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Jaeger D, Kalra R, Sebastian P, Gaisendrees C, Kosmopoulos M, Debaty G, Chouihed T, Bartos J, Yannopoulos D. Left rib fractures during cardiopulmonary resuscitation are associated with hemodynamic variations in a pig model of cardiac arrest. Resusc Plus 2023; 15:100429. [PMID: 37502743 PMCID: PMC10368933 DOI: 10.1016/j.resplu.2023.100429] [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: 05/24/2023] [Revised: 06/23/2023] [Accepted: 07/01/2023] [Indexed: 07/29/2023] Open
Abstract
Background Chest compressions (CC) are the cornerstone of cardiopulmonary resuscitation (CPR). But CC are also known to cause injuries, specifically rib fractures. The effects of such fractures have not been examined yet. This study aimed to investigate hemodynamic effects of rib fractures during mechanical CPR in a porcine model of cardiac arrest (CA). Methods We conducted a retrospective hemodynamic study in 31 pigs that underwent mechanical CC. Animals were divided into three groups based on the location of rib fractures: No Broken Ribs group (n = 11), Left Broken Ribs group (n = 13), and Right Broken Ribs group (n = 7). Hemodynamic measurements were taken at 10 seconds before and 10, 30, and 60 seconds after rib fractures. Results Baseline hemodynamic parameters did not differ between the three groups. Systolic aortic pressure was overall higher in the Left Broken Ribs group than in the No Broken Ribs group at 10, 30, and 60 seconds after rib fracture (p = 0.02, 0.01, and 0.006, respectively). The Left Broken Ribs group had a significantly higher right atrial pressure compared to the No Broken Rib group after rib fracture (p = 0.02, 0.01, and 0.03, respectively). There was no significant difference for any parameter for the Right Broken Ribs group, when compared to the No Broken Ribs group. Conclusion An increase in main hemodynamic parameters was observed after left rib fractures while right broken ribs were not associated with any change in hemodynamic parameters. Reporting fractures and their location seems worthwhile for future experimental studies.
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Affiliation(s)
- Deborah Jaeger
- Department of Medicine-Cardiovascular Division, University of Minnesota, Minneapolis, MN, USA
- INSERM U 1116, University of Lorraine, Vandœuvre-lès-Nancy, France
| | - Rajat Kalra
- Department of Medicine-Cardiovascular Division, University of Minnesota, Minneapolis, MN, USA
| | - Pierre Sebastian
- Department of Medicine-Cardiovascular Division, University of Minnesota, Minneapolis, MN, USA
| | - Christopher Gaisendrees
- Department of Medicine-Cardiovascular Division, University of Minnesota, Minneapolis, MN, USA
- Department of Cardiothoracic Surgery, Heart Centre, University of Cologne, Cologne, Germany
| | - Marinos Kosmopoulos
- Department of Medicine-Cardiovascular Division, University of Minnesota, Minneapolis, MN, USA
| | - Guillaume Debaty
- Department of Medicine-Cardiovascular Division, University of Minnesota, Minneapolis, MN, USA
- Université Grenoble Alpes, CNRS, CHU de Grenoble, TIMC-IMAG UMR 5525, Av. des Maquis du Grésivaudan, 38700 La Tronche, France
| | - Tahar Chouihed
- INSERM U 1116, University of Lorraine, Vandœuvre-lès-Nancy, France
| | - Jason Bartos
- Department of Medicine-Cardiovascular Division, University of Minnesota, Minneapolis, MN, USA
| | - Demetris Yannopoulos
- Department of Medicine-Cardiovascular Division, University of Minnesota, Minneapolis, MN, USA
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Aufderheide TP, Kalra R, Kosmopoulos M, Bartos JA, Yannopoulos D. Enhancing cardiac arrest survival with extracorporeal cardiopulmonary resuscitation: insights into the process of death. Ann N Y Acad Sci 2022; 1507:37-48. [PMID: 33609316 PMCID: PMC8377067 DOI: 10.1111/nyas.14580] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/30/2021] [Accepted: 02/02/2021] [Indexed: 01/03/2023]
Abstract
Extracorporeal cardiopulmonary resuscitation (ECPR) is an emerging method of cardiopulmonary resuscitation to improve outcomes from cardiac arrest. This approach targets patients with out-of-hospital cardiac arrest previously unresponsive and refractory to standard treatment, combining approximately 1 h of standard CPR followed by venoarterial extracorporeal membrane oxygenation (VA-ECMO) and coronary artery revascularization. Despite its relatively new emergence for the treatment of cardiac arrest, the approach is grounded in a vast body of preclinical and clinical data that demonstrate significantly improved survival and neurological outcomes despite unprecedented, prolonged periods of CPR. In this review, we detail the principles behind VA-ECMO-facilitated resuscitation, contemporary clinical approaches with outcomes, and address the emerging new understanding of the process of death and capability for neurological recovery.
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Affiliation(s)
- Tom P. Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Rajat Kalra
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN,Cardiovascular Division, University of Minnesota, Minneapolis, MN
| | - Marinos Kosmopoulos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Jason A. Bartos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN,Cardiovascular Division, University of Minnesota, Minneapolis, MN
| | - Demetris Yannopoulos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN,Cardiovascular Division, University of Minnesota, Minneapolis, MN
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Ripeckyj A, Kosmopoulos M, Shekar K, Carlson C, Kalra R, Rees J, Aufderheide TP, Bartos JA, Yannopoulos D. Sodium Nitroprusside-Enhanced Cardiopulmonary Resuscitation Improves Blood Flow by Pulmonary Vasodilation Leading to Higher Oxygen Requirements. ACTA ACUST UNITED AC 2020; 5:183-192. [PMID: 32140624 PMCID: PMC7046538 DOI: 10.1016/j.jacbts.2019.11.010] [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] [Received: 07/15/2019] [Revised: 11/26/2019] [Accepted: 11/26/2019] [Indexed: 01/14/2023]
Abstract
SNPeCPR improves coronary perfusion pressure, tissue perfusion, and carotid blood flow compared to epinephrine-based standard advanced cardiac life support. In a porcine model of prolonged resuscitation, SNPeCPR was associated with decreased arterial oxygen saturation but improved tissue oxygen delivery due to improvement in blood flow. Oxygen supplementation led to alleviation of hypoxemia and maintenance of the SNPeCPR hemodynamic benefits. Arterial oxygen saturation must be a safety endpoint that will be prospectively assessed in the first SNPeCPR clinical trial in humans.
Sodium nitroprusside–enhanced cardiopulmonary resuscitation has shown superior resuscitation rates and neurologic outcomes in large animal models supporting the need for a randomized human clinical trial. This study is the first to show nonselective pulmonary vasodilation as a potential mechanism for the hemodynamic benefits. The pulmonary shunting that is created requires increased oxygen treatment, but the overall improvement in blood flow increases minute oxygen delivery to tissues. In this context, hypoxemia is an important safety endpoint and a 100% oxygen ventilation strategy may be necessary for the first human clinical trial.
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Key Words
- A-a, alveolar-arterial
- ACLS, advanced cardiac life support
- BLS, basic life support
- CBF, carotid blood flow
- CPP, coronary perfusion pressure
- CPR, cardiopulmonary resuscitation
- FiO2, fraction of inspired oxygen
- ITD, impedance threshold device
- ROSC, return of spontaneous circulation
- SNP, sodium nitroprusside
- SNPeCPR, sodium nitroprusside–enhanced cardiopulmonary resuscitation
- VF, ventricular fibrillation
- cardiopulmonary resuscitation
- coronary perfusion pressure
- lactic acid
- pulmonary vasodilation
- sodium nitroprusside
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Affiliation(s)
- Adrian Ripeckyj
- Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota
| | | | - Kadambari Shekar
- Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota
| | - Claire Carlson
- Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota
| | - Rajat Kalra
- Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota
| | - Jennifer Rees
- Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota
| | - Tom P. Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jason A. Bartos
- Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota
- Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, Minnesota
| | - Demetris Yannopoulos
- Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota
- Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, Minnesota
- Address for correspondence: Dr. Demetris Yannopoulos, Center for Resuscitation Medicine, Office of Academic Clinical Affairs, University of Minnesota Medical School, 420 Delaware Street, Southeast, MMC 508 Mayo, Minneapolis, Minnesota 55455.
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Nichol G, Bartos J, Tonna JE, Ferrari M. Intraoperative Temperature Management. Ther Hypothermia Temp Manag 2020; 10:6-10. [PMID: 31928508 DOI: 10.1089/ther.2019.29068.gjn] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Graham Nichol
- University of Washington-Harborview Center for Prehospital Emergency Care, Seattle, Washington
| | - Jason Bartos
- Division of Cardiovascular, University of Minnesota School of Medicine, Minneapolis, Minnesota
| | - Joseph E Tonna
- Division of Cardiothoracic Surgery, University of Utah School of Medicine, Salt Lake City, Utah.,Division of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, Utah
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Abstract
PURPOSE OF REVIEW Survival with favorable neurological function after cardiac arrest remains low. The purpose of this review is to identify recent advances that focus on neuroprotection during cardiopulmonary resuscitation (CPR). RECENT FINDINGS Multiple strategies have been shown to enhance neuroprotection during CPR. Brain perfusion during CPR is increased with therapies such as active compression decompression CPR and intrathoracic pressure regulation that improve cardiac preload and decrease intracranial pressure. Head Up CPR has been shown to decrease intracranial pressure thereby increasing cerebral perfusion pressure and cerebral blood flow. Sodium nitroprusside enhanced CPR increases cerebral perfusion, facilitates heat exchange, and improves neurologic survival in swine after cardiac arrest. Postconditioning has been administered during CPR in laboratory settings. Poloxamer 188, a membrane stabilizer, and ischemic postconditioning have been shown to improve cardiac and neural function after cardiac arrest in animal models. Postconditioning with inhaled gases protects the myocardium, with more evidence mounting for the potential for neural protection. SUMMARY Multiple promising neuroprotective therapies are being developed in animal models of cardiac arrest, and are in early stages of human trials. These therapies have the potential to be bundled together to improve rates of favorable neurological survival after cardiac arrest.
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Yannopoulos D, Bartos JA, George SA, Sideris G, Voicu S, Oestreich B, Matsuura T, Shekar K, Rees J, Aufderheide TP. Sodium nitroprusside enhanced cardiopulmonary resuscitation improves short term survival in a porcine model of ischemic refractory ventricular fibrillation. Resuscitation 2016; 110:6-11. [PMID: 27771299 DOI: 10.1016/j.resuscitation.2016.09.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 09/16/2016] [Accepted: 09/30/2016] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Sodium nitroprusside (SNP) enhanced CPR (SNPeCPR) demonstrates increased vital organ blood flow and survival in multiple porcine models. We developed a new, coronary occlusion/ischemia model of prolonged resuscitation, mimicking the majority of out-of-hospital cardiac arrests presenting with shockable rhythms. HYPOTHESIS SNPeCPR will increase short term (4-h) survival compared to standard 2015 Advanced Cardiac Life Support (ACLS) guidelines in an ischemic refractory ventricular fibrillation (VF), prolonged CPR model. METHODS Sixteen anesthetized pigs had the ostial left anterior descending artery occluded leading to ischemic VF arrest. VF was untreated for 5min. Basic life support was performed for 10min. At minute 10 (EMS arrival), animals received either SNPeCPR (n=8) or standard ACLS (n=8). Defibrillation (200J) occurred every 3min. CPR continued for a total of 45min, then the balloon was deflated simulating revascularization. CPR continued until return of spontaneous circulation (ROSC) or a total of 60min, if unsuccessful. SNPeCPR animals received 2mg of SNP at minute 10 followed by 1mg every 5min until ROSC. Standard ACLS animals received 0.5mg epinephrine every 5min until ROSC. Primary endpoints were ROSC and 4-h survival. RESULTS All SNPeCPR animals (8/8) achieved sustained ROSC versus 2/8 standard ACLS animals within one hour of resuscitation (p=0.04). The 4-h survival was significantly improved with SNPeCPR compared to standard ACLS, 7/8 versus 1/8 respectively, p=0.0019. CONCLUSION SNPeCPR significantly improved ROSC and 4-h survival compared with standard ACLS CPR in a porcine model of prolonged ischemic, refractory VF cardiac arrest.
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Affiliation(s)
- Demetris Yannopoulos
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States.
| | - Jason A Bartos
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Stephen A George
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - George Sideris
- Department of Cardiology, Inserm U942, Lariboisiere Hospital, AP-HP, Paris Diderot University, Paris, France
| | - Sebastian Voicu
- Department of Cardiology, Inserm U942, Lariboisiere Hospital, AP-HP, Paris Diderot University, Paris, France
| | - Brett Oestreich
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Timothy Matsuura
- Department of Integrated Biology & Physiology, University of Minnesota, Minneapolis, MN, United States
| | - Kadambari Shekar
- Department of Integrated Biology & Physiology, University of Minnesota, Minneapolis, MN, United States
| | - Jennifer Rees
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Tom P Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
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Chalkias A, Athanasopoulos D, Xanthos T. Optimizing tissue perfusion during targeted temperature management. Injury 2016; 47:2383-2384. [PMID: 27401029 DOI: 10.1016/j.injury.2016.06.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 06/25/2016] [Indexed: 02/02/2023]
Affiliation(s)
- Athanasios Chalkias
- National and Kapodistrian University of Athens, Medical School, MSc "Cardiopulmonary Resuscitation", Athens, Greece; Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece.
| | | | - Theodoros Xanthos
- Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece; European University Cyprus, School of Medicine, Nicosia, Cyprus
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Abstract
The modern treatment of cardiac arrest is an increasingly complex medical procedure with a rapidly changing array of therapeutic approaches designed to restore life to victims of sudden death. The 2 primary goals of providing artificial circulation and defibrillation to halt ventricular fibrillation remain of paramount importance for saving lives. They have undergone significant improvements in technology and dissemination into the community subsequent to their establishment 60 years ago. The evolution of artificial circulation includes efforts to optimize manual cardiopulmonary resuscitation, external mechanical cardiopulmonary resuscitation devices designed to augment circulation, and may soon advance further into the rapid deployment of specially designed internal emergency cardiopulmonary bypass devices. The development of defibrillation technologies has progressed from bulky internal defibrillators paddles applied directly to the heart, to manually controlled external defibrillators, to automatic external defibrillators that can now be obtained over-the-counter for widespread use in the community or home. But the modern treatment of cardiac arrest now involves more than merely providing circulation and defibrillation. As suggested by a 3-phase model of treatment, newer approaches targeting patients who have had a more prolonged cardiac arrest include treatment of the metabolic phase of cardiac arrest with therapeutic hypothermia, agents to treat or prevent reperfusion injury, new strategies specifically focused on pulseless electric activity, which is the presenting rhythm in at least one third of cardiac arrests, and aggressive post resuscitation care. There are discoveries at the cellular and molecular level about ischemia and reperfusion pathobiology that may be translated into future new therapies. On the near horizon is the combination of advanced cardiopulmonary bypass plus a cocktail of multiple agents targeted at restoration of normal metabolism and prevention of reperfusion injury, as this holds the promise of restoring life to many patients for whom our current therapies fail.
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Affiliation(s)
- Kaustubha D Patil
- From the Department of Medicine, Division of Cardiology, Johns Hopkins University, Baltimore, MD (K.D.P., H.R.H.); Departments of Radiology and Biomedical Engineering, Johns Hopkins University, Baltimore, MD (H.R.H.); and Department of Emergency Medicine, University of Pennsylvania, Philadelphia (L.B.B.)
| | - Henry R Halperin
- From the Department of Medicine, Division of Cardiology, Johns Hopkins University, Baltimore, MD (K.D.P., H.R.H.); Departments of Radiology and Biomedical Engineering, Johns Hopkins University, Baltimore, MD (H.R.H.); and Department of Emergency Medicine, University of Pennsylvania, Philadelphia (L.B.B.)
| | - Lance B Becker
- From the Department of Medicine, Division of Cardiology, Johns Hopkins University, Baltimore, MD (K.D.P., H.R.H.); Departments of Radiology and Biomedical Engineering, Johns Hopkins University, Baltimore, MD (H.R.H.); and Department of Emergency Medicine, University of Pennsylvania, Philadelphia (L.B.B.).
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New application of a traditional vasoactive agent, sodium nitroprusside, in targeted temperature management during cardiac arrest and resuscitation. Crit Care Med 2015; 43:924-5. [PMID: 25768362 DOI: 10.1097/ccm.0000000000000844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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