOI: 10.1007/s12975-024-01233-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/12/2024] [Accepted: 02/01/2024] [Indexed: 02/09/2024]
Abstract
Perioperative stroke is a devastating complication that occurs during surgery or within 30 days following the surgical procedure. Its prevalence ranges from 0.08 to 10% although it is most likely an underestimation, as sedatives and narcotics can substantially mask symptomatology and clinical presentation. Understanding the underlying pathophysiology and identifying potential therapeutic targets are of paramount importance. Protease-activated receptors (PARs), a unique family of G-protein-coupled receptors, are widely expressed throughout the human body and play essential roles in various physiological and pathological processes. This review elucidates the biology and significance of PARs, outlining their diverse functions in health and disease, and their intricate involvement in cerebrovascular (patho)physiology and neuroprotection. PARs exhibit a dual role in cerebral ischemia, which underscores their potential as therapeutic targets to mitigate the devastating effects of stroke in surgical patients.
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Affiliation(s)
- Theodoros Mavridis
- Department of Neurology, Tallaght University Hospital (TUH)/The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH), Dublin, D24 NR0A, Ireland
- 1st Department of Neurology, Eginition Hospital, Medical School, National and Kapodistrian University of Athens, 11528, Athens, Greece
| | - Theodora Choratta
- Department of General Surgery, Metaxa Hospital, 18537, Piraeus, Greece
| | - Androniki Papadopoulou
- Department of Anesthesiology, G. Gennimatas General Hospital, 54635, Thessaloniki, Greece
| | - Assaf Sawafta
- Department of Cardiology, University Hospital of Larisa, 41110, Larisa, Greece
| | | | - Eleni Laou
- Department of Anesthesiology, Agia Sophia Children's Hospital, 15773, Athens, Greece
| | - Minas Sakellakis
- Department of Medicine, Jacobi Medical Center-North Central Bronx Hospital, Bronx, NY, 10467, USA
| | - Athanasios Chalkias
- Institute for Translational Medicine and Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104-5158, USA.
- Outcomes Research Consortium, Cleveland, OH, 44195, USA.
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Yılmaz F, Tekin Y, Toprak N, Eyı̇nç MB, Arslan ED. A case of massive pulmonary embolism causing cardiac arrest managed with successful systemic thrombolytic in the emergency department. EMERGENCY CARE JOURNAL 2022. [DOI: 10.4081/ecj.2022.10827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Pulmonary Embolism (PE), when complicated by cardiac arrest, is almost always fatal despite all resuscitative efforts. However, a more favorable is possible when PE is rapidly identified as the cause of cardiac arrest and pulmonary circulation is quickly re-established by specific therapy. A 54-year-old woman was brought to the Emergency Department (ED) by 112 emergency ambulance service with the complaint of shortness of breath that had started 2 hours ago. She developed cardiac arrest while being physical examined 2 minutes after admission, and Cardiopulmonary Resuscitation (CPR) was immediately begun. Massive PE was considered the most likely diagnosis in the light of her history, physical examined, and bedside ultrasonography findings; thus, recombinant tissue Plasminogen Activator (r-tPA) was administered during CPR. The second CPR attempt achieved return of spontaneous circulation within 5 minutes. She was treated at intensive care unit for 32 days and discharged from the hospital with complete recovery.
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Amini S, Rezabakhsh A, Hashemi J, Saghafi F, Azizi H, Sureda A, Habtemariam S, Khayat Kashani HR, Hesari Z, Sahebnasagh A. Pharmacotherapy consideration of thrombolytic medications in COVID-19-associated ARDS. J Intensive Care 2022; 10:38. [PMID: 35908022 PMCID: PMC9338522 DOI: 10.1186/s40560-022-00625-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 06/22/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND In late 2019, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which is responsible for coronavirus disease (COVID-19), was identified as the new pathogen to lead pneumonia in Wuhan, China, which has spread all over the world and developed into a pandemic. Despite the over 1 year of pandemic, due to the lack of an effective treatment plan, the morbidity and mortality of COVID-19 remains high. Efforts are underway to find the optimal management for this viral disease. MAIN BODY SARS-CoV-2 could simultaneously affect multiple organs with variable degrees of severity, from mild to critical disease. Overproduction of pro-inflammatory mediators, exacerbated cellular and humoral immune responses, and coagulopathy such as Pulmonary Intravascular Coagulopathy (PIC) contributes to cell injuries. Considering the pathophysiology of the disease and multiple microthrombi developments in COVID-19, thrombolytic medications seem to play a role in the management of the disease. Beyond the anticoagulation, the exact role of thrombolytic medications in the management of patients with COVID-19-associated acute respiratory distress syndrome (ARDS) is not explicit. This review focuses on current progress in underlying mechanisms of COVID-19-associated pulmonary intravascular coagulopathy, the historical use of thrombolytic drugs in the management of ARDS, and pharmacotherapy considerations of thrombolytic therapy, their possible benefits, and pitfalls in COVID-19-associated ARDS. CONCLUSIONS Inhaled or intravenous administration of thrombolytics appears to be a salvage therapy for severe ARDS associated with COVID-19 by prompt attenuation of lung injury. Considering the pathogenesis of COVID-19-related ARDS and mechanism of action of thrombolytic agents, thrombolytics appear attractive options in stable patients without contraindications.
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Affiliation(s)
- Shahideh Amini
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Aysa Rezabakhsh
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Javad Hashemi
- Department of Pathobiology and Laboratory Sciences, School of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Fatemeh Saghafi
- Department of Clinical Pharmacy, Faculty of Pharmacy and Pharmaceutical Sciences Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Hossein Azizi
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Antoni Sureda
- Research Group On Community Nutrition and Oxidative Stress, University of the Balearic Islands, Palma, Spain.,CIBEROBN (Physiopathology of Obesity and Nutrition CB12/03/30038), Instituto de Salud Carlos III, Madrid, Spain
| | - Solomon Habtemariam
- Pharmacognosy Research Laboratories and Herbal Analysis Services, University of Greenwich, Central Avenue, Chatham-Maritime, Kent, ME4 4TB, UK
| | | | - Zahra Hesari
- Laboratory Sciences Research Center, Golestan University of Medical Sciences, Gorgan, Iran
| | - Adeleh Sahebnasagh
- Clinical Research Center, Department of Internal Medicine, School of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran.
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Welle SR, Harrison MF. Massive Pulmonary Embolism Causing Cardiac Arrest Managed with Systemic Thrombolytic Therapy: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e931215. [PMID: 34228699 PMCID: PMC8272940 DOI: 10.12659/ajcr.931215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 05/31/2021] [Accepted: 05/16/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Approximately 290 000 cases of in-hospital cardiac arrest occur annually, the majority of which are due to cardiac or respiratory causes. Cardiac arrest due to acute pulmonary embolism (PE) is associated with a 90% incidence of mortality and, if identified, it can be treated with systemic thrombolytics. Here, we describe a case in which the outcome for such an event was favorable. CASE REPORT A 66-year-old woman was admitted with multiple rib and left ankle fractures due to accidental trauma. Before undergoing orthopedic surgery, she experienced a cardiac arrest with pulseless electrical activity, which was witnessed. She had refractory hypoxia and hypotension following intubation and a brief initial return of spontaneous circulation (ROSC) before a second cardiac arrest. A 100-mg bolus dose of systemic thrombolytic therapy was promptly administered, with rapid achievement of sustained ROSC. The results of a subsequent electrocardiogram, echocardiogram, and computed tomography scan further supported the diagnosis of acute PE with right heart strain. Supportive care in the Intensive Care Unit resulted in full neurological recovery and she was discharged to a physical rehabilitation facility 12 days after her cardiac arrest. CONCLUSIONS Systemic thrombolytic therapy is beneficial for cardiac arrest due to acute PE.
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Affiliation(s)
- Stephanie R. Welle
- Department of Intensive Care (Critical Care), Mayo Clinic Health System, Mankato, MN, USA
| | - Michael F. Harrison
- Department of Intensive Care (Critical Care), Mayo Clinic Health System, Mankato, MN, USA
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL, USA
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA
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Bakkum MJ, Schouten VL, Smulders YM, Nossent EJ, van Agtmael MA, Tuinman PR. Accelerated treatment with rtPA for pulmonary embolism induced circulatory arrest. Thromb Res 2021; 203:74-80. [PMID: 33971387 DOI: 10.1016/j.thromres.2021.04.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/17/2021] [Accepted: 04/26/2021] [Indexed: 11/29/2022]
Abstract
Patients with circulatory arrest due to pulmonary embolism (PE) should be treated with fibrinolytics. Current guidelines do not specify which regimen to apply, and it has been suggested that the regimen of 100 mg rtPA/2 h should be used, because this is recommended for hemodynamic instable PE in the ESC/ERS Guideline. This two hour regimen, however, is incompatible with key principles of cardiopulmonary resuscitation (CPR), such as employment of interventions that allow fast evaluation of effectiveness, and limitation of the total duration of CPR to avoid poor neurological outcomes. Additionally, the low flow-state during CPR has important consequences for the pharmacokinetic properties of rtPA. Arguably, the volume of distribution is lower, the metabolism reduced and the half life time longer. Therefore, these changes largely discard the rationale to use high dosages of rtPA over a prolonged period of time. More importantly, these changes highlight that the guideline recommendations, based on studies in patients without circulatory arrest, cannot be easily translated to the situation of circulatory arrest. An accelerated regimen of rtPA (0.6 mg/kg/15 min., max 50 mg) is mentioned by the 2019 ESC/ERS Guideline. However, empirical support or a rationale is not provided. Due to the rarity of the situation and ethical difficulties associated with randomizing unconscious patients, a randomized head-to-head comparison between the two regimens is unlikely to ever be performed. With this comprehensive overview of the pharmacokinetics of rtPA and current literature, a strong rationale is provided that the accelerated protocol is the regimen of choice for patients with PE-induced circulatory arrest.
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Affiliation(s)
- M J Bakkum
- Amsterdam UMC, Department of Internal Medicine, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands.
| | - V L Schouten
- Amsterdam UMC, Department of Intensive Care Medicine, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands; Noordwest Ziekenhuisgroep, Department of Intensive Care, Location Alkmaar and Den Helder, Wilhelminalaan 12, 1815 JD Alkmaar, the Netherlands
| | - Y M Smulders
- Amsterdam UMC, Department of Internal Medicine, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands
| | - E J Nossent
- Amsterdam UMC, Department of Pulmonology, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands
| | - M A van Agtmael
- Amsterdam UMC, Department of Internal Medicine, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands
| | - P R Tuinman
- Amsterdam UMC, Department of Intensive Care Medicine, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands
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The Effect of Prophylactic Anticoagulation with Heparin on the Brain Cells of Sprague-Dawley Rats in a Cardiopulmonary-Cerebral Resuscitation Model. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2020; 2020:8430746. [PMID: 33005203 PMCID: PMC7504766 DOI: 10.1155/2020/8430746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 07/08/2020] [Accepted: 08/25/2020] [Indexed: 12/13/2022]
Abstract
After a cardiac arrest (CA) of 5 to 10 min, a marked activation of blood coagulation occurs and microthrombi are found in the cerebral vessels. These microcirculatory disturbances directly affect the outcome on cardiopulmonary resuscitation (CPR). The purpose of this study was to investigate the effects and potential mechanisms of prophylactic anticoagulation on rat brain cells after cerebral CPR. After setting up an asphyxial CA model, we monitored the basic parameters such as the vitals and survival rate of the rats and assessed the respective neurological deficit (ND) and histological damage (HD) scores of their brain tissues. We, furthermore, investigated the influence of heparin on the expressions of TNF-α, IL-1β, CD40, NF-κB, and HIF-1α after asphyxial CA. The results showed that anticoagulation with heparin could obviously improve the outcome and prognosis of brain ischemia, including improvement of neurological function recovery and prevention of morphological and immunohistochemical injury on the brain, while significantly increasing the success rate of CPR. Treatment with heparin significantly inhibited the upregulation of CD40, NF-κB, and HIF-1α induced by asphyxial CA. Thrombolysis treatment may improve the outcome and prognosis of CPR, and future clinical studies need to evaluate the efficacy of early heparin therapy after CA.
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International Survey of Thrombolytic Use for Treatment of Cardiac Arrest Due to Massive Pulmonary Embolism. Crit Care Explor 2020; 2:e0132. [PMID: 32695997 PMCID: PMC7314323 DOI: 10.1097/cce.0000000000000132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Objectives This survey sought to characterize the national prescribing patterns and barriers to the use of thrombolytic agents in the treatment of pulmonary embolism, with a specific focus on treatment during actual or imminent cardiac arrest. Design A 19-question international, cross-sectional survey on thrombolytic use in pulmonary embolism was developed, validated, and administered. A multivariable logistic regression was conducted to determine factors predictive of utilization of thrombolytics in the setting of cardiac arrest secondary to pulmonary embolism. Setting International survey study. Subjects Physicians, pharmacists, nurses, and other healthcare professionals who were members of the Society of Critical Care Medicine. Interventions None. Measurements and Main Results Thrombolytic users were compared with nonusers. Respondents (n = 272) predominately were physicians (62.1%) or pharmacists (30.5%) practicing in an academic medical center (54.8%) or community teaching setting (24.6%). Thrombolytic users (n = 177; 66.8%) were compared with nonusers (n = 88; 33.2%) Thrombolytic users were more likely to work in pulmonary/critical care (80.2% thrombolytic use vs 59.8%; p < 0.01) and emergency medicine (6.8% vs 3.5%; p < 0.01). Users were more likely to have an institutional guideline or policy in place pertaining to the use of thrombolytics in cardiac arrest (27.8% vs 13.6%; p < 0.01) or have a pulmonary embolism response team (38.6% vs 19.3%; p < 0.01). Lack of evidence supporting use and the risk of adverse outcomes were barriers to thrombolytic use. Working in a pulmonary/critical care environment (odds ratio, 2.36; 95% CI, 1.24-4.52) and comfort level (odds ratio, 2.77; 95% CI, 1.7-4.53) were predictive of thrombolytic use in the multivariable analysis. Conclusions Most survey respondents used thrombolytics in the setting of cardiac arrest secondary to known or suspected pulmonary embolism. This survey study adds important data to the literature surrounding thrombolytics for pulmonary embolism as it describes thrombolytic user characteristic, barriers to use, and common prescribing practices internationally.
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9
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Wada T. Coagulofibrinolytic Changes in Patients with Post-cardiac Arrest Syndrome. Front Med (Lausanne) 2017; 4:156. [PMID: 29034235 PMCID: PMC5626829 DOI: 10.3389/fmed.2017.00156] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 09/11/2017] [Indexed: 01/08/2023] Open
Abstract
Whole-body ischemia and reperfusion due to cardiac arrest and subsequent return of spontaneous circulation constitute post-cardiac arrest syndrome (PCAS), which consists of four syndromes including systemic ischemia/reperfusion responses and post-cardiac arrest brain injury. The major pathophysiologies underlying systemic ischemia/reperfusion responses are systemic inflammatory response syndrome and increased coagulation, leading to disseminated intravascular coagulation (DIC), which clinically manifests as obstruction of microcirculation and multiple organ dysfunction. In particular, thrombotic occlusion in the brain due to DIC, referred to as the "no-reflow phenomenon," may be deeply involved in post-cardiac arrest brain injury, which is the leading cause of mortality in patients with PCAS. Coagulofibrinolytic changes in patients with PCAS are characterized by tissue factor-dependent coagulation, which is accelerated by impaired anticoagulant mechanisms, including antithrombin, protein C, thrombomodulin, and tissue factor pathway inhibitor. Damage-associated molecular patterns (DAMPs) accelerate not only tissue factor-dependent coagulation but also the factor XII- and factor XI-dependent activation of coagulation. Inflammatory cytokines are also involved in these changes via the expression of tissue factor on endothelial cells and monocytes, the inhibition of anticoagulant systems, and the release of neutrophil elastase from neutrophils activated by inflammatory cytokines. Hyperfibrinolysis in the early phase of PCAS is followed by inadequate endogenous fibrinolysis and fibrinolytic shutdown by plasminogen activator inhibitor-1. Moreover, cell-free DNA, which is also a DAMP, plays a pivotal role in the inhibition of fibrinolysis. DIC diagnosis criteria or fibrinolysis markers, including d-dimer and fibrin/fibrinogen degradation products, which are commonly tested in patients and easily accessible, can be used to predict the mortality or neurological outcome of PCAS patients with high accuracy. A number of studies have explored therapy for this unique pathophysiology since the first report on "no-reflow phenomenon" was published roughly 50 years ago. However, the optimum therapeutic strategy focusing on the coagulofibrinolytic changes in cardiac arrest or PCAS patients has not yet been established. The elucidation of more precise pathomechanisms of coagulofibrinolytic changes in PCAS may aid in the development of novel therapeutic targets, leading to an improvement in the outcomes of PCAS patients.
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Affiliation(s)
- Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Soar J, Nolan J, Böttiger B, Perkins G, Lott C, Carli P, Pellis T, Sandroni C, Skrifvars M, Smith G, Sunde K, Deakin C. Erweiterte Reanimationsmaßnahmen für Erwachsene („adult advanced life support“). Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0330-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Long-Term Outcomes in Critically Ill Septic Patients Who Survived Cardiopulmonary Resuscitation. Crit Care Med 2017; 44:1067-74. [PMID: 26807681 DOI: 10.1097/ccm.0000000000001608] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To evaluate the long-term survival rate of critically ill sepsis survivors following cardiopulmonary resuscitation on a national scale. DESIGN Retrospective and observational cohort study. SETTING Data were extracted from Taiwan's National Health Insurance Research Database. PATIENTS A total of 272,897 ICU patients with sepsis were identified during 2000-2010. Patients who survived to hospital discharge were enrolled. Post-discharge survival outcomes of ICU sepsis survivors who received cardiopulmonary resuscitation were compared with those of patients who did not experience cardiopulmonary arrest using propensity score matching with a 1:1 ratio. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Only 7% (n = 3,207) of sepsis patients who received cardiopulmonary resuscitation survived to discharge. The overall 1-, 2-, and 5-year postdischarge survival rates following cardiopulmonary resuscitation were 28%, 23%, and 14%, respectively. Compared with sepsis survivors without cardiopulmonary arrest, sepsis survivors who received cardiopulmonary resuscitation had a greater risk of all-cause mortality after discharge (hazard ratio, 1.38; 95% CI, 1.34-1.46). This difference in mortality risk diminished after 2 years (hazard ratio, 1.11; 95% CI, 0.96-1.28). Multivariable analysis showed that independent risk factors for long-term mortality following cardiopulmonary resuscitation were male sex, older age, receipt of care in a nonmedical center, higher Charlson Comorbidity Index score, chronic kidney disease, cancer, respiratory infection, vasoactive agent use, and receipt of renal replacement therapy during ICU stay. CONCLUSION The long-term outcome was worse in ICU survivors of sepsis who received in-hospital cardiopulmonary resuscitation than in those who did not, but this increased risk of mortality diminished at 2 years after discharge.
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Yang JN, Chen J, Xiao M. A protease-activated receptor 1 antagonist protects against global cerebral ischemia/reperfusion injury after asphyxial cardiac arrest in rabbits. Neural Regen Res 2017; 12:242-249. [PMID: 28400806 PMCID: PMC5361508 DOI: 10.4103/1673-5374.199011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Cerebral ischemia/reperfusion injury is partially mediated by thrombin, which causes brain damage through protease-activated receptor 1 (PAR1). However, the role and mechanisms underlying the effects of PAR1 activation require further elucidation. Therefore, the present study investigated the effects of the PAR1 antagonist SCH79797 in a rabbit model of global cerebral ischemia induced by cardiac arrest. SCH79797 was intravenously administered 10 minutes after the model was established. Forty-eight hours later, compared with those administered saline, rabbits receiving SCH79797 showed markedly decreased neuronal damage as assessed by serum neuron specific enolase levels and less neurological dysfunction as determined using cerebral performance category scores. Additionally, in the hippocampus, cell apoptosis, polymorphonuclear cell infiltration, and c-Jun levels were decreased, whereas extracellular signal-regulated kinase phosphorylation levels were increased. All of these changes were inhibited by the intravenous administration of the phosphoinositide 3-kinase/Akt pathway inhibitor LY29004 (3 mg/kg) 10 minutes before the SCH79797 intervention. These findings suggest that SCH79797 mitigates brain injury via anti-inflammatory and anti-apoptotic effects, possibly by modulating the extracellular signal-regulated kinase, c-Jun N-terminal kinase/c-Jun and phosphoinositide 3-kinase/Akt pathways.
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Affiliation(s)
- Jing-Ning Yang
- Department of Emergency Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei Province, China; Department of Immunology, Hubei University of Medicine, Shiyan, Hubei Province, China
| | - Jun Chen
- Department of Immunology, Hubei University of Medicine, Shiyan, Hubei Province, China
| | - Min Xiao
- Department of Emergency Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei Province, China
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Ono Y, Hayakawa M, Maekawa K, Kodate A, Sadamoto Y, Tominaga N, Murakami H, Yoshida T, Katabami K, Wada T, Sageshima H, Sawamura A, Gando S. Fibrin/fibrinogen degradation products (FDP) at hospital admission predict neurological outcomes in out-of-hospital cardiac arrest patients. Resuscitation 2016; 111:62-67. [PMID: 27940211 DOI: 10.1016/j.resuscitation.2016.11.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 11/23/2016] [Accepted: 11/24/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This study aimed to test the hypothesis that coagulation, fibrinolytic markers and disseminated intravascular coagulation (DIC) score (International Society on Thrombosis and Haemostasis) at hospital admission of out-of-hospital cardiac arrest (OHCA) patients can predict neurological outcomes 1 month after cardiac arrest. METHODS In this retrospective, observational analysis, data were collected from the Sapporo Utstein Registry and medical records at Hokkaido University Hospital. We included patients who experienced OHCA with successful return of spontaneous circulation (ROSC) between 2006 and 2012 and were transferred to Hokkaido University Hospital. From medical records, we collected information about the following coagulation and fibrinolytic factors at hospital admission: platelet count; prothrombin time; activated partial thromboplastin time; plasma levels of fibrinogen, D-dimer, fibrin/fibrinogen degradation products (FDP), and antithrombin; and calculated DIC score. Favorable neurological outcomes were defined as a cerebral performance category 1-2. RESULTS We analyzed data for 315 patients. Except for fibrinogen level, all coagulation variables, fibrinolytic variables, and DIC score were associated with favorable neurological outcomes. In the receiver operating characteristic curve analysis, FDP level had the largest area under the curve (AUC; 0.795). In addition, the AUC of FDP level was larger than that of lactate level. CONCLUSIONS All of the coagulation and fibrinolytic markers, except for fibrinogen level, and DIC score at hospital admission, were associated with favorable neurological outcomes. Of all of the variables, FDP level was most closely associated with favorable neurological outcomes in OHCA patients who successfully achieved ROSC.
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Affiliation(s)
- Yuichi Ono
- Hokkaido University, Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan.
| | - Mineji Hayakawa
- Hokkaido University, Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Kunihiko Maekawa
- Hokkaido University, Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Akira Kodate
- Hokkaido University, Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Yoshihiro Sadamoto
- Hokkaido University, Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Naoki Tominaga
- Hokkaido University, Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Hiromoto Murakami
- Hokkaido University, Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Tomonao Yoshida
- Hokkaido University, Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Kenichi Katabami
- Hokkaido University, Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Takeshi Wada
- Hokkaido University, Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Hisako Sageshima
- Hokkaido University, Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Atsushi Sawamura
- Hokkaido University, Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Satoshi Gando
- Hokkaido University, Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
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Soar J, Nolan JP, Böttiger BW, Perkins GD, Lott C, Carli P, Pellis T, Sandroni C, Skrifvars MB, Smith GB, Sunde K, Deakin CD. European Resuscitation Council Guidelines for Resuscitation 2015: Section 3. Adult advanced life support. Resuscitation 2016; 95:100-47. [PMID: 26477701 DOI: 10.1016/j.resuscitation.2015.07.016] [Citation(s) in RCA: 920] [Impact Index Per Article: 115.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK.
| | - Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, UK
| | - Bernd W Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Germany
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Heart of England NHS Foundation Trust, Birmingham, UK
| | - Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University, Mainz, Germany
| | - Pierre Carli
- SAMU de Paris, Department of Anaesthesiology and Intensive Care, Necker University Hospital, Paris, France
| | - Tommaso Pellis
- Anaesthesia, Intensive Care and Emergency Medical Service, Santa Maria degli Angeli Hospital, Pordenone, Italy
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
| | - Markus B Skrifvars
- Division of Intensive Care, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Gary B Smith
- Centre of Postgraduate Medical Research & Education, Bournemouth University, Bournemouth, UK
| | - Kjetil Sunde
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Charles D Deakin
- Cardiac Anaesthesia and Cardiac Intensive Care, NIHR Southampton Respiratory Biomedical Research Unit, University Hospital Southampton, Southampton, UK
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Lavonas EJ, Drennan IR, Gabrielli A, Heffner AC, Hoyte CO, Orkin AM, Sawyer KN, Donnino MW. Part 10: Special Circumstances of Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2016; 132:S501-18. [PMID: 26472998 DOI: 10.1161/cir.0000000000000264] [Citation(s) in RCA: 172] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Double Bolus Thrombolysis for Suspected Massive Pulmonary Embolism during Cardiac Arrest. Case Rep Emerg Med 2015; 2015:367295. [PMID: 26664765 PMCID: PMC4664787 DOI: 10.1155/2015/367295] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 10/27/2015] [Accepted: 10/28/2015] [Indexed: 12/29/2022] Open
Abstract
More than 70% of cardiac arrest cases are caused by acute myocardial infarction (AMI) or pulmonary embolism (PE). Although thrombolytic therapy is a recognised therapy for both AMI and PE, its indiscriminate use is not routinely recommended during cardiopulmonary resuscitation (CPR). We present a case describing the successful use of double dose thrombolysis during cardiac arrest caused by pulmonary embolism. Notwithstanding the relative lack of high-level evidence, this case suggests a scenario in which recombinant tissue Plasminogen Activator (rtPA) may be beneficial in cardiac arrest. In addition to the strong clinical suspicion of pulmonary embolism as the causative agent of the patient's cardiac arrest, the extremely low end-tidal CO2 suggested a massive PE. The absence of dilatation of the right heart on subxiphoid ultrasound argued against the diagnosis of PE, but not conclusively so. In the context of the circulatory collapse induced by cardiac arrest, this aspect was relegated in terms of importance. The second dose of rtPA utilised in this case resulted in return of spontaneous circulation (ROSC) and did not result in haemorrhage or an adverse effect.
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Monsieurs K, Nolan J, Bossaert L, Greif R, Maconochie I, Nikolaou N, Perkins G, Soar J, Truhlář A, Wyllie J, Zideman D. Kurzdarstellung. Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0097-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Kudenchuk PJ, Sandroni C, Drinhaus HR, Böttiger BW, Cariou A, Sunde K, Dworschak M, Taccone FS, Deye N, Friberg H, Laureys S, Ledoux D, Oddo M, Legriel S, Hantson P, Diehl JL, Laterre PF. Breakthrough in cardiac arrest: reports from the 4th Paris International Conference. Ann Intensive Care 2015; 5:22. [PMID: 26380990 PMCID: PMC4573754 DOI: 10.1186/s13613-015-0064-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 08/18/2015] [Indexed: 02/08/2023] Open
Abstract
Jean-Luc Diehl The French Intensive Care Society organized on 5th and 6th June 2014 its 4th "Paris International Conference in Intensive Care", whose principle is to bring together the best international experts on a hot topic in critical care medicine. The 2014 theme was "Breakthrough in cardiac arrest", with many high-quality updates on epidemiology, public health data, pre-hospital and in-ICU cares. The present review includes short summaries of the major presentations, classified into six main chapters: Epidemiology of CA Pre-hospital management Post-resuscitation management: targeted temperature management Post-resuscitation management: optimizing organ perfusion and metabolic parameters Neurological assessment of brain damages Public healthcare.
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Affiliation(s)
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy.
| | - Hendrik R Drinhaus
- Department of Anaesthesiology and Intensive Care Medicine, University of Koeln, Cologne, Germany.
| | - Bernd W Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University of Koeln, Cologne, Germany.
| | - Alain Cariou
- Medical Intensive Care Unit, AP-HP, Cochin Hospital, Paris, France.
- Paris Descartes University and Sorbonne Paris Cité-Medical School and INSERM U970 (Team 4), Cardiovascular Research Center, European Georges Pompidou Hospital, Paris, France.
| | - Kjetil Sunde
- Division of Emergencies and Critical Care, Department of Anaesthesiology, Surgical Intensive Care Unit Ullevål, Oslo University Hospital, Oslo, Norway.
| | - Martin Dworschak
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Vienna General Hospital, Medical University Vienna, Vienna, Austria.
| | - Fabio Silvio Taccone
- Department of Intensive Care, Laboratoire de Recherche Experimentale, Erasme Hospital, Brussels, Belgium.
| | - Nicolas Deye
- Medical Intensive Care Unit, AP-HP, Lariboisière University Hospital, Inserm U942, Paris, France.
| | - Hans Friberg
- Anaesthesiology and Intensive Care Medicine, Skåne University Hospital, Lund University, Lund, Sweden.
| | - Steven Laureys
- Coma Science Group, Cyclotron Research Centre, University of Liège and Liège 2 Department of Neurology, University Hospital of Liège, Liège, Belgium.
| | - Didier Ledoux
- Coma Science Group, Cyclotron Research Centre, University of Liège and Department of Intensive Care Medicine, University Hospital of Liège, Liège, Belgium.
| | - Mauro Oddo
- Department of Intensive Care Medicine, Faculty of Biology and Medicine, CHUV-University Hospital, Lausanne, Switzerland.
| | - Stéphane Legriel
- Intensive Care Unit, Centre Hospitalier de Versailles, Le Chesnay, France.
| | - Philippe Hantson
- Department of Intensive Care, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.
| | - Jean-Luc Diehl
- Medical Intensive Care Unit, AP-HP, European Georges Pompidou Hospital, Paris Descartes University and Sorbonne Paris Cité-Medical School, Paris, France.
| | - Pierre-Francois Laterre
- Department of Intensive Care, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain Brussels, Brussels, Belgium.
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Soar J, Nolan J, Böttiger B, Perkins G, Lott C, Carli P, Pellis T, Sandroni C, Skrifvars M, Smith G, Sunde K, Deakin C. Erweiterte Reanimationsmaßnahmen für Erwachsene („adult advanced life support“). Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0085-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Monsieurs KG, Nolan JP, Bossaert LL, Greif R, Maconochie IK, Nikolaou NI, Perkins GD, Soar J, Truhlář A, Wyllie J, Zideman DA, Alfonzo A, Arntz HR, Askitopoulou H, Bellou A, Beygui F, Biarent D, Bingham R, Bierens JJ, Böttiger BW, Bossaert LL, Brattebø G, Brugger H, Bruinenberg J, Cariou A, Carli P, Cassan P, Castrén M, Chalkias AF, Conaghan P, Deakin CD, De Buck ED, Dunning J, De Vries W, Evans TR, Eich C, Gräsner JT, Greif R, Hafner CM, Handley AJ, Haywood KL, Hunyadi-Antičević S, Koster RW, Lippert A, Lockey DJ, Lockey AS, López-Herce J, Lott C, Maconochie IK, Mentzelopoulos SD, Meyran D, Monsieurs KG, Nikolaou NI, Nolan JP, Olasveengen T, Paal P, Pellis T, Perkins GD, Rajka T, Raffay VI, Ristagno G, Rodríguez-Núñez A, Roehr CC, Rüdiger M, Sandroni C, Schunder-Tatzber S, Singletary EM, Skrifvars MB, Smith GB, Smyth MA, Soar J, Thies KC, Trevisanuto D, Truhlář A, Vandekerckhove PG, de Voorde PV, Sunde K, Urlesberger B, Wenzel V, Wyllie J, Xanthos TT, Zideman DA. European Resuscitation Council Guidelines for Resuscitation 2015: Section 1. Executive summary. Resuscitation 2015; 95:1-80. [PMID: 26477410 DOI: 10.1016/j.resuscitation.2015.07.038] [Citation(s) in RCA: 568] [Impact Index Per Article: 63.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Koenraad G Monsieurs
- Emergency Medicine, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium.
| | - Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, Bristol, UK
| | | | - Robert Greif
- Department of Anaesthesiology and Pain Medicine, University Hospital Bern, Bern, Switzerland; University of Bern, Bern, Switzerland
| | - Ian K Maconochie
- Paediatric Emergency Medicine Department, Imperial College Healthcare NHS Trust and BRC Imperial NIHR, Imperial College, London, UK
| | | | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Heart of England NHS Foundation Trust, Birmingham, UK
| | - Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Jonathan Wyllie
- Department of Neonatology, The James Cook University Hospital, Middlesbrough, UK
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Truhlář A, Deakin CD, Soar J, Khalifa GEA, Alfonzo A, Bierens JJLM, Brattebø G, Brugger H, Dunning J, Hunyadi-Antičević S, Koster RW, Lockey DJ, Lott C, Paal P, Perkins GD, Sandroni C, Thies KC, Zideman DA, Nolan JP, Böttiger BW, Georgiou M, Handley AJ, Lindner T, Midwinter MJ, Monsieurs KG, Wetsch WA. European Resuscitation Council Guidelines for Resuscitation 2015: Section 4. Cardiac arrest in special circumstances. Resuscitation 2015; 95:148-201. [PMID: 26477412 DOI: 10.1016/j.resuscitation.2015.07.017] [Citation(s) in RCA: 532] [Impact Index Per Article: 59.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic.
| | - Charles D Deakin
- Cardiac Anaesthesia and Cardiac Intensive Care, NIHR Southampton Respiratory Biomedical Research Unit, Southampton University Hospital NHS Trust, Southampton, UK
| | - Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | | | - Annette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife, UK
| | | | - Guttorm Brattebø
- Bergen Emergency Medical Services, Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Hermann Brugger
- EURAC Institute of Mountain Emergency Medicine, Bozen, Italy
| | - Joel Dunning
- Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
| | | | - Rudolph W Koster
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - David J Lockey
- Intensive Care Medicine and Anaesthesia, Southmead Hospital, North Bristol NHS Trust, Bristol, UK; School of Clinical Sciences, University of Bristol, UK
| | - Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-Universitaet, Mainz, Germany
| | - Peter Paal
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, Queen Mary University of London, London, UK; Department of Anaesthesiology and Critical Care Medicine, University Hospital Innsbruck, Austria
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Critical Care Unit, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
| | | | - David A Zideman
- Department of Anaesthetics, Imperial College Healthcare NHS Trust, London, UK
| | - Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, UK
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Prom R, Dull R, Delk B. Successful alteplase bolus administration for a presumed massive pulmonary embolism during cardiopulmonary resuscitation. Ann Pharmacother 2013; 47:1730-5. [PMID: 24259620 DOI: 10.1177/1060028013508644] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To describe the case of a patient successfully resuscitated with bolus alteplase for a presumed massive pulmonary embolism (PE) with associated cardiac arrest. CASE SUMMARY A 54-year-old man presented to the emergency department for evaluation of syncope following recent open reduction and internal fixation of his ankle. On arrival, his condition rapidly deteriorated and progressed to cardiopulmonary arrest. Because of noncompliance with postoperative thromboprophylaxis, there was high suspicion for PE. Following 40 minutes of advanced cardiac life support, empirical alteplase 50 mg was administered intravenously over 2 minutes with return of spontaneous circulation (ROSC) observed 6 minutes later. The diagnosis of PE using computed tomographic angiography was confirmed after fibrinolytic therapy. Although his hospital course was complicated by a gastrointestinal bleed requiring transfusion, he was discharged neurologically intact. DISCUSSION Clinical guidelines recommend fibrinolytic therapy for patients with PE and cardiac arrest. Data from retrospective analyses, case series, and case reports suggest that various fibrinolytic regimens may facilitate ROSC and improve neurologically intact survival without an increased risk of fatal hemorrhage. CONCLUSION The choice of fibrinolytic therapy should be based on hospital availability, with prompt initiation of treatment and incorporation of an intravenous bolus. A reasonable treatment regimen is alteplase 0.6 mg/kg (maximum of 50 mg) or fixed dose of alteplase 50 mg given over 2 to 15 minutes. Resuscitation should be continued for at least 30 minutes, or until ROSC, after fibrinolytic initiation to allow time for the medication to work.
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Effect of mild hypothermia on the coagulation-fibrinolysis system and physiological anticoagulants after cardiopulmonary resuscitation in a porcine model. PLoS One 2013; 8:e67476. [PMID: 23818980 PMCID: PMC3688589 DOI: 10.1371/journal.pone.0067476] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 05/19/2013] [Indexed: 11/22/2022] Open
Abstract
The aim of this study was to evaluate the effect of mild hypothermia on the coagulation-fibrinolysis system and physiological anticoagulants after cardiopulmonary resuscitation (CPR). A total of 20 male Wuzhishan miniature pigs underwent 8 min of untreated ventricular fibrillation and CPR. Of these, 16 were successfully resuscitated and were randomized into the mild hypothermia group (MH, n = 8) or the control normothermia group (CN, n = 8). Mild hypothermia (33°C) was induced intravascularly, and this temperature was maintained for 12 h before pigs were actively rewarmed. The CN group received normothermic post-cardiac arrest (CA) care for 72 h. Four animals were in the sham operation group (SO). Blood samples were taken at baseline, and 0.5, 6, 12, 24, and 72 h after ROSC. Whole-body mild hypothermia impaired blood coagulation during cooling, but attenuated blood coagulation impairment at 72 h after ROSC. Mild hypothermia also increased serum levels of physiological anticoagulants, such as PRO C and AT-III during cooling and after rewarming, decreased EPCR and TFPI levels during cooling but not after rewarming, and inhibited fibrinolysis and platelet activation during cooling and after rewarming. Finally, mild hypothermia did not affect coagulation-fibrinolysis, physiological anticoagulants, or platelet activation during rewarming. Thus, our findings indicate that mild hypothermia exerted an anticoagulant effect during cooling, which may have inhibitory effects on microthrombus formation. Furthermore, mild hypothermia inhibited fibrinolysis and platelet activation during cooling and attenuated blood coagulation impairment after rewarming. Slow rewarming had no obvious adverse effects on blood coagulation.
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Wada T, Gando S, Mizugaki A, Yanagida Y, Jesmin S, Yokota H, Ieko M. Coagulofibrinolytic changes in patients with disseminated intravascular coagulation associated with post-cardiac arrest syndrome--fibrinolytic shutdown and insufficient activation of fibrinolysis lead to organ dysfunction. Thromb Res 2013; 132:e64-9. [PMID: 23726093 DOI: 10.1016/j.thromres.2013.05.010] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2013] [Revised: 04/12/2013] [Accepted: 05/07/2013] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Post-cardiac arrest syndrome (PCAS) is often associated with disseminated intravascular coagulation (DIC), thus leading to the development of multiple organ dysfunction syndrome (MODS). The aim of this study was to examine the pathophysiological relationships between coagulation, fibrinolysis and fibrinolytic shutdown by evaluating the levels of coagulofibrinolytic markers, including soluble fibrin, thrombin-activatable fibrinolysis inhibitor (TAFI), tissue plasminogen activator-plasminogen activator inhibitor-1 complex (tPAIC), plasmin-alpha2 plasmin inhibitor complex (PPIC), neutrophil elastase and fibrin degradation product by neutrophil elastase (EXDP). MATERIALS AND METHODS Fifty-two resuscitated patients were divided into two groups: 22 DIC and 30 non-DIC patients. RESULTS The levels of soluble fibrin, PPIC, tPAIC, EXDP and neutrophil elastase in the DIC patients with PCAS were significantly higher than those observed in the non-DIC patients. The values of the tPAIC and JAAM DIC scores were found to be independent predictors of increased SOFA scores in the DIC patients. The MODS patients demonstrated significantly higher levels of soluble fibrin and tPAIC; however, the levels of TAFI and EXDP were identical between the patients with and without MODS. In addition, positive correlations were observed between the levels of tPAIC and EXDP in the patients with non-MODS; however, no correlations were observed between these markers in the MODS patients. CONCLUSIONS Thrombin activation and fibrinolytic shutdown play important roles in the development of organ dysfunction in PCAS patients. Neutrophil elastase-mediated fibrinolysis cannot overcome the fibrinolytic shutdown that occurs in DIC patients with PCAS, thus resulting in the development of MODS.
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Affiliation(s)
- Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
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Wada T, Jesmin S, Gando S, Yanagida Y, Mizugaki A, Sultana SN, Zaedi S, Yokota H. Angiogenic factors and their soluble receptors predict organ dysfunction and mortality in post-cardiac arrest syndrome. Crit Care 2012; 16:R171. [PMID: 23021336 PMCID: PMC3682270 DOI: 10.1186/cc11648] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2012] [Revised: 08/23/2012] [Accepted: 09/29/2012] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Post-cardiac arrest syndrome (PCAS) often leads to multiple organ dysfunction syndrome (MODS) with a poor prognosis. Endothelial and leukocyte activation after whole-body ischemia/reperfusion following resuscitation from cardiac arrest is a critical step in endothelial injury and related organ damage. Angiogenic factors, including vascular endothelial growth factor (VEGF) and angiopoietin (Ang), and their receptors play crucial roles in endothelial growth, survival signals, pathological angiogenesis and microvascular permeability. The aim of this study was to confirm the efficacy of angiogenic factors and their soluble receptors in predicting organ dysfunction and mortality in patients with PCAS. METHODS A total of 52 resuscitated patients were divided into two subgroups: 23 survivors and 29 non-survivors. The serum levels of VEGF, soluble VEGF receptor (sVEGFR)1, sVEGFR2, Ang1, Ang2 and soluble Tie2 (sTie2) were measured at the time of admission (Day 1) and on Day 3 and Day 5. The ratio of Ang2 to Ang1 (Ang2/Ang1) was also calculated. This study compared the levels of angiogenic factors and their soluble receptors between survivors and non-survivors, and evaluated the predictive value of these factors for organ dysfunction and 28-day mortality. RESULTS The non-survivors demonstrated more severe degrees of organ dysfunction and a higher prevalence of MODS. Non-survivors showed significant increases in the Ang2 levels and the Ang2/Ang1 ratios compared to survivors. A stepwise logistic regression analysis demonstrated that the Ang2 levels or the Ang2/Ang1 ratios on Day 1 independently predicted the 28-day mortality. The receiver operating characteristic curves of the Ang2 levels, and the Ang2/Ang1 ratios on Day 1 were good predictors of 28-day mortality. The Ang2 levels also independently predicted increases in the Sequential Organ Failure Assessment (SOFA) scores. CONCLUSIONS We observed a marked imbalance between Ang1 and Ang2 in favor of Ang2 in PCAS patients, and the effect was more prominent in non-survivors. Angiogenic factors and their soluble receptors, particularly Ang2 and Ang2/Ang1, are considered to be valuable predictive biomarkers in the development of organ dysfunction and poor outcomes in PCAS patients.
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Affiliation(s)
- Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, N17W5, Kita-ku, Sapporo 060-8638, Japan
| | - Subrina Jesmin
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, N17W5, Kita-ku, Sapporo 060-8638, Japan
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennoudai, Tsukuba, Ibaraki 305-8575, Japan
- Health and Diseases Research Center for Rural Peoples (HDRCRP), 14/15, 1st floor, Probal Housing Ltd., Shekertak (Adjacent to Shekertak Road 1), Mohammadpur, Dhaka 1207. Bangladesh
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, N17W5, Kita-ku, Sapporo 060-8638, Japan
| | - Yuichiro Yanagida
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, N17W5, Kita-ku, Sapporo 060-8638, Japan
| | - Asumi Mizugaki
- Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi Bunkyo-ku, Tokyo 113-8603, Japan
| | - Sayeeda N Sultana
- Health and Diseases Research Center for Rural Peoples (HDRCRP), 14/15, 1st floor, Probal Housing Ltd., Shekertak (Adjacent to Shekertak Road 1), Mohammadpur, Dhaka 1207. Bangladesh
| | - Sohel Zaedi
- Health and Diseases Research Center for Rural Peoples (HDRCRP), 14/15, 1st floor, Probal Housing Ltd., Shekertak (Adjacent to Shekertak Road 1), Mohammadpur, Dhaka 1207. Bangladesh
| | - Hiroyuki Yokota
- Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi Bunkyo-ku, Tokyo 113-8603, Japan
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Current pharmacological advances in the treatment of cardiac arrest. Emerg Med Int 2011; 2012:815857. [PMID: 22145080 PMCID: PMC3226361 DOI: 10.1155/2012/815857] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Accepted: 09/06/2011] [Indexed: 12/13/2022] Open
Abstract
Cardiac arrest is defined as the sudden cessation of spontaneous ventilation and circulation. Within 15 seconds of cardiac arrest, the patient loses consciousness, electroencephalogram becomes flat after 30 seconds, pupils dilate fully after 60 seconds, and cerebral damage takes place within 90–300 seconds. It is essential to act immediately as irreversible damage can occur in a short time. Cardiopulmonary resuscitation (CPR) is an attempt to restore spontaneous circulation through a broad range of interventions which are early defibrillation, high-quality and uninterrupted chest compressions, advanced airway interventions, and pharmacological interventions. Drugs should be considered only after initial shocks have been delivered (when indicated) and chest compressions and ventilation have been started. During cardiopulmonary resuscitation, no specific drug therapy has been shown to improve survival to hospital discharge after cardiac arrest, and only few drugs have a proven benefit for short-term survival. This paper reviews current pharmacological treatment of cardiac arrest. There are three groups of drugs relevant to the management of cardiac arrest: vasopressors, antiarrhythmics, and other drugs such as sodium bicarbonate, calcium, magnesium, atropine, fibrinolytic drugs, and corticosteroids.
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Nolan JP, Soar J, Zideman DA, Biarent D, Bossaert LL, Deakin C, Koster RW, Wyllie J, Böttiger B. European Resuscitation Council Guidelines for Resuscitation 2010 Section 1. Executive summary. Resuscitation 2011; 81:1219-76. [PMID: 20956052 DOI: 10.1016/j.resuscitation.2010.08.021] [Citation(s) in RCA: 847] [Impact Index Per Article: 65.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
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European Resuscitation Council Guidelines for Resuscitation 2010 Section 4. Adult advanced life support. Resuscitation 2011; 81:1305-52. [PMID: 20956049 DOI: 10.1016/j.resuscitation.2010.08.017] [Citation(s) in RCA: 751] [Impact Index Per Article: 57.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Effect of enoxaparin and aspirin on hemodynamic disturbances after global cerebral ischemia in rats. Resuscitation 2010; 81:1709-13. [DOI: 10.1016/j.resuscitation.2010.07.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2010] [Revised: 07/05/2010] [Accepted: 07/30/2010] [Indexed: 11/21/2022]
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Abstract
BACKGROUND Mild to moderate hypothermia (32-35 degrees C) is the first treatment with proven efficacy for postischemic neurological injury. In recent years important insights have been gained into the mechanisms underlying hypothermia's protective effects; in addition, physiological and pathophysiological changes associated with cooling have become better understood. OBJECTIVE To discuss hypothermia's mechanisms of action, to review (patho)physiological changes associated with cooling, and to discuss potential side effects. DESIGN Review article. INTERVENTIONS None. MAIN RESULTS A myriad of destructive processes unfold in injured tissue following ischemia-reperfusion. These include excitotoxicty, neuroinflammation, apoptosis, free radical production, seizure activity, blood-brain barrier disruption, blood vessel leakage, cerebral thermopooling, and numerous others. The severity of this destructive cascade determines whether injured cells will survive or die. Hypothermia can inhibit or mitigate all of these mechanisms, while stimulating protective systems such as early gene activation. Hypothermia is also effective in mitigating intracranial hypertension and reducing brain edema. Side effects include immunosuppression with increased infection risk, cold diuresis and hypovolemia, electrolyte disorders, insulin resistance, impaired drug clearance, and mild coagulopathy. Targeted interventions are required to effectively manage these side effects. Hypothermia does not decrease myocardial contractility or induce hypotension if hypovolemia is corrected, and preliminary evidence suggests that it can be safely used in patients with cardiac shock. Cardiac output will decrease due to hypothermia-induced bradycardia, but given that metabolic rate also decreases the balance between supply and demand, is usually maintained or improved. In contrast to deep hypothermia (<or=30 degrees C), moderate hypothermia does not induce arrhythmias; indeed, the evidence suggests that arrhythmias can be prevented and/or more easily treated under hypothermic conditions. CONCLUSIONS Therapeutic hypothermia is a highly promising treatment, but the potential side effects need to be properly managed particularly if prolonged treatment periods are required. Understanding the underlying mechanisms, awareness of physiological changes associated with cooling, and prevention of potential side effects are all key factors for its effective clinical usage.
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Cavallaro F, Sandroni C, Bocci MG, Marano C. Good neurological recovery after cardiopulmonary resuscitation and thrombolysis in two old patients with pulmonary embolism. Acta Anaesthesiol Scand 2009; 53:400-2. [PMID: 19243326 DOI: 10.1111/j.1399-6576.2008.01861.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The use of thrombolysis as an emergency treatment for cardiac arrest (CA) due to massive pulmonary embolism (MPE) has been described. However, there are no reports of successful treatment of MPE-associated CA in patients over 77 years of age. We report two cases of successful cardiopulmonary resuscitation for an MPE-associated CA in two very old women (87 and 86 years of age). In both cases, typical signs of MPE were documented using emergency echocardiography, which showed an acute right ventricle enlargement and a paradoxical movement of the interventricular septum. Emergency thrombolysis was administered during resuscitation, which lasted 45 and 21 min, respectively. Despite old age and prolonged resuscitation efforts, both patients had good neurological recovery and one of them was alive and neurologically intact 1 year later. Thrombolysis is a potentially useful therapy in MPE-associated CA. A good neurological outcome can be obtained even in very old patients and after prolonged resuscitation.
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Affiliation(s)
- F Cavallaro
- Department of Anaesthesiology and Intensive Care, Intensive Care Unit, Catholic University School of Medicine, Policlinico A. Gemelli, Rome, Italy.
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Matyal R, Grinberg AO, Panzica PJ, Darke M, Lerner AB, Fisher L, Campbell D, Mahmood F. Heparin administration during cardiopulmonary resuscitation. J Cardiothorac Vasc Anesth 2008; 22:861-3. [PMID: 18834837 DOI: 10.1053/j.jvca.2008.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2008] [Indexed: 11/11/2022]
Affiliation(s)
- Robina Matyal
- Department of Anesthesia and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
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Keuper W, Dieker HJ, Brouwer MA, Verheugt FW. Reperfusion therapy in out-of-hospital cardiac arrest: Current insights. Resuscitation 2007; 73:189-201. [DOI: 10.1016/j.resuscitation.2006.08.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2006] [Revised: 07/26/2006] [Accepted: 08/03/2006] [Indexed: 10/23/2022]
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Koroneos A, Koutsoukou A, Zervakis D, Politis P, Sourlas S, Pagoni E, Roussos C. Successful resuscitation with thrombolysis of a patient suffering fulminant pulmonary embolism after recent intracerebral haemorrhage. Resuscitation 2006; 72:154-7. [PMID: 17084012 DOI: 10.1016/j.resuscitation.2006.06.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2006] [Revised: 06/07/2006] [Accepted: 06/12/2006] [Indexed: 11/20/2022]
Abstract
We report the life-saving administration of thrombolysis during cardiopulmonary resuscitation in a patient with recent intracerebral haemorrhage. A 53-year-old male with intracerebral haemorrhage was admitted to the intensive care unit. On the 24th day of treatment he suffered cardiac arrest with pulseless electrical activity. Transoesophageal echocardiography was performed during ongoing cardiopulmonary resuscitation. Thrombi in the right heart cavities with excessive right ventricular dysfunction confirmed the diagnosis of fulminant pulmonary embolism. Permanent restoration of a spontaneous rhythm was feasible only after administration of systemic thrombolysis with recombinant tissue plasminogen activator. Neurological examination and a computed tomogram of the brain did not show rebleeding. We conclude that under extreme circumstances absolute contraindications to thrombolysis should be weighed against the potential benefit.
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Affiliation(s)
- Apostolos Koroneos
- Department of Pulmonary and Critical Care Services, University of Athens Medical School, Evangelismos Hospital, Athens, Greece.
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37
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Popp E, Böttiger BW. Cerebral resuscitation: state of the art, experimental approaches and clinical perspectives. Neurol Clin 2006; 24:73-87, vi. [PMID: 16443131 DOI: 10.1016/j.ncl.2005.10.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Neuronal injury following global cerebral ischemia continues to bea central problem of patients in the postresuscitation phase following cardiocirculatory arrest. In addition to measures focusing on rapid restoration of spontaneous circulation, the most effective treatment after cardiac arrest, as shown by large randomized trials,is the use of therapeutic mild hypothermia. Current guidelines of the International Liaison Committee on Resuscitation (ILCOR)are recommending the use of therapeutic mild hypothermia for all unconscious patients after cardiac arrest. At present there is no specific neuroprotective treatment available. Promising animal experimental data concerning the use of thrombolytic agents during cardiopulmonary resuscitation have led to a large European multicenter trial (TROICA trial) that will provide its data in 2006.
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Affiliation(s)
- Erik Popp
- Department of Anesthesiology, University of Heidelberg, Im Neuenheimer Feld 110, D-69120, Heidelberg, Germany
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38
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Nolan JP, Deakin CD, Soar J, Böttiger BW, Smith G, Baubin M, Dirks B, Wenzel V. Erweiterte Reanimationsmaßnahmen für Erwachsene (ALS). Notf Rett Med 2006; 9:38-80. [PMID: 32834772 PMCID: PMC7371819 DOI: 10.1007/s10049-006-0796-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- J. P. Nolan
- Sektion Notfallmedizin, Universitätsklinik für Anästhesiologie, Ulm
| | - C. D. Deakin
- Sektion Notfallmedizin, Universitätsklinik für Anästhesiologie, Ulm
| | - J. Soar
- Sektion Notfallmedizin, Universitätsklinik für Anästhesiologie, Ulm
| | - B. W. Böttiger
- Sektion Notfallmedizin, Universitätsklinik für Anästhesiologie, Ulm
| | - G. Smith
- Sektion Notfallmedizin, Universitätsklinik für Anästhesiologie, Ulm
| | - M. Baubin
- Klinik für Anästhesie und allgemeine Intensivmedizin, Universität, Innsbruck, Österreich
| | - B. Dirks
- Sektion Notfallmedizin, Universitätsklinik für Anästhesiologie, Ulm
- Sektion Notfallmedizin, Universitätsklinik für Anästhesiologie, Prittwitzstraße 43, 89075 Ulm
| | - V. Wenzel
- Klinik für Anästhesie und allgemeine Intensivmedizin, Universität, Innsbruck, Österreich
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Nolan JP, Deakin CD, Soar J, Böttiger BW, Smith G. European Resuscitation Council Guidelines for Resuscitation 2005. Resuscitation 2005; 67 Suppl 1:S39-86. [PMID: 16321716 DOI: 10.1016/j.resuscitation.2005.10.009] [Citation(s) in RCA: 606] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Adams BD, Zeiler K, Jackson WO, Hughes B. Emergency medicine residents effectively direct inhospital cardiac arrest teams. Am J Emerg Med 2005; 23:304-10. [PMID: 15915402 DOI: 10.1016/j.ajem.2005.02.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY OBJECTIVE We compared 2 models of physician leadership for inhospital cardiac arrest teams (CATs): emergency medicine (EM) residents and staff hospitalist physicians. METHODS A before-after study was conducted on all adult inhospital CAT activations over a 2-year period. The primary outcome was return of spontaneous circulation (ROSC). RESULTS There were 749 total code blues during the 2-year study period. Ninety-one were excluded by protocol. EM residents directed 288 codes, hospitalists directed 248 codes, and other specialties directed the remaining 62. There was no statistically significant difference in percent ROSC or survival to hospital discharge. EM residents responded first for 59.2% of the codes compared with a first response rate of 28% for hospitalists (P<.05). Time to achieve ROSC was quicker in the EM resident cohort. CONCLUSION Our findings validate the use of a 24-hour EM resident staffing model for CAT response to inhospital cardiac arrests.
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Affiliation(s)
- Bruce D Adams
- Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, TX 78234-6200, USA.
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41
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Abstract
Until recently, perioperative thrombolysis has always been thought to be a contraindication, because of the risk of bleeding complications. However, many case reports now show that thrombolytic drugs can be successfully used in the perioperative period. Possible indications for perioperative thrombolysis are massive pulmonary embolism and cardiopulmonary resuscitation which are also important causes of cardiac arrest. Thrombolysis can be the decisive therapeutical option, e.g. when normal cardiopulmonary resuscitation measures are not successful. Nevertheless, even against the background of many positive case reports the indication for perioperative thrombolysis should be a case-specific decision as the frequency of complications depends on the surgical intervention and must be weighed against the possible benefits of early thrombolysis. For perioperative thrombolysis there are no data available showing a beneficial effect of one particular therapeutic regimen. In the literature it is suggested that thrombolysis should be performed as quickly as possible, because the risk of bleeding complications depends more on the duration of thrombolysis than on the dosage or the thrombolytic drug itself.
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Affiliation(s)
- F Spöhr
- Klinik für Anaesthesiologie, Universitätsklinikum, Heidelberg.
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42
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Spöhr F, Arntz HR, Bluhmki E, Bode C, Carli P, Chamberlain D, Danays T, Poth J, Skamira C, Wenzel V, Böttiger BW. International multicentre trial protocol to assess the efficacy and safety of tenecteplase during cardiopulmonary resuscitation in patients with out-of-hospital cardiac arrest: the Thrombolysis in Cardiac Arrest (TROICA) Study. Eur J Clin Invest 2005; 35:315-23. [PMID: 15860043 DOI: 10.1111/j.1365-2362.2005.01491.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Prehospital cardiac arrest has been associated with a very poor prognosis. Acute myocardial infarction and massive pulmonary embolism are the underlying causes of out-of-hospital cardiac arrest in 50-70% of patients. Although fibrinolysis is an effective treatment strategy for both myocardial infarction and pulmonary embolism, clinical experience for this therapy performed during resuscitation has been limited owing to the anticipated risk of severe bleeding complications. The TROICA study is planned as one of the largest randomized, double-blind, placebo-controlled trials to assess the efficacy and safety of prehospital thrombolytic therapy in cardiac arrest of presumed cardiac origin. Approximately 1000 patients with cardiac arrest will be randomized at approximately 60 international study centres to receive either a weight-adjusted dose of tenecteplase or placebo after the first dose of a vasopressor. Patients can be included if they are at least 18 years, presenting with a witnessed cardiac arrest of presumed cardiac origin, and if either basic life support had started within 10 min of onset and had been performed up to 10 min or advanced life support is started within 10 min of onset of cardiac arrest. Primary endpoint of the study is the 30-day survival rate, and the coprimary endpoint is hospital admission. Secondary endpoints are the return of spontaneous circulation (ROSC), survival after 24 h, survival to hospital discharge, and neurological performance. Safety endpoints include major bleeding complications and symptomatic intracranial haemorrhage.
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Affiliation(s)
- F Spöhr
- Department of Anaesthesiology, University of Heidelberg, Heidelberg, Germany
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Carey HV, Andrews MT, Martin SL. Mammalian hibernation: cellular and molecular responses to depressed metabolism and low temperature. Physiol Rev 2003; 83:1153-81. [PMID: 14506303 DOI: 10.1152/physrev.00008.2003] [Citation(s) in RCA: 785] [Impact Index Per Article: 37.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Mammalian hibernators undergo a remarkable phenotypic switch that involves profound changes in physiology, morphology, and behavior in response to periods of unfavorable environmental conditions. The ability to hibernate is found throughout the class Mammalia and appears to involve differential expression of genes common to all mammals, rather than the induction of novel gene products unique to the hibernating state. The hibernation season is characterized by extended bouts of torpor, during which minimal body temperature (Tb) can fall as low as -2.9 degrees C and metabolism can be reduced to 1% of euthermic rates. Many global biochemical and physiological processes exploit low temperatures to lower reaction rates but retain the ability to resume full activity upon rewarming. Other critical functions must continue at physiologically relevant levels during torpor and be precisely regulated even at Tb values near 0 degrees C. Research using new tools of molecular and cellular biology is beginning to reveal how hibernators survive repeated cycles of torpor and arousal during the hibernation season. Comprehensive approaches that exploit advances in genomic and proteomic technologies are needed to further define the differentially expressed genes that distinguish the summer euthermic from winter hibernating states. Detailed understanding of hibernation from the molecular to organismal levels should enable the translation of this information to the development of a variety of hypothermic and hypometabolic strategies to improve outcomes for human and animal health.
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Affiliation(s)
- Hannah V Carey
- Department of Comparative Biosciences, School of Veterinary Medicine, University of Wisconsin, Madison, WI 53706, USA.
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44
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Abstract
The prognosis is generally poor for patients who experience a cardiac arrest. The most common causes of sudden cardiac arrest are massive pulmonary embolism (PE) and acute myocardial infarction (MI). While thrombolysis is a first-line treatment option in massive PE and acute MI, cardiopulmonary resuscitation (CPR) has been regarded as a relative contraindication for thrombolysis because of the anticipated bleeding risk caused by traumatic cardiocompressions. However, an increasing number of case reports and clinical studies on thrombolysis during and after CPR highlight an increased frequency of the return of spontaneous circulation and a better neurological outcome of surviving patients. These effects are mainly due to the thrombolysis of macroscopic blood clots and the amelioration of microcirculatory reperfusion. This article reviews case reports and clinical studies of thrombolysis during and shortly after CPR in order to estimate the risk of severe bleeding events caused by CPR in association with thrombolysis compared with CPR without thrombolysis. Although thrombolysis per se can cause severe and potentially fatal haemorrhage, there is no evidence that severe bleeding events occur more often when thrombolysis is combined with cardiocompressions. In addition, by far the majority of bleeding complications can be treated effectively. Thus, in many cases, the possible benefit of thrombolysis during CPR seems to outweigh the potential risks. However, there may be a publication bias in some case reports and studies towards reporting successful rather than unsuccessful CPRs. In addition, not enough controlled clinical trials have yet been conducted. Therefore, data from large randomised, multicentre studies are needed to definitely answer the question of the relationship between safety and efficacy of this promising treatment option. We conclude that the currently available data do not indicate that thrombolysis contributes to a significant increase in bleeding complications when administered during CPR.
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Affiliation(s)
- Fabian Spöhr
- Department of Anaesthesiology, University of Heidelberg, Heidelberg, Germany.
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45
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Böttiger BW, Spöhr F. The risk of thrombolysis in association with cardiopulmonary resuscitation: no reason to withhold this causal and effective therapy. J Intern Med 2003; 253:99-101. [PMID: 12542549 DOI: 10.1046/j.1365-2796.2003.01106.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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46
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Epperson LE, Martin SL. Quantitative assessment of ground squirrel mRNA levels in multiple stages of hibernation. Physiol Genomics 2002; 10:93-102. [PMID: 12181366 DOI: 10.1152/physiolgenomics.00004.2002] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Hibernators in torpor dramatically reduce their metabolic, respiratory, and heart rates and core body temperature. These extreme physiological conditions are frequently and rapidly reversed during the winter hibernation season via endogenous mechanisms. This phenotype must derive from regulated expression of the hibernator's genome; to identify its molecular components, a cDNA subtraction was used to enrich for seasonally upregulated mRNAs in liver of golden-mantled ground squirrels. The relative steady-state levels for seven mRNAs identified by this screen, plus five others, were measured and analyzed for seasonal and stage-specific differences using kinetic RT-PCR. Four mRNAs show seasonal upregulation in which all five winter stages differ significantly from and are higher than summer (alpha2-macroglobulin, apolipoprotein A1, cathepsin H, and thyroxine-binding globulin). One of these mRNAs, alpha2-macroglobulin, varies during the winter stages with significantly lower levels at late torpor. None of the 12 mRNAs increased during torpor. The implications for these newly recognized upregulated mRNAs for hibernation as well as more global issues of maintaining steady-state levels of mRNA during torpor are discussed.
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Affiliation(s)
- L Elaine Epperson
- Program in Molecular Biology, Department of Cellular and Structural Biology, University of Colorado Health Sciences Center, Denver, Colorado 80262, USA
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Nolan JP, De Latorre FJ, Steen PA, Chamberlain DA, Bossaert LL. Advanced life support drugs: do they really work? Curr Opin Crit Care 2002; 8:212-8. [PMID: 12386499 DOI: 10.1097/00075198-200206000-00003] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Basic life support and rapid defibrillation for ventricular fibrillation or pulseless ventricular tachycardia are the only two interventions that have been shown unequivocally to improve survival after cardiac arrest. Several drugs are advocated to treat cardiac arrest, but despite very encouraging animal data, no drug has been reliably proven to increase survival to hospital discharge after cardiac arrest. This review focuses on recent experimental and clinical data concerning the use of vasopressin, amiodarone, magnesium, and fibrinolytics during advanced life support (ALS). Animal data indicate that, in comparison with epinephrine (adrenaline), vasopressin produces better vital organ blood flow during cardiopulmonary resuscitation (CPR). These apparent advantages have yet to be converted into improved survival in large-scale trials of cardiac arrest in humans. Data from two prospective, randomized trials suggest that amiodarone may improve short-term survival after out-of-hospital ventricular fibrillation cardiac arrest. On the basis of anecdotal data, magnesium is recommended therapy for torsades de pointes and for shock-resistant ventricular fibrillation associated with hypomagnesemia. In the past, CPR has been a contraindication to giving fibrinolytics, but several studies have demonstrated the relative safety of fibrinolysis during and after CPR. Fibrinolytics are likely to be beneficial when cardiac arrest is associated with plaque rupture and fresh coronary thrombus or massive pulmonary embolism. Fibrinolysis may also improve cerebral microcirculatory perfusion once a spontaneous circulation has been restored. A planned, prospective, randomized trial may help to define the role of fibrinolysis during out-of-hospital CPR.
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Affiliation(s)
- Jerry P Nolan
- Advanced Life Support Working Group of the European Resuscitation Council and Royal United Hospital, Combe Park, Bath, UK
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48
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Padosch SA, Martin E, Böttiger BW. Thrombolytic therapy during and/or after cardiopulmonary resuscitation. Intensive Care Med 2002; 28:665. [PMID: 12029422 DOI: 10.1007/s00134-002-1278-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2001] [Accepted: 02/20/2002] [Indexed: 11/24/2022]
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49
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Padosch SA, Milde AS, Martin E, Böttiger W. Thrombolytic therapy during cardiopulmonary resuscitation--is the initial cardiac rhythm a critical issue? Acta Anaesthesiol Scand 2002; 46:620-1. [PMID: 12027864 DOI: 10.1034/j.1399-6576.2002.460526_2.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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50
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Abstract
Permanent brain damage after cardiac arrest and resuscitation is determined by many factors, predominantly arrest (no-flow) time, cardiopulmonary resuscitation (low-flow) time, and temperature. Research since around 1970 into cardiopulmonary-cerebral resuscitation has attempted to mitigate the postischemic-anoxic encephalopathy. These efforts' results have recently shown outcome benefits as documented in clinically relevant outcome models in dogs and in clinical trials. Pharmacologic strategies have so far yielded relatively disappointing results. In a recent exploration of 14 drugs in dogs, only the antioxidant tempol administered at the start of prolonged cardiac arrest improved functional outcome in dogs. Cerebral blood flow promotion by hypertensive reperfusion and hemodilution has resulted in improved outcome in dogs, and brief hypertension after restoration of spontaneous circulation is associated with improved outcome in patients. Postarrest hypercoagulability of blood seems to yield to therapeutic thrombolysis, which is associated with improved cerebral outcome in animals and patients. In a clinically relevant dog outcome model, mild postarrest cerebral hypothermia (34 degrees C), initiated with reperfusion and continued for 12 hrs, combined with cerebral blood-flow promotion increased from 5 to >10 mins the previously longest normothermic no-flow time that could be reversed to complete cerebral recovery. Mild hypothermia by surface cooling after prolonged cardiac arrest in patients has been found effective in recent clinical studies in Australia and Europe. Preliminary data on the recent randomized study in Europe have been reported. For presently unresuscitable cardiac arrests, research since the 1980s in dog outcome models of prolonged exsanguination cardiac arrest has culminated in brain and organism preservation during cardiac arrest (no-flow) durations of up to 90 mins, perhaps 120 mins, at a tympanic temperature of 10 degrees C and complete recovery of function and normal histology. This "suspended animation for delayed resuscitation" strategy includes use of an aortic flush of cold saline (or preservation solution) within the first 5 mins of no flow. This strategy should also be explored for the larger number of patients with unresuscitable out-of-hospital cardiac arrests. Suspended animation for prolonged preservation of viability could buy time for transport and repair during hypothermic no flow followed by resuscitation, or it could serve as a bridge to prolonged cardiopulmonary bypass.
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Affiliation(s)
- Peter Safar
- Safar Center for Resuscitation Research, Department of Anesthesiology and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15260, USA.
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