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Brainard BM, Lane SL, Burkitt-Creedon JM, Boller M, Fletcher DJ, Crews M, Fausak ED. 2024 RECOVER Guidelines: Monitoring. Evidence and knowledge gap analysis with treatment recommendations for small animal CPR. J Vet Emerg Crit Care (San Antonio) 2024; 34 Suppl 1:76-103. [PMID: 38924672 DOI: 10.1111/vec.13390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 04/25/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVE To systematically review evidence on and devise treatment recommendations for patient monitoring before, during, and following CPR in dogs and cats, and to identify critical knowledge gaps. DESIGN Standardized, systematic evaluation of literature pertinent to peri-CPR monitoring following Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Prioritized questions were each reviewed by Evidence Evaluators, and findings were reconciled by Monitoring Domain Chairs and Reassessment Campaign on Veterinary Resuscitation (RECOVER) Co-Chairs to arrive at treatment recommendations commensurate to quality of evidence, risk:benefit relationship, and clinical feasibility. This process was implemented using an Evidence Profile Worksheet for each question that included an introduction, consensus on science, treatment recommendations, justification for these recommendations, and important knowledge gaps. A draft of these worksheets was distributed to veterinary professionals for comment for 4 weeks prior to finalization. SETTING Transdisciplinary, international collaboration in university, specialty, and emergency practice. RESULTS Thirteen questions pertaining to hemodynamic, respiratory, and metabolic monitoring practices for identification of cardiopulmonary arrest, quality of CPR, and postcardiac arrest care were examined, and 24 treatment recommendations were formulated. Of these, 5 recommendations pertained to aspects of end-tidal CO2 (ETco2) measurement. The recommendations were founded predominantly on very low quality of evidence, with some based on expert opinion. CONCLUSIONS The Monitoring Domain authors continue to support initiation of chest compressions without pulse palpation. We recommend multimodal monitoring of patients at risk of cardiopulmonary arrest, at risk of re-arrest, or under general anesthesia. This report highlights the utility of ETco2 monitoring to verify correct intubation, identify return of spontaneous circulation, evaluate quality of CPR, and guide basic life support measures. Treatment recommendations further suggest intra-arrest evaluation of electrolytes (ie, potassium and calcium), as these may inform outcome-relevant interventions.
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Affiliation(s)
- Benjamin M Brainard
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, Georgia, USA
| | - Selena L Lane
- Veterinary Emergency Group, Cary, North Carolina, USA
| | - Jamie M Burkitt-Creedon
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
| | - Manuel Boller
- VCA Canada Central Victoria Veterinary Hospital, Victoria, British Columbia, Canada
- Department of Veterinary Clinical and Diagnostic Sciences, Faculty of Veterinary Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Daniel J Fletcher
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
| | - Molly Crews
- Department of Small animal Clinical Sciences, College of Veterinary Medicine & Biomedical Sciences, Texas A&M University, College Station, Texas, USA
| | - Erik D Fausak
- University Library, University of California, Davis, Davis, California, USA
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Zhang L, Du WQ, Zong ZW, Zhong X, Jia YJ, Jiang RQ, Ye Z. Modified Glucose-insulin-potassium Therapy for Hemorrhage-induced Traumatic Cardiac Arrest in Rabbits. Curr Med Sci 2023; 43:1238-1246. [PMID: 37955782 DOI: 10.1007/s11596-023-2796-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 08/14/2023] [Indexed: 11/14/2023]
Abstract
OBJECTIVE Resuscitation with whole blood is known to be better than that with saline in attaining the return of spontaneous circulation (ROSC) and improving the short-term survival rate for hemorrhage-induced traumatic cardiac arrest (HiTCA). However, the resuscitation with whole blood alone fails to address the pathophysiological abnormalities, including hyperglycemia, hyperkalemia and coagulopathy, after HiTCA. The present study aimed to determine whether the modified glucose-insulin-potassium (GIK) therapy can ameliorate the above-mentioned pathophysiological abnormalities, enhance the ROSC, improve the function of key organs, and reduce the mortality after HiTCA. METHODS HiTCA was induced in rabbits (n=36) by controlled hemorrhage. Following arrest, the rabbits were randomly divided into three groups (n=12 each): group A (no resuscitation), group B (resuscitation with whole blood), and group C (resuscitation with whole blood plus GIK). The GIK therapy was administered based on the actual concentration of glucose and potassium. The ROSC rate and survival rate were obtained. Hemodynamical and biochemical changes were detected. Thromboelastography (TEG) was used to measure coagulation parameters, and enzyme-linked immunosorbent assay to detect parameters related to inflammation, coagulation and the function of brain. RESULTS All animals in groups B and C attained ROSC. Two rabbits died 24-48 h after HiTCA in group B, while no rabbits died in group C. The GIK therapy significantly reduced the levels of blood glucose, potassium, and biological markers for inflammatory reaction, and improved the heart, kidney, liver and brain function in group C when compared to group B. Furthermore, the R values of TEG were significantly lower in group C than in group B, and the maximum amplitude of TEG was slightly lower in group B than in group C, with no significant difference found. CONCLUSION Resuscitation with whole blood and modified GIK therapy combined can ameliorate the pathophysiological disorders, including hyperglycemia, hyperkalemia and coagulopathy, and may improve the function of key organs after HiTCA.
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Affiliation(s)
- Lin Zhang
- State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care, Army Medical University, Chongqing, 400038, China
| | - Wen-Qiong Du
- State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care, Army Medical University, Chongqing, 400038, China
| | - Zhao-Wen Zong
- State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care, Army Medical University, Chongqing, 400038, China.
- Department of Orthopedics, Xinqiao Hospital, Army Medical University, Chongqing, 400037, China.
| | - Xin Zhong
- State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care, Army Medical University, Chongqing, 400038, China
| | - Yi-Jun Jia
- State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care, Army Medical University, Chongqing, 400038, China
| | - Ren-Qing Jiang
- State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care, Army Medical University, Chongqing, 400038, China
| | - Zhao Ye
- State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care, Army Medical University, Chongqing, 400038, China
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Vammen L, Rahbek S, Secher N, Povlsen JA, Jessen N, Løfgren B, Granfeldt A. Type 2 diabetes mellitus worsens neurological injury following cardiac arrest: an animal experimental study. Intensive Care Med Exp 2018; 6:23. [PMID: 30088108 PMCID: PMC6081485 DOI: 10.1186/s40635-018-0193-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 07/30/2018] [Indexed: 01/22/2023] Open
Abstract
Background Cardiac arrest carries a poor prognosis. The typical cardiac arrest patient is comorbid, and studies have shown that diabetes mellitus is an independent risk factor for increased mortality after cardiac arrest. Despite this, animal studies lack to investigate cardiac arrest in the setting of diabetes mellitus. We hypothesize that type 2 diabetes mellitus in a rat model of cardiac arrest is associated with increased organ dysfunction when compared with non-diabetic rats. Methods Zucker diabetic fatty (ZDF) rats (n = 13), non-diabetic Zucker lean control (ZLC) rats (n = 15), and non-diabetic Sprague Dawley (SprD) rats (n = 8), underwent asphyxia-induced cardiac arrest. Animals were resuscitated and monitored for 180 min after return of spontaneous circulation (ROSC). Blood levels of neuron-specific enolase were measured to assess neurological injury. Cardiac function was evaluated by echocardiography. Results No differences in cardiac output or neuron-specific enolase existed between the groups at baseline. Median levels of neuron-specific enolase 180 min after ROSC was 10.8 μg/L (Q25;Q75—7.6;11.3) in the ZDF group, which was significantly higher compared to the ZLC group at 2.0 μg/L (Q25;Q75—1.7;2.3, p < 0.05) and the SprD group at 2.8 μg/L (Q25;Q75—2.3;3.4, p < 0.05). At 180 min after ROSC, cardiac output was 129 mL/min/kg (SD 45) in the ZDF group, which was not different from 106 mL/min/kg (SD 31) in the ZLC group or 123 mL/min/kg (SD 26, p = 0.72) in the SprD group. Conclusions In a cardiac arrest model, neuronal injury is increased in type 2 diabetes mellitus animals compared with non-diabetic controls. Although this study lacks to uncover the specific mechanisms causing increased neuronal injury, the establishment of a cardiac arrest model of type 2 diabetes mellitus lays the important foundation for further experimental investigations within this field.
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Affiliation(s)
- Lauge Vammen
- Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark.,Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Søren Rahbek
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Niels Secher
- Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Niels Jessen
- Department of Clinical Pharmacology, Aarhus University, Aarhus, Denmark
| | - Bo Løfgren
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Internal Medicine, Regional Hospital of Randers, Randers, Denmark
| | - Asger Granfeldt
- Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark.
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Lindblom RPF, Molnar M, Israelsson C, Röjsäter B, Wiklund L, Lennmyr F. Hyperglycemia Alters Expression of Cerebral Metabolic Genes after Cardiac Arrest. J Stroke Cerebrovasc Dis 2018; 27:1200-1211. [PMID: 29306595 DOI: 10.1016/j.jstrokecerebrovasdis.2017.11.036] [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: 09/14/2017] [Accepted: 11/26/2017] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Survivors of cardiac arrest often experience neurologic deficits. To date, treatment options are limited. Associated hyperglycemia is believed to further worsen the neurologic outcome. The aim with this study was to characterize expression pathways induced by hyperglycemia in conjunction with global brain ischemia. METHODS Pigs were randomized to high or normal glucose levels, as regulated by glucose and insulin infusions with target levels of 8.5-10 mM and 4-5.5 mM, respectively. The animals were subjected to 5-minute cardiac arrest followed by 8 minutes of cardiopulmonary resuscitation and direct-current shock to restore spontaneous circulation. Global expression profiling of the cortex using microarrays was performed in both groups. RESULTS A total of 102 genes differed in expression at P < .001 between the hyperglycemic and the normoglycemic pigs. Several of the most strongly differentially regulated genes were involved in transport and metabolism of glucose. Functional clustering using bioinformatics tools revealed enrichment of multiple biological processes, including membrane processes, ion transport, and glycoproteins. CONCLUSIONS Hyperglycemia during cardiac arrest leads to differential early gene expression compared with normoglycemia. The functional relevance of these expressional changes cannot be deduced from the current study; however, the identified candidates have been linked to neuroprotective mechanisms and constitute interesting targets for further studies.
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Affiliation(s)
- Rickard Per Fredrik Lindblom
- Department of Cardiothoracic Surgery and Anaesthesia, Uppsala University Hospital, Uppsala, Sweden; Department of Surgical Sciences, Section of Thoracic Surgery, Uppsala University, Uppsala, Sweden
| | - Maria Molnar
- Department of Surgical Sciences, Section of Anaesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden.
| | - Charlotte Israelsson
- Department of Neuroscience, Developmental Neuroscience, Uppsala University, Uppsala, Sweden
| | - Belinda Röjsäter
- Department of Medical Sciences, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Lars Wiklund
- Department of Surgical Sciences, Section of Anaesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden
| | - Fredrik Lennmyr
- Department of Cardiothoracic Surgery and Anaesthesia, Uppsala University Hospital, Uppsala, Sweden; Department of Surgical Sciences, Section of Thoracic Surgery, Uppsala University, Uppsala, Sweden
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Peng TJ, Andersen LW, Saindon BZ, Giberson TA, Kim WY, Berg K, Novack V, Donnino MW. The administration of dextrose during in-hospital cardiac arrest is associated with increased mortality and neurologic morbidity. Crit Care 2015; 19:160. [PMID: 25887120 PMCID: PMC4415309 DOI: 10.1186/s13054-015-0867-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 03/09/2015] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Dextrose may be used during cardiac arrest resuscitation to prevent or reverse hypoglycemia. However, the incidence of dextrose administration during cardiac arrest and the association of dextrose administration with survival and other outcomes are unknown. METHODS We used the Get With The Guidelines®-Resuscitation national registry to identify adult patients with an in-hospital cardiac arrest between the years 2000 and 2010. To assess the adjusted effects of dextrose administration on survival, we used multivariable regression models with adjustment for multiple patient, event, and hospital characteristics. We performed additional analyses to examine the effects of dextrose on neurological outcome and return of spontaneous circulation. RESULTS Among the 100,029 patients included in our study, 4,189 (4.2%) received dextrose during cardiac arrest resuscitation. The rate of dextrose administration increased during the study period (odds ratio 1.11, 95% confidence interval (CI) 1.09-1.12 per year, P <0.001). Patients who received dextrose during resuscitation had lower rates of survival compared with patients who did not receive dextrose (relative risk 0.88, 95% CI 0.80-0.98, P = 0.02). Administration of dextrose was associated with worse neurological outcome (relative risk 0.88, 95% CI 0.79-0.99, P = 0.03) but an increased chance of return of spontaneous circulation (relative risk 1.07, 95% CI 1.04-1.10, P <0.001). CONCLUSIONS In this dataset, the administration of dextrose during resuscitation in patients with in-hospital cardiac arrest was found to be associated with a significantly decreased chance of survival and a decreased chance of good neurological outcome.
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Affiliation(s)
- Teng J Peng
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, One Deaconess Road, W/CC 2, Boston, MA, 02215, USA.
| | - Lars W Andersen
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, One Deaconess Road, W/CC 2, Boston, MA, 02215, USA.
- Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark.
| | - Brian Z Saindon
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, One Deaconess Road, W/CC 2, Boston, MA, 02215, USA.
| | - Tyler A Giberson
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, One Deaconess Road, W/CC 2, Boston, MA, 02215, USA.
| | - Won Young Kim
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, One Deaconess Road, W/CC 2, Boston, MA, 02215, USA.
| | - Katherine Berg
- Department of Medicine, Division of Critical Care, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Victor Novack
- Department of Medicine, Division of Critical Care, Beth Israel Deaconess Medical Center, Boston, MA, USA.
- Clinical Research Center, Soroka University Medical Centers, Beer-Shave, Israel.
| | - Michael W Donnino
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, One Deaconess Road, W/CC 2, Boston, MA, 02215, USA.
- Department of Medicine, Division of Critical Care, Beth Israel Deaconess Medical Center, Boston, MA, USA.
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Kim SH, Choi SP, Park KN, Lee SJ, Lee KW, Jeong TO, Youn CS. Association of blood glucose at admission with outcomes in patients treated with therapeutic hypothermia after cardiac arrest. Am J Emerg Med 2014; 32:900-4. [DOI: 10.1016/j.ajem.2014.05.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 04/02/2014] [Accepted: 05/01/2014] [Indexed: 01/04/2023] Open
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Taccone FS, Donadello K, Kalfon P. Give me less sugar: how to manage glucose levels in post-anoxic injury? Intensive Care Med 2014; 40:903-6. [PMID: 24789620 DOI: 10.1007/s00134-014-3309-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2014] [Accepted: 04/15/2014] [Indexed: 01/31/2023]
Affiliation(s)
- Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Erasme, Route de Lennik, 808, 1070, Brussels, Belgium,
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