Current pharmacological advances in the treatment of cardiac arrest

Neonatal methicillin-resistant Staphylococcus aureus pneumonia-related recurrent fatal pyopneumothorax: A case report and review of literature

BACKGROUND

Although neonatal Staphylococcus aureus pneumonia is common and usually curable, it can also be refractory and life-threatening. Herein, we report a case of severe neonatal community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) necrotizing pneumonia with bilateral recurrent pyopneumothorax, respiratory failure, heart failure, and cardiac arrest. We hope our report will add to the understanding of this disease.

CASE SUMMARY

An 18-d-old boy presented with cough for five days, fever for three days, and dyspnea for two days. Preadmission chest radiograph revealed high-density shadows in both lungs. On admission, his oxygen saturation fluctuated around 90% under synchronized intermittent mandatory ventilation. He was unconscious, with dyspnea, weak heart sounds and hepatomegaly. Moist crackles were present throughout his left lung, while the breath sounds in the right lung were decreased. After high-frequency oscillatory ventilation, empiric antimicrobials (meropenem and vancomycin), improved circulation, and right pleural cavity drainage for right pneumothorax (approximately 90% compression), his oxygen saturation level stayed above 95%, and recruitment of the right lung was observed. His condition did not deteriorate until the 5th day of hospitalization (DOH 5). On the morning of DOH 5, his oxygen saturation decreased. Subsequent chest radiograph showed bilateral pneumothorax with nearly 100% compression of the left lung. Desaturation was not relieved after urgent left pleural cavity drainage, and cardiac arrest occurred soon thereafter. Although his spontaneous heartbeat returned through emergency resuscitation and salvage antibacterial therapy (linezolid and levofloxacin) was administered given the detection and antimicrobial susceptibility of MRSA, he showed no improvement, with recurrent pyopneumothorax and continued drainage of purulent fluid and necrotic lung tissue fragments from the pleural cavity. Eventually, his parents refused extracorporeal membrane oxygenation (ECMO) and gave up all the treatments, and the newborn passed away soon after withdrawal on DOH 13.

CONCLUSION

Neonatal MRSA pneumonia can be refractory and lethal, especially in cases where necrotizing pneumonia leads to extensive lung necrosis and recurrent pneumothorax. Despite treatment with linezolid and other medical measures, it may still be ineffective. Currently, ECMO has been a remedial therapy, but if the lung tissue is too severely eroded to be repaired, it may be useless unless the infection can be controlled and lung transplantation can be performed. Regardless of whether ECMO is initiated, the key to successful treatment is to achieve control over the pneumonia caused by MRSA as soon as possible and to reverse lung injury as much as possible.

Nicotinamide restores tissue NAD+ and improves survival in rodent models of cardiac arrest

Metabolic suppression in the ischemic heart is characterized by reduced levels of NAD+ and ATP. Since NAD+ is required for most metabolic processes that generate ATP, we hypothesized that nicotinamide restores ischemic tissue NAD+ and improves cardiac function in cardiomyocytes and isolated hearts, and enhances survival in a mouse model of cardiac arrest. Mouse cardiomyocytes were exposed to 30 min simulated ischemia and 90 min reperfusion. NAD+ content dropped 40% by the end of ischemia compared to pre-ischemia. Treatment with 100 μM nicotinamide (NAM) at the start of reperfusion completely restored the cellular level of NAD+ at 15 min of reperfusion. This rescue of NAD+ depletion was associated with improved contractile recovery as early as 10 min post-reperfusion. In a mouse model of cardiac arrest, 100 mg/kg NAM administered IV immediately after cardiopulmonary resuscitation resulted in 100% survival at 4 h as compared to 50% in the saline group. In an isolated rat heart model, the effect of NAM on cardiac function was measured for 20 min following 18 min global ischemia. Rate pressure product was reduced by 26% in the control group following arrest. Cardiac contractile function was completely recovered with NAM treatment given at the start of reperfusion. NAM restored tissue NAD+ and enhanced production of lactate and ATP, while reducing glucose diversion to sorbitol in the heart. We conclude that NAM can rapidly restore cardiac NAD+ following ischemia and enhance glycolysis and contractile recovery, with improved survival in a mouse model of cardiac arrest.

Is epinephrine still the drug of choice during cardiac arrest in the emergency department of the hospital? A meta-analysis

Epinephrine is the first-line emergency drug for cardiac arrest and anaphylactic reactions but is reported to be associated with many challenges resulting in its under- or improper utilization. Therefore, in this meta-analysis, the efficacy and safety of epinephrine as a first-line cardiac emergency drug for both out-of-hospital and in-hospital patients was assessed. Pertinent articles were searched in central databases like PubMed, Scopus, and Web of Science, using appropriate keywords as per the PRISMA guidelines. Retrospective and prospective studies were included according to the predefined PICOS criteria. RevMan and MedCalc software were used and statistical parameters such as odds ratio and risk ratio were calculated. Twelve clinical trials with a total of 208,690 cardiac arrest patients from 2000 to 2022 were included, in accordance with the chosen inclusion criteria. In the present meta-analysis, a high odds ratio (OR) value of 3.67 (95 % CI 2.32-5.81) with a tau2 value of 0.64, a chi2 value of 12,446.86, df value of 11, I2 value of 100 %, Z-value 5.53, and a p-value < 0.00001 were reported. Similarly, the risk ratio of 1.89 (95 % CI 1.47-2.43) with a tau2 value of 0.19, chi2 value of 11,530.67, df value of 11, I2 value of 100 %, Z-value of 4.95, and p-value < 0.000001. The present meta-analysis strongly prefers epinephrine injection as the first cardiac emergency drug for both out-of-hospital and in-hospital patients during cardiac arrest.

Therapeutic Effect and Prognosis of PiCCO in the Treatment of Myocardial Injury Complicated with Septic Shock

Objective

To explore the effect of pulse-induced contour cardiac output (PiCCO) monitoring on the survival and prognosis of patients with myocardial injury and septic shock.

Methods

A total of 400 patients with MI and septic shock who were treated in our hospital from May 2018 to June 2021 were included in the study. They were randomly grouped into the PiCCO group (n = 200) and the control group (n = 200) according to whether PiCCO was used for monitoring during the treatment period. The clinical baseline characteristics of all the patients were recorded. For comparison, we recorded hemodynamic parameters including mean arterial pressure (MAP), central venous pressure (CVP), heart rate (HR), troponin I (TnI), brain natriuretic peptide (BNP), oxygen metabolism parameters including systemic central venous oxygen saturation (ScvO₂), and lactate before and 6 h after intervention. In addition, white blood cell count (WBC) and C-reactive protein (CPR) levels before and 6 h, 24 h, 48 h, and 72 h after intervention were measured in both groups. Finally, the survival and prognostic parameters were compared between the two groups.

Results

At 6 h after monitoring intervention, the hemodynamic parameters of the patients in the PiCCO group were significantly increased. Additionally, compared with the control group, the ScvO₂ level was higher while the lactate level was lower in the PiCCO group. An intergroup comparison on inflammation also showed that WBC and CPR levels recovered better in the PiCCO group than in the control group. Moreover, patients with PiCCO monitoring showed better performance in outcome measures such as mortality, duration of invasive mechanical ventilation, length of hospital stay, duration of ventilator use, acute physiology and chronic health scores, and postoperative complications.

Conclusion

With the monitoring and guidance of the PiCCO technique, the nursing outcomes, survival rate, and prognosis of patients with myocardial injury and septic shock can be improved.

How effective is extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest? A systematic review and meta-analysis

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) has gained increasing as a promising but resource-intensive intervention for out-of-hospital cardiac arrest (OHCA). There is little data to quantify the impact of this intervention and the patients likely to benefit from its use. We conducted a meta-analysis of the literature to assess the survival benefit associated with ECPR for OHCA.

METHODS

We searched PubMed, Embase, and Scopus databases to identify relevant observational studies and randomized control trials. We used the Newcastle-Ottawa Scale and Cochrane risk-of-bias tool to assess studies' quality. We performed random-effects meta-analysis for the primary outcome of survival to hospital discharge and used meta-regressions to assess heterogeneity.

RESULTS

We identified 1287 articles, reviewed the full text of 209 and included 44 in our meta-analysis. Our analysis included 3097 patients with OHCA. Patients' mean age was 52, 79% were male, and 60% had primary ventricular fibrillation/ventricular tachycardia arrest. We identified a survival-to-discharge rate of 24%; 18% survived with favorable neurologic function. 30- and 90-days survival rates were both around 18%. The majority of included articles were high quality studies.

CONCLUSIONS

Extracorporeal cardiopulmonary resuscitation is a promising but resource-intensive intervention that may increase rates of survival to hospital discharge among patients who experience OHCA.

The Effect of Prearrest Acid-Base Status on Response to Sodium Bicarbonate and Achievement of Return of Spontaneous Circulation

BACKGROUND

The efficacy of sodium bicarbonate (SB) administration during in-hospital cardiac arrest (IHCA) for treatment of acidosis is not well described. The available literature has only evaluated out-of-hospital arrest events in patients with suspected acidosis caused by prolonged arrest.

OBJECTIVE

This study evaluated SB and its effects on return of spontaneous circulation (ROSC) in patients experiencing IHCA, based on presence of acidosis at baseline as determined by prearrest bicarbonate levels.

METHODS

We conducted a retrospective cohort study of patients who all received intravenous SB during IHCA. Patients with prearrest bicarbonate levels >21 mmol/L (nonacidotic group) were compared with those with prearrest bicarbonate levels ≤21 mmol/L (acidotic group) for the primary outcome of ROSC.

RESULTS

A total of 225 patients (102 acidotic, 123 nonacidotic) were evaluated. Asystole (37.3% vs 34.1%; P = 0.63) and pulseless electrical activity (30.4% vs 29.3%; P = 0.85) were the most common presenting rhythms. There were no differences in ROSC in the overall population (53.9% vs 48.8%; P = 0.44) or between those who had early (within 20 minutes) or delayed (after 20 minutes) ROSC. Secondary outcomes, including cardiopulmonary resuscitation duration, epinephrine administration, and total SB, were similar between groups.

CONCLUSIONS AND RELEVANCE

In this cohort study, administration of SB for IHCA in patients with prearrest acidosis was not associated with increased incidence of ROSC compared with those without prearrest acidosis. Our data suggest that there may be no benefit to the administration of SB in the setting of IHCA, regardless of prearrest acidotic status. Further investigation into the effect of SB for treatment of acidosis in IHCA is warranted.

TAT delivery of a PTEN peptide inhibitor has direct cardioprotective effects and improves outcomes in rodent models of cardiac arrest

We have recently shown that pharmacologic inhibition of PTEN significantly increases cardiac arrest survival in a mouse model, however, this protection required pretreatment 30 min before the arrest. To improve the onset of PTEN inhibition during cardiac arrest treatment, we have designed a TAT fused cell-permeable peptide (TAT-PTEN9c) based on the C-terminal PDZ binding motif of PTEN for rapid tissue delivery and protection. Western blot analysis demonstrated that TAT-PTEN9c peptide significantly enhanced Akt activation in mouse cardiomyocytes in a concentration- and time-dependent manner. Mice were subjected to 8 min asystolic arrest followed by CPR, and 30 mice with successful CPR were then randomly assigned to receive either saline or TAT-PTEN9c treatment. Survival was significantly increased in TAT-PTEN9c-treated mice compared with that of saline control at 4 h after CPR. The treated mice had increased Akt phosphorylation at 30 min resuscitation with significantly decreased sorbitol content in heart or brain tissues and reduced release of taurine and glutamate in blood, suggesting improved glucose metabolism. In an isolated rat heart Langendorff model, direct effects of TAT-PTEN9c on cardiac function were measured for 20 min following 20 min global ischemia. Rate pressure product was reduced by >20% for both TAT vehicle and nontreatment groups following arrest. Cardiac contractile function was completely recovered with TAT-PTEN9c treatment given at the start of reperfusion. We conclude that TAT-PTEN9c enhances Akt activation and decreases glucose shunting to the polyol pathway in critical organs, thereby preventing osmotic injury and early cardiovascular collapse and death.NEW & NOTEWORTHY We have designed a cell-permeable peptide, TAT-PTEN9c, to improve cardiac arrest survival. It blocked endogenous PTEN binding to its adaptor and enhanced Akt signaling in mouse cardiomyocytes. It improved mouse survival after cardiac arrest, which is related to improved glucose metabolism and reduced glucose shunting to sorbitol in critical organs.

[Drug Repositioning Research Utilizing a Large-scale Medical Claims Database to Improve Survival Rates after Cardiopulmonary Arrest]

 Approximately 100000 people suffer cardiopulmonary arrest in Japan every year, and the aging of society means that this number is expected to increase. Worldwide, approximately 100 million develop cardiac arrest annually, making it an international issue. Although survival has improved thanks to advances in cardiopulmonary resuscitation, there is a high rate of postresuscitation encephalopathy after the return of spontaneous circulation, and the proportion of patients who can return to normal life is extremely low. Treatment for postresuscitation encephalopathy is long term, and if sequelae persist then nursing care is required, causing immeasurable economic burdens as a result of ballooning medical costs. As at present there is no drug treatment to improve postresuscitation encephalopathy as a complication of cardiopulmonary arrest, the development of novel drug treatments is desirable. In recent years, new efficacy for existing drugs used in the clinical setting has been discovered, and drug repositioning has been proposed as a strategy for developing those drugs as therapeutic agents for different diseases. This review describes a large-scale database study carried out following a discovery strategy for drug repositioning with the objective of improving survival rates after cardiopulmonary arrest and discusses future repositioning prospects.

The influence of targeted temperature management on the pharmacokinetics of drugs administered during and after cardiac arrest: a systematic review

OBJECTIVE

Pharmacokinetic parameters of drugs are widely investigated under normothermic conditions and normal hemodynamic parameters. The European Resuscitation Council recommends the use of targeted temperature management (TTM) with a target temperature of 34 °C in cardiac arrest (CA) patients. The aim of this literature review is to investigate the influence of CA combined with TTM on the pharmacokinetics of drugs. Results of preclinical and clinical studies are compared with each other. Only the most important drugs, administered during CA in emergency setting, were studied.

METHODS

A literature search was conducted within PubMed and Google Scholar. The search terms included 'therapeutic hypothermia', 'TTM', 'drug metabolism', 'pharmacokinetics during hypothermia', 'cardiac arrest/etiology'. In Pubmed, MeSH-terms were also included: 'myocardial infarction/therapy', 'heart arrest/complications' and 'hypothermia'. To search for preclinical studies: the search terms 'pigs' and 'swine' were used. After the primary shift of relevant findings, further articles were found through references of these (snowballing method), as well as through related articles as suggested by the databases.

RESULTS

Due to the reduced cardiac output during TTM, most of the distribution volume ([Formula: see text]) of drugs included in this literature study is decreased. Only the [Formula: see text] of chlorzoxazone in CA rats and midazolam in non-CA patients are significantly increased during respectively deep and mild hypothermia. The renal, hepatic and biliary clearance of drugs administered during CA/TTM/hypothermia are decreased.

DISCUSSION

The combination of a decreased [Formula: see text] and a decrease in the metabolization/excretion of drugs during CA/TTM result in higher plasma concentrations compared to the plasma concentrations during CA without TTM.

Inflammatory mechanisms involved in brain injury following cardiac arrest and cardiopulmonary resuscitation

Cardiac arrest (CA) is a leading cause of fatality and long-term disability worldwide. Recent advances in cardiopulmonary resuscitation (CPR) have improved survival rates; however, the survivors are prone to severe neurological injury subsequent to successful CPR following CA. Effective therapeutic options to protect the brain from CA remain limited, due to the complexities of the injury cascades caused by global cerebral ischemia/reperfusion (I/R). Although the precise mechanisms of neurological impairment following CA-initiated I/R injury require further clarification, evidence supports that one of the key cellular pathways of cerebral injury is inflammation. The inflammatory response is orchestrated by activated glial cells in response to I/R injury. Increased release of danger-associated molecular pattern molecules and cellular dysfunction in activated microglia and astrocytes contribute to ischemia-induced cytotoxic and pro-inflammatory cytokines generation, and ultimately to delayed death of neurons. Furthermore, cytokines and adhesion molecules generated within activated microglia, as well as astrocytes, are involved in the innate immune response; modulate influx of peripheral immune and inflammatory cells into the brain, resulting in neurological injury. The present review discusses the molecular aspects of immune and inflammatory mechanisms in global cerebral I/R injury following CA and CPR, and the potential therapeutic strategies that target neuroinflammation and the innate immune system.

Use of Sodium Bicarbonate in Cardiac Arrest: Current Guidelines and Literature Review

The aim of the review was to summarize the literature over the last 25 years regarding bicarbonate administration in out-of-hospital cardiac arrest. A PubMed search was conducted using the terms "bicarbonates" and "cardiac arrest", limited to human studies and reviews published in English (or at least with a meaningful abstract in English) in the last 25 years. Clinical and experimental data raised questions regarding the safety and effectiveness of sodium bicarbonate (SB) administration during cardiac arrest. Earlier advanced cardiac life support (ACLS) guidelines recommended routine bicarbonate administration as part of the ACLS algorithm, but recent guidelines no longer recommend its use. The debate in the literature is ongoing, but at the present time, SB administration is only recommended for cardiac arrest related to hypokalemia or overdose of tricyclic antidepressants. Several studies challenge the assumption that bicarbonate administration is beneficial for treatment of acidosis in cardiac arrest. At the present time, there is a trend against using bicarbonates in cardiac arrest, and this trend is supported by guidelines published by professional societies and organizations.

Glucocorticoids as an emerging pharmacologic agent for cardiopulmonary resuscitation

Although cardiac arrest (CA) constitutes a major health problem with dismal prognosis, no specific drug therapy has been shown to improve survival to hospital discharge. CA causes adrenal insufficiency which is associated with poor outcome and increased mortality. Adrenal insufficiency may manifest as an inability to increase cortisol secretion during and after cardiopulmonary resuscitation (CPR). Several studies suggest that glucocorticoids during and after CPR seem to confer benefits with respect to return of spontaneous circulation (ROSC) rates and long term survival. They have beneficial hemodynamic effects that may favor their use during CPR and in the early post-resuscitation period. Moreover, they have anti-inflammatory and anti-apoptotic properties that improve organ function by reducing ischemia/reperfusion (I/R) injury. However, glucocorticoid supplementation has shown conflicting results with regard to survival to hospital discharge and neurological outcome. The purpose of this article is to review the pathophysiology of hypothalamic-pituitary-adrenal (HPA) axis during CPR. Furthermore, this article reviews the effects of glucocorticoids use during CRP and the post-resuscitation phase.

Vasopressin Associated With an Increase in Return of Spontaneous Circulation in Acidotic Cardiopulmonary Arrest Patients

Background: During respiratory and metabolic acidosis, the vasoconstrictive effects of epinephrine may be blunted, whereas the response to vasopressin remains unchanged. The impact of this effect during advanced cardiac life support (ACLS) remains unclear. Objective: Determine if vasopressin therapy in combination with epinephrine was associated with improved outcomes in patients with cardiac arrest compared to epinephrine alone. The primary outcome was difference in rate of return of spontaneous circulation (ROSC). Secondary outcomes included evaluation of rates of ROSC for patients with an initial pH <7.2 and by initial pulseless rhythm. Methods: Single-center, retrospective review conducted from July 2010 to July 2012. Patients ≥18 years of age with documented cardiac arrest requiring ACLS and vasopressor therapy were included. Results: A total of 101 patients met inclusion criteria. There was no difference in rate of ROSC (56% vs 60%, P = 0.68) or survival to hospital discharge (9% vs 5%, P = 0.46) between patients who received vasopressin in combination with epinephrine (n = 43) compared to epinephrine alone (n = 58). Subgroup analysis of ROSC in patients with an arterial pH of <7.2 (n = 35) showed an increased rate of ROSC (63% vs 37%, P = 0.01) in the vasopressin plus epinephrine group versus the epinephrine alone group, respectively. Subgroup analysis by initial cardiac rhythm showed no difference in rate of ROSC. Conclusions: Vasopressin in combination with epinephrine demonstrated improved ROSC in cardiac arrest patients with initial arterial pH <7.2 compared with epinephrine alone, without improving survival to hospital discharge.