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Jeppesen AN, Hvas AM, Grejs AM, Duez CHV, Sorensen BS, Kirkegaard H. Post-cardiac arrest level of free-plasma DNA and DNA-histone complexes. Acta Anaesthesiol Scand 2017; 61:523-531. [PMID: 28337742 DOI: 10.1111/aas.12882] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 02/22/2017] [Accepted: 02/26/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Plasma DNA-histone complexes and total free-plasma DNA have the potential to quantify the ischaemia-reperfusion damages occurring after cardiac arrest. Furthermore, DNA-histone complexes may have the potential of being a target for future treatment. The aim was to examine if plasma DNA-histone complexes and the levels of total free-plasma DNA were elevated in post-cardiac arrest patients compared with healthy individuals, and to examine if these biomarkers were capable of predicting mortality. METHODS We included 42 comatose out-of-hospital cardiac arrest patients and collected blood samples after 22, 46 and 70 h. Samples for DNA-histone complexes were quantified by Cell Death Detection ELISAplus . The total free-plasma DNA analyses were quantified with qPCR by analysing the Beta-2 microglobulin gene. The control group comprised 40 healthy individuals. RESULTS We found no difference in the level of DNA-histone complexes between the 22-h sample and healthy individuals (P = 0.10). In the 46-h sample, there was an increased level of DNA-histone complexes in non-survivors compared with survivors 30 days after the cardiac arrest (P < 0.01) and the area under the ROC curve was 0.78 (95% confidence interval: 0.59;0.96). The level of total free-plasma DNA was increased in the 22-h sample compared with healthy individuals (P < 0.001) but no significant difference was found between non-survivors and survivors 30 days after the cardiac arrest (all P ≥ 0.06). CONCLUSION An increased level of DNA-histone complexes was associated with increased mortality and that the level of total free-plasma DNA was elevated post-cardiac arrest.
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Affiliation(s)
- A. N. Jeppesen
- Department of Anaesthesiology and Intensive Care Medicine; Aarhus University Hospital; Aarhus N Denmark
| | - A.-M. Hvas
- Department of Clinical Biochemistry; Aarhus University Hospital; Aarhus N Denmark
| | - A. M. Grejs
- Department of Anaesthesiology and Intensive Care Medicine; Aarhus University Hospital; Aarhus N Denmark
| | - C. H. V. Duez
- Department of Anaesthesiology and Intensive Care Medicine; Aarhus University Hospital; Aarhus N Denmark
| | - B. S. Sorensen
- Department of Clinical Biochemistry; Aarhus University Hospital; Aarhus N Denmark
| | - H. Kirkegaard
- Research Centre for Emergency Medicine; Aarhus University Hospital; Aarhus C Denmark
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Kim YM, Park KN, Choi SP, Lee BK, Park K, Kim J, Kim JH, Chung SP, Hwang SO. Part 4. Post-cardiac arrest care: 2015 Korean Guidelines for Cardiopulmonary Resuscitation. Clin Exp Emerg Med 2016; 3:S27-S38. [PMID: 27752644 PMCID: PMC5052921 DOI: 10.15441/ceem.16.130] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 03/19/2016] [Accepted: 03/19/2016] [Indexed: 11/23/2022] Open
Affiliation(s)
- Young-Min Kim
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Kyu Nam Park
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Seung Pill Choi
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Kyungil Park
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Jeongmin Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hoon Kim
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Oh Hwang
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
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Abstract
Cardiac arrest afflicts more than 300,000 persons annually in North America alone. Advances in systematic, regimented postresuscitation care have lowered mortality and improved neurologic outcomes in select cohorts of patients over the last decade. Postcardiac arrest care now comprises its own link in the chain of survival. For most patients, high-quality postcardiac arrest care begins in the Emergency Department. This article reviews the evidence and offers treatment strategies for the key components of postcardiac arrest care.
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Affiliation(s)
- Jon C Rittenberger
- Department of Emergency Medicine, University of Pittsburgh, Suite 10028, Forbes Tower, Pittsburgh, PA 15260, USA
| | - Ankur A Doshi
- Department of Emergency Medicine, University of Pittsburgh, Suite 10028, Forbes Tower, Pittsburgh, PA 15260, USA
| | - Joshua C Reynolds
- Department of Emergency Medicine, Michigan State University College of Human Medicine, 15 Michigan Street Northeast, Suite 420, Grand Rapids, MI 49503, USA.
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Remote ischemic pre- and postconditioning improve postresuscitation myocardial and cerebral function in a rat model of cardiac arrest and resuscitation. Crit Care Med 2015; 43:e12-8. [PMID: 25365722 DOI: 10.1097/ccm.0000000000000684] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Cardiac arrest and resuscitation are models of whole body ischemia reperfusion injury. Postresuscitation myocardial and cerebral dysfunction are major causes of high mortality and morbidity. Remote ischemic postconditioning has been proven to provide potent protection of the heart and brain against ischemia reperfusion injury. In this study, we investigated the effects of remote ischemic postconditioning on postresuscitation myocardial and cerebral function in a rat model of cardiac arrest and resuscitation. DESIGN Prospective, randomized, controlled experimental study. SETTING University-affiliated animal research institution. SUBJECTS Twenty-eight healthy male Sprague-Dawley rats. INTERVENTIONS The animals were randomized into four groups: 1) remote ischemic preconditioning initiated 40 minutes before induction of ventricular fibrillation, 2) remote ischemic postconditioning initiated coincident with the start of cardiopulmonary resuscitation, 3) remote ischemic postconditioning initiated 5 minutes after successful resuscitation, and 4) control. Remote ischemic pre- and postconditioning was induced by four cycles of 5 minutes of limb ischemia, followed by 5 minutes of reperfusion. Ventricular fibrillation was induced and untreated for 6 minutes while defibrillation was attempted after 8 minutes of cardiopulmonary resuscitation. The animals were then monitored for 4 hours and observed for an additional 68 hours after resuscitation. MEASUREMENTS AND MAIN RESULTS Hemodynamic measurements and myocardial function, including cardiac output, left ventricular ejection fraction, and myocardial performance index, were measured at baseline and hourly for 4 hours after resuscitation. Postresuscitation cerebral function was evaluated by neurologic deficit score at 24-hour intervals for a total of 72 hours. Consequently, significantly better myocardial and cerebral function with a longer duration of survival were observed in the three groups treated with remote ischemic pre- and postconditioning. CONCLUSIONS In a rat model of cardiac arrest and resuscitation, remote ischemic pre-and postconditioning attenuated postresuscitation myocardial and cerebral dysfunction and improved the duration of survival.
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Johnson CO, Lemaitre RN, Fahrenbruch CE, Hesselson S, Sotoodehnia N, McKnight B, Rice KM, Kwok PY, Siscovick DS, Rea TD. Common variation in fatty acid genes and resuscitation from sudden cardiac arrest. ACTA ACUST UNITED AC 2012; 5:422-9. [PMID: 22661490 DOI: 10.1161/circgenetics.111.961912] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Fatty acids provide energy and structural substrates for the heart and brain and may influence resuscitation from sudden cardiac arrest (SCA). We investigated whether genetic variation in fatty acid metabolism pathways was associated with SCA survival. METHODS AND RESULTS Subjects (mean age, 67 years; 80% male, white) were out-of-hospital SCA patients found in ventricular fibrillation in King County, WA. We compared subjects who survived to hospital admission (n=664) with those who did not (n=689), and subjects who survived to hospital discharge (n=334) with those who did not (n=1019). Associations between survival and genetic variants were assessed using logistic regression adjusting for age, sex, location, time to arrival of paramedics, whether the event was witnessed, and receipt of bystander cardiopulmonary resuscitation. Within-gene permutation tests were used to correct for multiple comparisons. Variants in 5 genes were significantly associated with SCA survival. After correction for multiple comparisons, single-nucleotide polymorphisms in ACSL1 and ACSL3 were significantly associated with survival to hospital admission. Single-nucleotide polymorphisms in ACSL3, AGPAT3, MLYCD, and SLC27A6 were significantly associated with survival to hospital discharge. CONCLUSIONS Our findings indicate that variants in genes important in fatty acid metabolism are associated with SCA survival in this population.
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Affiliation(s)
- Catherine O Johnson
- Department of Medicine, University of Washington CHRU, 1730 Minor Ave, Seattle, WA 98101, USA.
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Brader EW, Jehle D, Mineo M, Safar P. Protective head-cooling during cardiac arrest and cardiopulmonary resuscitation: the original animal studies. Neurol Int 2010; 2:e3. [PMID: 21577339 PMCID: PMC3093211 DOI: 10.4081/ni.2010.e3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2009] [Revised: 01/29/2010] [Accepted: 01/29/2010] [Indexed: 12/26/2022] Open
Abstract
Prolonged standard cardiopulmonary resuscitation (CPR) does not reliably sustain brain viability during cardiac arrest. Pre-hospital adjuncts to standard CPR are needed in order to improve outcomes. A preliminary dog study demonstrated that surface cooling of the head during arrest and CPR can achieve protective levels of brain hypothermia (30°C) within 10 minutes. We hypothesized that protective head-cooling during cardiac arrest and CPR improves neurological outcomes. Twelve dogs under light ketamine-halothane-nitrous oxide anesthesia were arrested by transthoracic fibrillation. The treated group consisted of six dogs whose shaven heads were moistened with saline and packed in ice immediately after confirmation of ventricular fibrillation. Six control dogs remained at room temperature. All 12 dogs were subjected to four minutes of ventricular fibrillation and 20 minutes of standard CPR. Spontaneous circulation was restored with drugs and countershocks. Intensive care was provided for five hours post-arrest and the animals were observed for 24 hours. In both groups, five of the six dogs had spontaneous circulation restored. After three hours, mean neurological deficit was significantly lower in the treated group (P=0.016, with head-cooled dogs averaging 37% and the normothermic dogs 62%). Two of the six head-cooled dogs survived 24 hours with neurological deficits of 9% and 0%, respectively. None of the control group dogs survived 24 hours. We concluded that head-cooling attenuates brain injury during cardiac arrest with prolonged CPR. We review the literature related to the use of hypothermia following cardiac arrest and discuss some promising approaches for the pre-hospital setting.
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Takeuchi I, Takehana H, Satoh D, Fukaya H, Tamura Y, Nishi M, Shinagawa H, Imai H, Yoshida T, Tojo T, Inomata T, Aoyama N, Soma K, Izumi T. Effect of hypothermia therapy after outpatient cardiac arrest due to ventricular fibrillation. Circ J 2009; 73:1877-80. [PMID: 19661722 DOI: 10.1253/circj.cj-09-0088] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Several investigators have emphasized the positive effect of hypothermia therapy on patients who have suffered from cardiac arrest. Salvaging patients from circulatory collapse is a pivotal task, but it is unclear whether additional hypothermia can practically contribute to an improvement in the neurological outcome. METHODS AND RESULTS Since December 2005, our hospital has been using hypothermia therapy. Forty-six comatose patients after recovery of spontaneous circulation were consecutively enrolled in the present study. Twenty-five of the enrolled patients received hypothermia therapy and 21 did not because they were treated prior to 2005. The time from collapse to spontaneous circulation (P=0.09), the rates of performance of bystander CPR (P=0.370) and presence of a witnessed collapse (P=0.067) were not significantly different between the recovery group (n=28) and the non-recovery group (n=18). The additional hypothermia therapy was an independent predictor of neurological recovery (P=0.005, OR 6.5, 95%CI 1.74-24.27). The recovery rate was significantly higher in patients who received hypothermia therapy (80%) compared to those who did not (38%). CONCLUSIONS Hypothermia therapy is very useful for treating patients who have had an out-of-hospital cardiac arrest; it should be induced rapidly and smoothly.
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Affiliation(s)
- Ichiro Takeuchi
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, Sagamihara, Japan.
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Walcott G, Melnick S, Killingsworth C, Ideker R. Burst Stimulation Improves Hemodynamics During Resuscitation After Prolonged Ventricular Fibrillation. Circ Arrhythm Electrophysiol 2009; 2:57-62. [DOI: 10.1161/circep.108.799890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Although return of spontaneous circulation is frequently achieved during resuscitation for sudden cardiac arrest, systolic blood pressure can then decrease, requiring additional myocardial support. Previous studies have shown that a series of 1-ms electric pulses delivered through the defibrillation patches during ventricular fibrillation can stimulate the autonomic nervous system to increase myocardial function after defibrillation. We hypothesized that a similar series of electric pulses could increase myocardial function and blood pressure during the early postresuscitation period.
Methods and Results—
Six swine were studied that underwent 6 to 7 minutes of fibrillation. Each animal received 5, 10, 15, or 20 pulse packets consisting of six 10-A, 1-ms pulses every 3 to 4 s in random order whenever systolic blood pressure became <50 mm Hg. All 4 sets of pulse packets were delivered to each animal. Systolic blood pressure and cardiac function (left ventricular+dP/dt) were increased to above prestimulation levels or above by all 4 sets of pulse packets. The increases were significantly greater for the longer than the shorter number of pulse packets. The mean�SD duration of the time that the systolic pressure remained above 50 mm Hg after pulse delivery was 4.2�2.5 minutes.
Conclusions—
Electric stimulation during regular rhythm after prolonged ventricular fibrillation and resuscitation can increase blood pressure and cardiac function to above prestimulation levels.
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Affiliation(s)
- Gregory Walcott
- From the University of Alabama at Birmingham, Birmingham, Ala
| | - Sharon Melnick
- From the University of Alabama at Birmingham, Birmingham, Ala
| | | | - Raymond Ideker
- From the University of Alabama at Birmingham, Birmingham, Ala
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Adams JA, Bassuk JA, Arias J, Wu H, Jorapur V, Lamas GA, Kurlansky P. Acute effects of "delayed postconditioning" with periodic acceleration after asphyxia induced shock in pigs. Pediatr Res 2008; 64:533-7. [PMID: 18596578 DOI: 10.1203/pdr.0b013e318183f147] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Asphyxia cardiac arrest and shock are models for whole body ischemia reperfusion injury. Periodic acceleration (pGz) achieved by moving the body on a platform is a novel method for inducing pulsatile vascular shear stress and endogenous production of endothelial nitric oxide, prostaglandin E2, tissue plasminogen activator, and adrenomedullin. The aforementioned are cardioprotective during and after ischemia reperfusion injury. We investigated whether pGz, applied 15 min after return of spontaneous circulation (ROSC) would serve as an effective "delayed" post conditioning tactic to lessen acute reperfusion injury markers in a pediatric swine model of asphyxia induced shock. Asphyxia shock was induced in 20 swine weight 3.9 +/- 0.6 kg. Fifteen minutes after ROSC, the animals were randomized to receive conventional mechanical ventilation (CMV, [Control]) or CMV with pGz. All animals had ROSC and no significant differences in blood gases or hemodynamics after ROSC. pGz treated had significantly less myocardial dysfunction post resuscitation, (i.e. better % ejection fraction (EF), % fractional shortening (FS), and wall motion score index) and lower biochemical indices of reperfusion injury (lower TNF-alpha, IL-6, and Troponin I, and myeloperoxidase activity). Delayed postconditioning with pGz ameliorates acute post resuscitation reperfusion injury and improves myocardial dysfunction after asphyxia-induced shock.
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Affiliation(s)
- Jose A Adams
- Divisions of Neonatology, Mt Sinai Medical Center, Miami Beach, Florida 33140, USA.
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10
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Influence of the skeletal muscle activity on time and frequency domain properties of the body surface ECG during evolving ventricular fibrillation in the pig. Resuscitation 2008; 78:215-23. [DOI: 10.1016/j.resuscitation.2008.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2007] [Revised: 02/17/2008] [Accepted: 03/04/2008] [Indexed: 11/24/2022]
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CPR during ischemia and reperfusion: a model for survival benefits. Resuscitation 2008; 77:6-9. [PMID: 18083284 DOI: 10.1016/j.resuscitation.2007.10.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2007] [Revised: 09/28/2007] [Accepted: 10/04/2007] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Manual CPR improves the likelihood of neurologically intact survival following cardiac arrest. The mechanism of this benefit is not completely understood. We propose a mechanism whereby manual CPR simultaneously limits ischemia and specifically protects against reperfusion injury. We derive a conceptual framework that describes cell survival as it relates to the ischemic and reperfusion stages and CPR effects. RESULTS Based on a synthesis of basic science and clinical information, we propose that the benefit of the subnormal circulation produced by manual CPR is multifaceted and specifically includes attenuating reperfusion injury by providing graded blood flow to the heart and brain. Although manual CPR produces reperfusion pathophysiology, the low flow from CPR limits reperfusion injury specifically through mechanisms of post-ischemic conditioning which include attenuating peak levels of oxidative substrate and activating pathways that protect against oxidative stress. CONCLUSIONS If such a hypothesis of post-ischemic conditioning is borne out, CPR may be considered a dose-sensitive therapy whereby certain physiologic states would be best served by different levels of circulation and hence distinct grades of CPR.
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Laver SR, Padkin A, Atalla A, Nolan JP. Therapeutic hypothermia after cardiac arrest: a survey of practice in intensive care units in the United Kingdom. Anaesthesia 2006; 61:873-7. [PMID: 16922754 DOI: 10.1111/j.1365-2044.2006.04552.x] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A telephone survey was carried out on the use of hypothermia as part of the management of unconscious patients following cardiac arrest admitted to United Kingdom (UK) intensive care units (ICUs). All 256 UK ICUs listed in the Critical Care Services Manual 2004 were contacted to determine how many units have implemented therapeutic hypothermia for unconscious patients admitted following cardiac arrest, how it is implemented, and the reasons for non-implementation. Two hundred and forty-six (98.4%) ICUs agreed to participate. Sixty-seven (28.4%) ICUs have cooled patients after cardiac arrest, although the majority of these have treated fewer than 10 patients. The commonest reasons given for not using therapeutic hypothermia in this situation are logistical or resource issues, or the perceived lack of evidence or consensus within individual ICU teams.
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Affiliation(s)
- S R Laver
- Royal United Hospital, Bath BA1 3NG, UK.
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13
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Wu D, Bassuk J, Arias J, Peschiera I, Lamet A, Kurlansky P, Adams JA. Post-resuscitation reperfusion injury: Comparison of periodic Gz acceleration versus Thumper CPR. Resuscitation 2006; 70:454-62. [PMID: 16828959 DOI: 10.1016/j.resuscitation.2005.12.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2005] [Revised: 12/19/2005] [Accepted: 12/19/2005] [Indexed: 11/18/2022]
Abstract
The effects of whole body, periodic acceleration (pGz) on cardiopulmonary resuscitation outcome, organ blood flow and tissue inflammatory injury were examined in an experimental pig model, and compared with Thumper (TH)-CPR. VF was induced in 16 pigs, and remained untreated for 3 min, followed by either pGz-CPR or TH-CPR for 15 min. Defibrillation attempts were made at 18 min of VF. Six of eight animals had ROSC in both groups. Post-arrest myocardial dysfunction was present in both groups and progressed over hours. pGz-CPR animals had less wall motion abnormality and higher left ventricular ejection fraction than TH-CPR. The post-resuscitation haemodynamic variables returned to baseline after 3h of ROSC in pGz-CPR group, and remained low in TH-CPR group. The brain blood flow during CPR was similar between TH-CPR and pGz-CPR, 17% and 20% of pre-fibrillation values, respectively. The cardiac blood flow during CPR was significantly lower in pGz-CPR than TH-CPR (TH: 10.2% and pGz: 1.9% of pre-fibrillation value), as well as in other organs. The brain and heart blood flow was significantly higher than pre-fibrillation values after 30 min of ROSC in both groups. The pGz group had significantly higher blood flow in brain, heart and kidney than TH-CPR after 30 min of ROSC. Blood flow in all organs decreased below pre-fibrillation values at 2h of ROSC. Tissue inflammatory injury progressed over hours in the post-resuscitation phase. pGz-CPR group had significantly lower myeloperoxidase (MPO) activity and plasma creatine phosphokinase (CPK) and cardiac troponin I, TNF-alpha, and IL-6 than TH-CPR. Results from the present study demonstrate again that pGz-CPR is an effective method of cardiopulmonary resuscitation, with less post-reperfusion injury compared to TH-CPR.
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Affiliation(s)
- Dongmei Wu
- Department of Research and Division of Neonatology, Mount Sinai Medical Center, 4300 Alton Road, Miami Beach, FL 33140, USA.
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Marill KA, Ellinor PT. Case records of the Massachusetts General Hospital. Case 37-2005. A 35-year-old man with cardiac arrest while sleeping. N Engl J Med 2005; 353:2492-501. [PMID: 16339098 DOI: 10.1056/nejmcpc059033] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Keith A Marill
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, USA
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15
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Berg MD, Clark LL, Valenzuela TD, Kern KB, Berg RA. Post-shock chest compression delays with automated external defibrillator use. Resuscitation 2005; 64:287-91. [PMID: 15733755 DOI: 10.1016/j.resuscitation.2004.07.017] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2003] [Revised: 07/21/2004] [Accepted: 07/21/2004] [Indexed: 11/29/2022]
Abstract
PRIMARY OBJECTIVE In a swine model of out-of-hospital ventricular fibrillation (VF) cardiac arrest, we established that automated external defibrillator (AED) defibrillation could worsen outcome from prolonged VF compared with manual defibrillation. Worse outcomes were due to substantial interruptions and delays in chest compressions for AED rhythm analyses and shock advice. In particular, the mean interval from first AED shock to first post-shock compressions was 46+/-6s. We hypothesized that the delay from shock to provision of chest compressions is similar in the out-of-hospital setting. MATERIALS AND METHODS We conducted a retrospective observational review of AED-treated adult VF cardiac arrest victims over a 26-month period to determine the interval from the first AED defibrillation attempt to the initial provision of post-shock chest compressions for out-of-hospital VF cardiac arrests. A two-tiered, single emergency medical service (EMS) system with AED-equipped first responders serves our area of 400 km2 with a population of 487,000 people. The defibrillators record a detailed sequence of events during the resuscitation effort that includes the electrocardiogram with real clock times and a recording of surrounding audible actions. RESULTS A median of 38 s (IQR 15, 61 s) elapsed between the first shock and the initiation of chest compressions. Approximately half of the delay was due to mechanical/electronic factors and the remainder due to human factors. Of 64 adults in VF, 45 (70%) died before hospital admission, 19 (30%) survived to admission and 10 (16%) survived to hospital discharge. CONCLUSION Substantial delays in the provision of post-shock chest compressions are typical in this EMS system with AED-equipped first responders.
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Affiliation(s)
- Marc D Berg
- Department of Pediatrics, Steele Memorial Children's Research Center, Sarver Heart Center, University of Arizona College of Medicine, P.O. Box 245073, 1501 N Campbell Avenue, Tucson, AZ 85724, USA.
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16
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Pepe PE, Fowler RL, Roppolo LP, Wigginton JG. Clinical review: Reappraising the concept of immediate defibrillatory attempts for out-of-hospital ventricular fibrillation. Crit Care 2004; 8:41-5. [PMID: 14975044 PMCID: PMC420055 DOI: 10.1186/cc2379] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Despite well developed emergency medical services with rapid response advanced life support capabilities, survival rates following out-of-hospital ventricular fibrillation (VF) have remained bleak in many venues. Generally, these poor resuscitation rates are attributed to delays in the performance of basic cardiopulmonary resuscitation by bystanders or delays in defibrillation, but recent laboratory data suggest that the current standard of immediately providing a countershock as the first therapeutic intervention may be detrimental when VF is prolonged beyond several minutes. Several studies now suggest that when myocardial energy supplies begin to dwindle following more prolonged periods of VF, improvements in coronary artery perfusion must first be achieved in order to prime the heart for successful return of spontaneous circulation after defibrillation. Therefore, before countershocks, certain pharmacologic and/or mechanical interventions might take precedence during resuscitative efforts. This evolving concept has been substantiated recently by clinical studies, including a controlled clinical trial, demonstrating a significant improvement in survival when basic cardiopulmonary resuscitation is provided for several minutes before the initial countershock. Although this evolving concept differs from current standards and may pose a potential problem for automated defibrillator initiatives (e.g. public access defibrillation), successful defibrillation and return of spontaneous circulation have been rendered more predictable by evolving technologies that can score the VF waveform signal and differentiate between those who can be shocked immediately and those who should receive other interventions first.
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Affiliation(s)
- Paul E Pepe
- Professor of Medicine, Surgery, Public Health and Riggs Family Chair in Emergency Medicine, The University of Texas Southwestern Medical Center and the Parkland Health and Hospital System, Dallas, Texas, USA.
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Sterz F, Holzer M, Roine R, Zeiner A, Losert H, Eisenburger P, Uray T, Behringer W. Hypothermia after cardiac arrest: a treatment that works. Curr Opin Crit Care 2003; 9:205-10. [PMID: 12771671 DOI: 10.1097/00075198-200306000-00006] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Sudden death from cardiac arrest is a major health problem that still receives too little publicity. Current therapy after cardiac arrest concentrates on resuscitation efforts because, until now, no specific therapy for brain protection after restoration of spontaneous circulation was available. Therapeutic mild or moderate resuscitative hypothermia is a novel therapy with multifaceted chemical and physical effects by preventing or mitigating the derangements seen in the postresuscitation syndrome. RECENT FINDINGS AND SUMMARY In 2002, two prospective, randomized studies reported improved outcomes when deliberate hypothermia was induced in comatose survivors after resuscitation from cardiac arrest. However, several issues with regard to resuscitative cooling are still unanswered and should be studied further. These include the optimal timing to initiate cooling, the optimal cooling period, the optimal temperature level, and rewarming strategy. Even important questions, such as which cooling technique will be available in the near future that would combine ease of use with high efficacy, are not answered yet.
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Affiliation(s)
- Fritz Sterz
- Department of Emergency Medicine, University of Vienna, Austria.
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Pepe PE, Wigginton JG, Fowler RL. Immediate Defibrillation for Out-of-Hospital Ventricular Fibrillation. Intensive Care Med 2003. [DOI: 10.1007/978-1-4757-5548-0_44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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D'Cruz BJ, Fertig KC, Filiano AJ, Hicks SD, DeFranco DB, Callaway CW. Hypothermic reperfusion after cardiac arrest augments brain-derived neurotrophic factor activation. J Cereb Blood Flow Metab 2002; 22:843-51. [PMID: 12142569 DOI: 10.1097/00004647-200207000-00009] [Citation(s) in RCA: 100] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Induction of mild hypothermia improves neurologic outcome after global cerebral ischemia. This study measured levels of brain-derived neurotrophic factor (BDNF) and nerve growth factor (NGF) in hippocampal tissue of rats after resuscitation from 8 minutes of normothermic, asphyxial cardiac arrest. After resuscitation, rats were maintained either at normal temperature (37 degrees C) or cooled to mild hypothermia (33 degrees C, beginning 60 minutes after resuscitation). After 12 or 24 hours, neurotrophin levels in hippocampus were measured by immunoblotting. Ischemia and reperfusion increased hippocampal levels of BDNF. Induction of hypothermia during reperfusion potentiated the increase in BDNF after 24 hours, but not after 12 hours. Levels of NGF were not increased by postresuscitation hypothermia. Hypothermia also increased tissue levels and tyrosine phosphorylation of TrkB, the receptor for BDNF. Increased BDNF levels were correlated with activation of the extracellularly regulated kinase (ERK), a downstream element in the signal transduction cascade induced by BDNF. In contrast to the many deleterious processes during ischemia and reperfusion that are inhibited by induced hypothermia, increasing BDNF levels is a potentially restorative process that is augmented. Increased activation of BDNF signaling is a possible mechanism by which mild hypothermia is able to reduce the neuronal damage typically occurring after cardiac arrest.
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Affiliation(s)
- Brian J D'Cruz
- Department of Emergency Medicine, University of Pittsburgh, Pennsylvania 15213, USA
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