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El-Menyar A, Wahlen BM. Cardiac arrest, stony heart, and cardiopulmonary resuscitation: An updated revisit. World J Cardiol 2024; 16:126-136. [PMID: 38576519 PMCID: PMC10989225 DOI: 10.4330/wjc.v16.i3.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/17/2024] [Accepted: 02/26/2024] [Indexed: 03/21/2024] Open
Abstract
The post-resuscitation period is recognized as the main predictor of cardiopulmonary resuscitation (CPR) outcomes. The first description of post-resuscitation syndrome and stony heart was published over 50 years ago. Major manifestations may include but are not limited to, persistent precipitating pathology, systemic ischemia/reperfusion response, post-cardiac arrest brain injury, and finally, post-cardiac arrest myocardial dysfunction (PAMD) after successful resuscitation. Why do some patients initially survive successful resuscitation, and others do not? Also, why does the myocardium response vary after resuscitation? These questions have kept scientists busy for several decades since the first successful resuscitation was described. By modifying the conventional modalities of resuscitation together with new promising agents, rescuers will be able to salvage the jeopardized post-resuscitation myocardium and prevent its progression to a dismal, stony heart. Community awareness and staff education are crucial for shortening the resuscitation time and improving short- and long-term outcomes. Awareness of these components before and early after the restoration of circulation will enhance the resuscitation outcomes. This review extensively addresses the underlying pathophysiology, management, and outcomes of post-resuscitation syndrome. The pattern, management, and outcome of PAMD and post-cardiac arrest shock are different based on many factors, including in-hospital cardiac arrest vs out-of-hospital cardiac arrest (OHCA), witnessed vs unwitnessed cardiac arrest, the underlying cause of arrest, the duration, and protocol used for CPR. Although restoring spontaneous circulation is a vital sign, it should not be the end of the game or lone primary outcome; it calls for better understanding and aggressive multi-disciplinary interventions and care. The development of stony heart post-CPR and OHCA remain the main challenges in emergency and critical care medicine.
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Affiliation(s)
- Ayman El-Menyar
- Department of Trauma and Vascular Surgery, Clinical Research, Hamad Medical Corporation, Doha 3050, Qatar
- Department of Clinical Medicine, Weill Cornell Medical College, Doha 24144, Qatar.
| | - Bianca M Wahlen
- Department of Anesthesiology, Hamad Medical Corporation, Doha 3050, Qatar
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Li Z, Gao J, Wang J, Xie H, Guan Y, Zhuang X, Liu Q, Fu L, Hou X, Hei F. Mortality risk factors in patients receiving ECPR after cardiac arrest: Development and validation of a clinical prognostic prediction model. Am J Emerg Med 2024; 76:111-122. [PMID: 38056056 DOI: 10.1016/j.ajem.2023.11.048] [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: 08/16/2023] [Revised: 10/31/2023] [Accepted: 11/25/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Previous studies have shown an increasing trend of extracorporeal cardiopulmonary resuscitation (ECPR) use in patients with cardiac arrest (CA). Although ECPR have been found to reduce mortality in patients with CA compared with conventional cardiopulmonary resuscitation (CCPR), the mortality remains high. This study was designed to identify the potential mortality risk factors for ECPR patients for further optimization of patient management and treatment selection. METHODS We conducted a prospective, multicentre study collecting 990 CA patients undergoing ECPR in 61 hospitals in China from January 2017 to May 2022 in CSECLS registry database. A clinical prediction model was developed using cox regression and validated with external data. RESULTS The data of 351 patients meeting the inclusion criteria before October 2021 was used to develop a prediction model and that of 68 patients after October 2021 for validation. Of the 351 patients with CA treated with ECPR, 227 (64.8%) patients died before hospital discharge. Multivariate analysis suggested that a medical history of cerebrovascular diseases, pulseless electrical activity (PEA)/asystole and higher Lactate (Lac) were risk factors for mortality while aged 45-60, higher pH and intra-aortic balloon pump (IABP) during ECPR have protective effects. Internal validation by bootstrap resampling was subsequently used to evaluate the stability of the model, showing moderate discrimination, especially in the early stage following ECPR, with a C statistic of 0.70 and adequate calibration with GOF chi-square = 10.4 (p = 0.50) for the entire cohort. Fair discrimination with c statistic of 0.65 and good calibration (GOF chi-square = 6.1, p = 0.809) in the external validation cohort demonstrating the model's ability to predict in-hospital death across a wide range of probabilities. CONCLUSION Risk factors have been identified among ECPR patients including a history of cerebrovascular diseases, higher Lac and presence of PEA or asystole. While factor such as age 45-60, higher pH and use of IABP have been found protective against in-hospital mortality. These factors can be used for risk prediction, thereby improving the management and treatment selection of patients for this resource-intensive therapy.
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Affiliation(s)
- Zhe Li
- Department of Anesthesia, China-Japan Friendship Hospital (Institute of Clinical Medical Science), Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Jie Gao
- Department of Anesthesia, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Jingyu Wang
- Key Laboratory of Cardiovascular Epidemiology & Department of Epidemiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Haixiu Xie
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Yulong Guan
- Department of Extracorporeal Circulation, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Xiaoli Zhuang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Qindong Liu
- Department of Extracorporeal Circulation, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Lin Fu
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Feilong Hei
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, People's Republic of China.
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Battaglini D, Bogossian EG, Anania P, Premraj L, Cho SM, Taccone FS, Sekhon M, Robba C. Monitoring of Brain Tissue Oxygen Tension in Cardiac Arrest: a Translational Systematic Review from Experimental to Clinical Evidence. Neurocrit Care 2024; 40:349-363. [PMID: 37081276 DOI: 10.1007/s12028-023-01721-5] [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: 12/05/2022] [Accepted: 03/24/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Cardiac arrest (CA) is a sudden event that is often characterized by hypoxic-ischemic brain injury (HIBI), leading to significant mortality and long-term disability. Brain tissue oxygenation (PbtO2) is an invasive tool for monitoring brain oxygen tension, but it is not routinely used in patients with CA because of the invasiveness and the absence of high-quality data on its effect on outcome. We conducted a systematic review of experimental and clinical evidence to understand the role of PbtO2 in monitoring brain oxygenation in HIBI after CA and the effect of targeted PbtO2 therapy on outcomes. METHODS The search was conducted using four search engines (PubMed, Scopus, Embase, and Cochrane), using the Boolean operator to combine mesh terms such as PbtO2, CA, and HIBI. RESULTS Among 1,077 records, 22 studies were included (16 experimental studies and six clinical studies). In experimental studies, PbtO2 was mainly adopted to assess the impact of gas exchanges, drugs, or systemic maneuvers on brain oxygenation. In human studies, PbtO2 was rarely used to monitor the brain oxygen tension in patients with CA and HIBI. PbtO2 values had no clear association with patients' outcomes, but in the experimental studies, brain tissue hypoxia was associated with increased inflammation and neuronal damage. CONCLUSIONS Further studies are needed to validate the effect and the threshold of PbtO2 associated with outcome in patients with CA, as well as to understand the physiological mechanisms influencing PbtO2 induced by gas exchanges, drug administration, and changes in body positioning after CA.
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Affiliation(s)
- Denise Battaglini
- Anesthesiology and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Elisa Gouvea Bogossian
- Department of Intensive Care, Hospital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Pasquale Anania
- Department of Neurosurgery, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.
| | - Lavienraj Premraj
- Griffith University School of Medicine, Gold Coast, QLD, Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Sung-Min Cho
- Departments of Neurology, Surgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hospital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Mypinder Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Chiara Robba
- Anesthesiology and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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Salvas JP, Leyba KA, Schepers LE, Paiyabhroma N, Goergen CJ, Sicard P. Neurovascular Hypoxia Trajectories Assessed by Photoacoustic Imaging in a Murine Model of Cardiac Arrest and Resuscitation. IEEE TRANSACTIONS ON ULTRASONICS, FERROELECTRICS, AND FREQUENCY CONTROL 2023; 70:1661-1670. [PMID: 37043326 DOI: 10.1109/tuffc.2023.3265800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Cardiac arrest is a common cause of death annually mainly due to postcardiac arrest syndrome that leads to multiple organ global hypoxia and dysfunction after resuscitation. The ability to quantify vasculature changes and tissue oxygenation is crucial to adapt patient treatment in order to minimize major outcomes after resuscitation. For the first time, we applied high-resolution ultrasound associated with photoacoustic imaging (PAI) to track neurovascular oxygenation and cardiac function trajectories in a murine model of cardiac arrest and resuscitation. We report the preservation of brain oxygenation is greater compared to that in peripheral tissues during the arrest. Furthermore, distinct patterns of cerebral oxygen decay may relate to the support of vital brain functions. In addition, we followed trajectories of cerebral perfusion and cardiac function longitudinally after induced cardiac arrest and resuscitation. Volumetric cerebral oxygen saturation (sO2) decreased 24 h postarrest, but these levels rebounded at one week. However, systolic and diastolic cardiac dysfunction persisted throughout and correlated with cerebral hypoxia. Pathophysiologic biomarker trends, identified via cerebral PAI in preclinical models, could provide new insights into understanding the pathophysiology of cardiac arrest and resuscitation.
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Hua T, Chu Y, Wang M, Zhang Y, Shi W, Huang Q, Zhang L, Yang M. Protective effect of canagliflozin on post-resuscitation myocardial function in a rat model of cardiac arrest. Intensive Care Med Exp 2023; 11:78. [PMID: 37966667 PMCID: PMC10651816 DOI: 10.1186/s40635-023-00562-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/06/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND Currently, most patients with cardiac arrest (CA) show reversible myocardial dysfunction, hemodynamic instability, systemic inflammation and other pathophysiological state in early stage of resuscitation, some patients may eventually progress to multiple organ failure. There is evidence that heart failure is the terminal stage in the development of various cardiovascular diseases. Although the cardio-protective effect of canagliflozin (CANA) has been confirmed in large clinical studies and recommended in domestic and international heart failure-related guidelines, the effectiveness of CANA after resuscitation remains unclear. In this study, we constructed a modified CA/CPR rat model to investigate whether CANA administered on post-resuscitation improves myocardial function. METHODS Twenty-fourth healthy male Sprague-Dawley rats were randomized into four groups: (1) Sham + placebo group, (2) Sham + CANA group, (3) CPR + placebo group, and (4) CPR + CANA group. Ventricular fibrillation was induced by transcutaneous electrical stimulation on epicardium. After 6 min untreated ventricular fibrillation, chest compressions was initiated. The rats were received an injection of placebo or canagliflozin (3 ug/kg) randomly 15 min after restore of spontaneous circulation (ROSC). Electrocardiogram (ECG) and blood pressure were continuously detected in each group throughout the experiment. The rats were killed 6 h after ROSC to collected the arterial serum and myocardial tissue. Myocardial injury was estimated with concentrations of inflammatory factors, oxidative stress indexes and, apoptosis index, myocardial injury markers, echocardiography and myocardial pathological slices. RESULTS After resuscitation, mean arterial pressure (MAP) were significantly increased after cardiopulmonary resuscitation in CANA group rats when compared with placebo group. Heart rate, body lactate returned and left ventricular ejection fraction (LVEF) to normal levels in a shorter time and the myocardial injury was obviously attenuated in CPR + CANA group. Inflammatory factors (IL-6, TNF-α) and oxidative stress indexes (MAD, SOD, CAT) were dramatically decreased with the administration of CANA. The expression of apoptosis index (BAX, caspase-3) were higher in CPR + placebo group and the expression of anti-apoptosis index (Bcl-2) was lower (P < 0.05). CONCLUSIONS The administration of CANA effectively reduces myocardial ischaemia/reperfusion (I/R) injury after cardiac arrest and cardiopulmonary resuscitation (CPR), and the underlying mechanism may be related to anti-inflammation, oxidative stress and apoptosis.
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Affiliation(s)
- Tianfeng Hua
- The Second Department of Critical Care Medicine and The Laboratory of Cardiopulmonary Resuscitation and Critical Care, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Road, Hefei, 230601, Anhui Province, China
| | - Yuqian Chu
- The Second Department of Critical Care Medicine and The Laboratory of Cardiopulmonary Resuscitation and Critical Care, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Road, Hefei, 230601, Anhui Province, China
| | - Minjie Wang
- The Second Department of Critical Care Medicine and The Laboratory of Cardiopulmonary Resuscitation and Critical Care, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Road, Hefei, 230601, Anhui Province, China
| | - Yijun Zhang
- The Second Department of Critical Care Medicine and The Laboratory of Cardiopulmonary Resuscitation and Critical Care, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Road, Hefei, 230601, Anhui Province, China
| | - Wei Shi
- The Second Department of Critical Care Medicine and The Laboratory of Cardiopulmonary Resuscitation and Critical Care, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Road, Hefei, 230601, Anhui Province, China
| | - Qihui Huang
- The Second Department of Critical Care Medicine and The Laboratory of Cardiopulmonary Resuscitation and Critical Care, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Road, Hefei, 230601, Anhui Province, China
| | - Liangliang Zhang
- The Second Department of Critical Care Medicine and The Laboratory of Cardiopulmonary Resuscitation and Critical Care, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Road, Hefei, 230601, Anhui Province, China
| | - Min Yang
- The Second Department of Critical Care Medicine and The Laboratory of Cardiopulmonary Resuscitation and Critical Care, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Road, Hefei, 230601, Anhui Province, China.
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Sarma D, Jentzer JC. Indications for Cardiac Catheterization and Percutaneous Coronary Intervention in Patients with Resuscitated Out-of-Hospital Cardiac Arrest. Curr Cardiol Rep 2023; 25:1523-1533. [PMID: 37874467 DOI: 10.1007/s11886-023-01980-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2023] [Indexed: 10/25/2023]
Abstract
PURPOSE OF REVIEW The role of emergent cardiac catheterization after resuscitated out-of-hospital cardiac arrest (OHCA) has evolved based on recent randomized evidence. This review aims to discuss the latest evidence and current indications for emergent coronary angiography (CAG) and mechanical circulatory support (MCS) use following OHCA. RECENT FINDINGS In contrast to previous observational data, recent RCTs evaluating early CAG in resuscitated OHCA patients without ST elevation have uniformly demonstrated a lack of benefit in terms of survival or neurological outcome. There is currently no randomized evidence supporting MCS use specifically in patients with resuscitated OHCA and cardiogenic shock. Urgent CAG should be considered in all patients with ST elevation, recurrent electrical or hemodynamic instability, those who are awake following resuscitated OHCA, and those receiving extracorporeal cardiopulmonary resuscitation (ECPR). Recent evidence suggests that CAG may be safely delayed in hemodynamically stable patients without ST-segment elevation following resuscitated OHCA.
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Affiliation(s)
- Dhruv Sarma
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine and Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, The Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Li Z, Xing J. Contribution and therapeutic value of mitophagy in cerebral ischemia-reperfusion injury after cardiac arrest. Biomed Pharmacother 2023; 167:115492. [PMID: 37716121 DOI: 10.1016/j.biopha.2023.115492] [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: 07/08/2023] [Revised: 09/11/2023] [Accepted: 09/12/2023] [Indexed: 09/18/2023] Open
Abstract
Cardiopulmonary resuscitation and related life support technologies have improved substantially in recent years; however, mortality and disability rates from cardiac arrest (CA) remain high and are closely associated with the high incidence of cerebral ischemia-reperfusion injury (CIRI), which is explained by a "double-hit" model (i.e., resulting from both ischemia and reperfusion). Mitochondria are important power plants in the cell and participate in various biochemical processes, such as cell differentiation and signaling in eukaryotes. Various mitochondrial processes, including energy metabolism, calcium homeostasis, free radical production, and apoptosis, are involved in several important stages of the progression and development of CIRI. Mitophagy is a key mechanism of the endogenous removal of damaged mitochondria to maintain organelle function and is a critical target for CIRI treatment after CA. Mitophagy also plays an essential role in attenuating ischemia-reperfusion in other organs, particularly during post-cardiac arrest myocardial dysfunction. Regulation of mitophagy may influence necroptosis (a programmed cell death pathway), which is the main endpoint of organ ischemia-reperfusion injury. In this review, we summarize the main signaling pathways related to mitophagy and their associated regulatory proteins. New therapeutic methods and drugs targeting mitophagy in ischemia-reperfusion animal models are also discussed. In-depth studies of the mechanisms underlying the regulation of mitophagy will enhance our understanding of the damage and repair processes in CIRI after CA, thereby contributing to the development of new therapeutic strategies.
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Affiliation(s)
- Zheng Li
- Department of Emergency Medicine, The First Hospital of Jilin University, Changchun, Jilin 130021, China.
| | - Jihong Xing
- Department of Emergency Medicine, The First Hospital of Jilin University, Changchun, Jilin 130021, China.
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Grand J, Hassager C, Schmidt H, Mølstrøm S, Nyholm B, Høigaard HF, Dahl JS, Meyer M, Beske RP, Obling L, Kjaergaard J, Møller JE. Serial assessments of cardiac output and mixed venous oxygen saturation in comatose patients after out-of-hospital cardiac arrest. Crit Care 2023; 27:410. [PMID: 37891623 PMCID: PMC10612339 DOI: 10.1186/s13054-023-04704-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/22/2023] [Indexed: 10/29/2023] Open
Abstract
AIM To assess the association with outcomes of cardiac index (CI) and mixed venous oxygen saturation (SvO2) in comatose patients resuscitated from out-of-hospital cardiac arrest (OHCA). METHODS In the cohort study of 789 patients included in the "BOX"-trial, 565 (77%) patients were included in this hemodynamic substudy (age 62 ± 13 years, male sex 81%). Pulmonary artery catheters were inserted shortly after ICU admission. CI and SvO2 were measured as soon as possible in the ICU and until awakening or death. The endpoints were all-cause mortality at 1 year and renal failure defined as need for renal replacement therapy. RESULTS First measured CI was median 1.7 (1.4-2.1) l/min/m2, and first measured SvO2 was median 67 (61-73) %. CI < median with SvO2 > median was present in 222 (39%), and low SvO2 with CI < median was present in 59 (11%). Spline analysis indicated that SvO2 value < 55% was associated with poor outcome. Low CI at admission was not significantly associated with mortality in multivariable analysis (p = 0.14). SvO2 was significantly inversely associated with mortality (hazard ratioadjusted: 0.91 (0.84-0.98) per 5% increase in SvO2, p = 0.01). SvO2 was significantly inversely associated with renal failure after adjusting for confounders (ORadjusted: 0.73 [0.62-0.86] per 5% increase in SvO2, p = 0.001). The combination of lower CI and lower SvO2 was associated with higher risk of mortality (hazard ratioadjusted: 1.54 (1.06-2.23) and renal failure (ORadjusted: 5.87 [2.34-14.73]. CONCLUSION First measured SvO2 after resuscitation from OHCA was inversely associated with mortality and renal failure. If SvO2 and CI were below median, the risk of poor outcomes increased significantly. REGISTRATION The BOX-trial is registered at clinicaltrials.gov (NCT03141099, date 2017-30-04, retrospectively registered).
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Affiliation(s)
- Johannes Grand
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Department of Cardiology, Copenhagen University Hospital Amager-Hvidovre, Copenhagen, Denmark.
| | - Christian Hassager
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Schmidt
- Department of Anesthesiology and Intensive Care, Odense University Hospital, 5000, Odense, Denmark
| | - Simon Mølstrøm
- Department of Anesthesiology and Intensive Care, Odense University Hospital, 5000, Odense, Denmark
| | - Benjamin Nyholm
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | | | - Jordi S Dahl
- Department of Cardiology, Odense University Hospital, 5000, Odense, Denmark
- Clinical Institute University of Southern Denmark, Odense, Denmark
| | - Martin Meyer
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Rasmus P Beske
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Laust Obling
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jacob E Møller
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Cardiology, Odense University Hospital, 5000, Odense, Denmark
- Clinical Institute University of Southern Denmark, Odense, Denmark
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Cotter EKH, Jacobs M, Jain N, Chow J, Estimé SR. Post-cardiac arrest care in the intensive care unit. Int Anesthesiol Clin 2023; 61:71-78. [PMID: 37678200 DOI: 10.1097/aia.0000000000000418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Affiliation(s)
- Elizabeth K H Cotter
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas
| | - Matthew Jacobs
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, Illinois
| | - Nisha Jain
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, Illinois
| | - Jarva Chow
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, Illinois
| | - Stephen R Estimé
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, Illinois
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10
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Gardner MM, Wang Y, Himebauch AS, Conlon TW, Graham K, Morgan RW, Feng R, Berg RA, Yehya N, Mercer-Rosa L, Topjian AA. Impaired echocardiographic left ventricular global longitudinal strain after pediatric cardiac arrest children is associated with mortality. Resuscitation 2023; 191:109936. [PMID: 37574003 PMCID: PMC10802989 DOI: 10.1016/j.resuscitation.2023.109936] [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: 05/17/2023] [Revised: 07/17/2023] [Accepted: 08/06/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Global longitudinal strain (GLS) is an echocardiographic method to identify left ventricular (LV) dysfunction after cardiac arrest that is less sensitive to loading conditions. We aimed to identify the frequency of impaired GLS following pediatric cardiac arrest, and its association with hospital mortality. METHODS This is a retrospective single-center cohort study of children <18 years of age treated in the pediatric intensive care unit (PICU) after in- or out-of-hospital cardiac arrest (IHCA and OHCA), with echocardiogram performed within 24 hours of initiation of post-arrest PICU care between 2013 and 2020. Patients with congenital heart disease, post-arrest extracorporeal support, or inability to measure GLS were excluded. Echocardiographic LV ejection fraction (EF) and shortening fraction (SF) were abstracted from the chart. GLS was measured post hoc; impaired strain was defined as LV GLS ≥ 2 SD worse than age-dependent normative values. Demographics and pre-arrest, arrest, and post-arrest characteristics were compared between subjects with normal versus impaired GLS. Correlation between GLS, SF and EF were calculated with Pearson comparison. Logistic regression tested the association of GLS with mortality. Area under the receiver operator curve (AUROC) was calculated for discriminative utility of GLS, EF, and SF with mortality. RESULTS GLS was measured in 124 subjects; impaired GLS was present in 46 (37.1%). Subjects with impaired GLS were older (median 7.9 vs. 1.9 years, p < 0.001), more likely to have ventricular tachycardia/fibrillation as initial rhythm (19.6% versus 3.8%, p = 0.017) and had higher peak troponin levels in the first 24 hours post-arrest (median 2.5 vs. 0.5, p = 0.002). There were no differences between arrest location or CPR duration by GLS groups. Subjects with impaired GLS compared to normal GLS had lower median EF (42.6% versus 62.3%) and median SF (23.3% versus 36.6%), all p < 0.001, with strong inverse correlation between GLS and EF (rho -0.76, p < 0.001) and SF (rho -0.71, p < 0.001). Patients with impaired GLS had higher rates of mortality (60% vs. 32%, p = 0.009). GLS was associated with mortality when controlling for age and initial rhythm [aOR 1.17 per 1% increase in GLS (95% CI 1.09-1.26), p < 0.001]. GLS, EF and SF had similar discrimination for mortality: GLS AUROC 0.69 (95% CI 0.60-0.79); EF AUROC 0.71 (95% CI 0.58-0.88); SF AUROC 0.71 (95% CI 0.61-0.82), p = 0.101. CONCLUSIONS Impaired LV function as measured by GLS after pediatric cardiac arrest is associated with hospital mortality. GLS is a novel complementary metric to traditional post-arrest echocardiography that correlates strongly with EF and SF and is associated with mortality. Future large prospective studies of post-cardiac arrest care should investigate the prognostic utilities of GLS, alongside SF and EF.
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Affiliation(s)
- Monique M Gardner
- Division of Cardiac Critical Care Medicine, Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States.
| | - Yan Wang
- Division of Cardiology, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Adam S Himebauch
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, United States
| | - Thomas W Conlon
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, United States
| | - Kathryn Graham
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, United States
| | - Ryan W Morgan
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, United States
| | - Rui Feng
- Department of Biostatistics and Epidemiology, the Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Robert A Berg
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, United States
| | - Nadir Yehya
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, United States
| | - Laura Mercer-Rosa
- Division of Cardiology, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Alexis A Topjian
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, United States
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11
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Zhu X, Li J, Wang H, Gasior FM, Lee C, Lin S, Justice CN, O’Donnell JM, Vanden Hoek TL. Nicotinamide restores tissue NAD+ and improves survival in rodent models of cardiac arrest. PLoS One 2023; 18:e0291598. [PMID: 37713442 PMCID: PMC10503771 DOI: 10.1371/journal.pone.0291598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 09/04/2023] [Indexed: 09/17/2023] Open
Abstract
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.
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Affiliation(s)
- Xiangdong Zhu
- Center for Advanced Resuscitation Medicine and Department of Emergency Medicine, Center for Cardiovascular Research, University of Illinois Hospital & Health Sciences System, Chicago, Illinois, United States of America
| | - Jing Li
- Center for Advanced Resuscitation Medicine and Department of Emergency Medicine, Center for Cardiovascular Research, University of Illinois Hospital & Health Sciences System, Chicago, Illinois, United States of America
| | - Huashan Wang
- Center for Advanced Resuscitation Medicine and Department of Emergency Medicine, Center for Cardiovascular Research, University of Illinois Hospital & Health Sciences System, Chicago, Illinois, United States of America
| | - Filip M. Gasior
- Department of Physiology and Biophysics, Center for Cardiovascular Research, University of Illinois Hospital & Health Sciences System, Chicago, Illinois, United States of America
| | - Chunpei Lee
- Center for Advanced Resuscitation Medicine and Department of Emergency Medicine, Center for Cardiovascular Research, University of Illinois Hospital & Health Sciences System, Chicago, Illinois, United States of America
| | - Shaoxia Lin
- Center for Advanced Resuscitation Medicine and Department of Emergency Medicine, Center for Cardiovascular Research, University of Illinois Hospital & Health Sciences System, Chicago, Illinois, United States of America
| | - Cody N. Justice
- Center for Advanced Resuscitation Medicine and Department of Emergency Medicine, Center for Cardiovascular Research, University of Illinois Hospital & Health Sciences System, Chicago, Illinois, United States of America
- Department of Physiology and Biophysics, Center for Cardiovascular Research, University of Illinois Hospital & Health Sciences System, Chicago, Illinois, United States of America
| | - J. Michael O’Donnell
- Department of Physiology and Biophysics, Center for Cardiovascular Research, University of Illinois Hospital & Health Sciences System, Chicago, Illinois, United States of America
| | - Terry L. Vanden Hoek
- Center for Advanced Resuscitation Medicine and Department of Emergency Medicine, Center for Cardiovascular Research, University of Illinois Hospital & Health Sciences System, Chicago, Illinois, United States of America
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12
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Wender ER, Counts CR, Van Dyke M, Sayre MR, Maynard C, Johnson NJ. Prehospital Administration of Norepinephrine and Epinephrine for Shock after Resuscitation from Cardiac Arrest. PREHOSP EMERG CARE 2023; 28:453-458. [PMID: 37642521 DOI: 10.1080/10903127.2023.2252500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 08/18/2023] [Accepted: 08/23/2023] [Indexed: 08/31/2023]
Abstract
INTRODUCTION Shock after resuscitation from out-of-hospital cardiac arrest (OHCA) is often treated with vasopressors. We examined whether infusion of epinephrine versus norepinephrine was associated with prehospital rearrest and neurologically favorable survival among OHCA patients. METHODS This retrospective study included OHCA cases in Seattle, Washington from 2014-2021 who had return of spontaneous circulation (ROSC) followed by vasopressor infusion. Our primary exposure was infusion of epinephrine or norepinephrine. Our primary outcome was prehospital rearrest. Secondary outcomes included survival and neurologically favorable outcome (Cerebral Performance Category score of 1 or 2). We used multivariable logistic regression to test associations between exposures and outcomes adjusting for key covariates. RESULTS Of 451 OHCA patients with ROSC followed by vasopressor infusion, 253 (56%) received norepinephrine and 198 (44%) received epinephrine infusions. Those who received epinephrine were older (median 66 [interquartile ranges {IQR} 53-79] vs 63 [IQR 47-75] years), but otherwise had similar baseline characteristics. Patients who received epinephrine were twice as likely to rearrest (55% vs 25%). After adjustment, the difference in rearrest rates between epinephrine and norepinephrine persisted (OR 3.28, 95%CI 2.25-5.08), and the odds of pulses at hospital arrival were lower in the epinephrine group (OR 0.52 95%CI 0.32-0.83). After adjustment, there was no difference in neurologically favorable survival, survival to hospital admission, or survival to discharge. CONCLUSION Patients who received epinephrine infusions after ROSC suffered prehospital rearrest more frequently than those who received norepinephrine. Survival and neurological status at hospital discharge were similar. Future trials should examine the optimal approach to hemodynamic management for post-OHCA shock.
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Affiliation(s)
- Emma R Wender
- Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Catherine R Counts
- Department of Emergency Medicine, University of Washington, Seattle, Washington
- Seattle Fire Department, Seattle, Washington
| | - Molly Van Dyke
- Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Michael R Sayre
- Department of Emergency Medicine, University of Washington, Seattle, Washington
- Seattle Fire Department, Seattle, Washington
| | - Charles Maynard
- Department of Health Systems and Population Health, University of Washington, Seattle, Washington
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington, Seattle, Washington
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13
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Schoenthal T, Hoiland R, Griesdale DE, Sekhon MS. Cerebral hemodynamics after cardiac arrest: implications for clinical management. Minerva Anestesiol 2023; 89:824-833. [PMID: 37676177 DOI: 10.23736/s0375-9393.23.17268-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
Following resuscitation from cardiac arrest, hypoxic ischemic brain injury (HIBI) ensues, which is the primary determinant of adverse outcome. The pathophysiology of HIBI can be compartmentalized into primary and secondary injury, resulting from cerebral ischemia during cardiac arrest and reperfusion following successful resuscitation, respectively. During the secondary injury phase, increased attention has been directed towards the optimization of cerebral oxygen delivery to prevent additive injury to the brain. During this phase, cerebral hemodynamics are characterized by early hyperemia following resuscitation and then a protracted phase of cerebral hypoperfusion termed "no-reflow" during which additional hypoxic-ischemic injury can occur. As such, identification of therapeutic strategies to optimize cerebral delivery of oxygen is at the forefront of HIBI research. Unfortunately, randomized control trials investigating the manipulation of arterial carbon dioxide tension and mean arterial pressure augmentation as methods to potentially improve cerebral oxygen delivery have shown no impact on clinical outcomes. Emerging literature suggests differential patient-specific phenotypes may exist in patients with HIBI. The potential to personalize therapeutic strategies in the critical care setting based upon patient-specific pathophysiology presents an attractive strategy to improve HIBI outcomes. Herein, we review the cerebral hemodynamic pathophysiology of HIBI, discuss patient phenotypes as it pertains to personalizing care, as well as suggest future directions.
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Affiliation(s)
- Tison Schoenthal
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Ryan Hoiland
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Department of Cellular and Physiological Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Center for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, Faculty of Health and Social Development, University of British Columbia Okanagan, Kelowna, BC, Canada
- International Collaboration on Repair Discoveries, Vancouver, BC, Canada
| | - Donald E Griesdale
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Center for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada -
- International Collaboration on Repair Discoveries, Vancouver, BC, Canada
- Djavad Mowafaghian Center for Brain Health, University of British Columbia, Vancouver, BC, Canada
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14
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Li K, Zhu Z, Sun X, Zhao L, Liu Z, Xing J. Harnessing the therapeutic potential of mesenchymal stem cell-derived exosomes in cardiac arrest: Current advances and future perspectives. Biomed Pharmacother 2023; 165:115201. [PMID: 37480828 DOI: 10.1016/j.biopha.2023.115201] [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: 05/31/2023] [Revised: 07/16/2023] [Accepted: 07/18/2023] [Indexed: 07/24/2023] Open
Abstract
BACKGROUND Cardiac arrest (CA), characterized by sudden onset and high mortality rates, is one of the leading causes of death globally, with a survival rate of approximately 6-24%. Studies suggest that the restoration of spontaneous circulation (ROSC) hardly improved the mortality rate and prognosis of patients diagnosed with CA, largely due to ischemia-reperfusion injury. MAIN BODY Mesenchymal stem cells (MSCs) exhibit self-renewal and strong potential for multilineage differentiation. Their effects are largely mediated by extracellular vesicles (EVs). Exosomes are the most extensively studied subgroup of EVs. EVs mainly mediate intercellular communication by transferring vesicular proteins, lipids, nucleic acids, and other substances to regulate multiple processes, such as cytokine production, cell proliferation, apoptosis, and metabolism. Thus, exosomes exhibit significant potential for therapeutic application in wound repair, tissue reconstruction, inflammatory reaction, and ischemic diseases. CONCLUSION Based on similar pathological mechanisms underlying post-cardiac arrest syndrome involving various tissues and organs in many diseases, the review summarizes the therapeutic effects of MSC-derived exosomes and explores the prospects for their application in the treatment of CA.
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Affiliation(s)
- Ke Li
- Department of Emergency Medicine, The First Hospital of Jilin University, Changchun 130021, China.
| | - Zhu Zhu
- Department of Breast Surgery, General Surgery Center, The First Hospital of Jilin University, Changchun 130021, China.
| | - Xiumei Sun
- Department of Emergency Medicine, The First Hospital of Jilin University, Changchun 130021, China.
| | - Linhong Zhao
- Northeast Normal University, Changchun 130022, China.
| | - Zuolong Liu
- Department of Emergency Medicine, The First Hospital of Jilin University, Changchun 130021, China.
| | - Jihong Xing
- Department of Emergency Medicine, The First Hospital of Jilin University, Changchun 130021, China.
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15
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Mark J, Lopez J, Wahood W, Dodge J, Belaunzaran M, Losiniecki F, Santos-Roman Y, Danckers M. The role of targeted temperature management in 30-day hospital readmissions in cardiac arrest survivors: A national population-based study. IJC HEART & VASCULATURE 2023; 46:101207. [PMID: 37113651 PMCID: PMC10127122 DOI: 10.1016/j.ijcha.2023.101207] [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: 02/27/2023] [Revised: 04/08/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023]
Abstract
Background Targeted temperature management (TTM) implementation following resuscitation from cardiac arrest is controversial. Although prior studies have shown that TTM improves neurological outcomes and mortality, less is known about the rates or causes of readmission in cardiac arrest survivors within 30 days. We aimed to determine whether the implementation of TTM improves all-cause 30-day unplanned readmission rates in cardiac arrest survivors. Methods Using the Nationwide Readmissions Database, we identified 353,379 adult cardiac arrest index hospitalizations and discharges using the International Classification of Diseases, 9th and 10th codes. The primary outcome was 30-day all-cause unplanned readmissions following cardiac arrest discharge. Secondary outcomes included 30-day readmission rates and reasons, including impacts on other organ systems. Results Of 353,379 discharges for cardiac arrest with 30-day readmission, 9,898 (2.80%) received TTM during index hospitalization. TTM implementation was associated with lower 30-day all-cause unplanned readmission rates versus non-recipients (6.30% vs. 9.30%, p < 0.001). During index hospitalization, receiving TTM was also associated with higher rates of AKI (41.12% vs. 37.62%, p < 0.001) and AHF (20.13% vs. 17.30%, p < 0.001). We identified an association between lower rates of 30-day readmission for AKI (18.34% vs. 27.48%, p < 0.05) and trend toward lower AHF readmissions (11.32% vs. 17.97%, p = 0.05) among TTM recipients. Conclusions Our study highlights a possible negative association between TTM and unplanned 30-day readmission in cardiac arrest survivors, thereby potentially reducing the impact and burden of increased short-term readmission in these patients. Future randomized studies are warranted to optimize TTM use during post-arrest care.
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Affiliation(s)
- Justin Mark
- Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, FL, United States
- Corresponding author at: 3301 College Ave, Fort Lauderdale, FL 33314, United States.
| | - Jose Lopez
- Department of Internal Medicine, HCA Florida Aventura Hospital, FL, United States
| | - Waseem Wahood
- Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, FL, United States
| | - Joshua Dodge
- Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, FL, United States
| | - Miguel Belaunzaran
- Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, FL, United States
| | - Fergie Losiniecki
- Division of Clinical Cardiac Electrophysiology, Medical University of South Carolina, SC, United States
| | | | - Mauricio Danckers
- Division of Critical Care, HCA Florida Aventura Hospital, FL, United States
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16
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Vallabhajosyula S, Verghese D, Henry TD, Katz JN, Nicholson WJ, Jaber WA, Jentzer JC. Contemporary Management of Concomitant Cardiac Arrest and Cardiogenic Shock Complicating Myocardial Infarction. Mayo Clin Proc 2022; 97:2333-2354. [PMID: 36464466 DOI: 10.1016/j.mayocp.2022.06.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 06/08/2022] [Accepted: 06/24/2022] [Indexed: 12/03/2022]
Abstract
Cardiogenic shock (CS) and cardiac arrest (CA) are the most life-threatening complications of acute myocardial infarction. Although there is a significant overlap in the pathophysiology with approximately half the patients with CS experiencing a CA and approximately two-thirds of patients with CA developing CS, comprehensive guideline recommendations for management of CA + CS are lacking. This paper summarizes the current evidence on the incidence, pathophysiology, and short- and long-term outcomes of patients with acute myocardial infarction complicated by concomitant CA + CS. We discuss the hemodynamic factors and unique challenges that need to be accounted for while developing treatment strategies for these patients. A summary of expert-based step-by-step recommendations to the approach and treatment of these patients, both in the field before admission and in-hospital management, are presented.
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Affiliation(s)
- Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Dhiran Verghese
- Section of Advanced Cardiac Imaging, Division of Cardiovascular Medicine, Department of Medicine, Harbor UCLA Medical Center, Torrance, CA, USA; Department of Cardiovascular Medicine, NCH Heart Institute, Naples, FL, USA
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education at the Christ Hospital Health Network, Cincinnati, OH, USA
| | - Jason N Katz
- Divisions of Cardiovascular Diseases and Pulmonary and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - William J Nicholson
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Wissam A Jaber
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
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17
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Heart rate and diastolic arterial pressure in cardiac arrest patients: A nationwide, multicenter prospective registry. PLoS One 2022; 17:e0274130. [PMID: 36103505 PMCID: PMC9473410 DOI: 10.1371/journal.pone.0274130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 08/22/2022] [Indexed: 11/19/2022] Open
Abstract
Background
Guidelines have recommended monitoring mean arterial pressure (MAP) and systolic arterial pressure (SAP) in cardiac arrest patients, but there has been relatively little regard for diastolic arterial pressure (DAP) and heart rate (HR). We aimed to determine the prognostic significance of hemodynamic parameters at all time points during targeted temperature management (TTM).
Methods
We reviewed the SAP, DAP, MAP, and HR data in out-of-hospital cardiac arrest (OHCA) survivors from the prospective multicenter registry of 22 teaching hospitals. This study included 1371 patients who underwent TTM among 10,258 cardiac arrest patients. The hemodynamic parameters were recorded every 6 hours from the return of spontaneous circulation (ROSC) to 4 days. The risks of those according to time points during TTM were compared.
Results
Of the included patients, 943 (68.8%) had poor neurological outcomes. The predictive ability of DAP surpassed that of SAP and MAP at all time points, and among the hemodynamic variables HR/DAP was the best predictor of the poor outcome. The risks in patients with DAP < 55 to 70 mmHg and HR > 70 to 100 beats/min were steeply increased for 2 days after ROSC and correlated with the poor outcome at all time points. Bradycardia showed lower risks only at 6 hours to 24 hours after ROSC.
Conclusion
Hemodynamic parameters should be intensively monitored especially for 2 days after ROSC because cardiac arrest patients may be vulnerable to hemodynamic instability during TTM. Monitoring HR/DAP can help access the risks in cardiac arrest patients.
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18
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Cunningham CA, Coppler PJ, Skolnik AB. The immunology of the post-cardiac arrest syndrome. Resuscitation 2022; 179:116-123. [PMID: 36028143 DOI: 10.1016/j.resuscitation.2022.08.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 08/17/2022] [Accepted: 08/18/2022] [Indexed: 10/15/2022]
Abstract
Patients successfully resuscitated from cardiac arrest often have brain injury, myocardial dysfunction, and systemic ischemia-reperfusion injury, collectively termed the post-cardiac arrest syndrome (PCAS). To improve outcomes, potential therapies must be able to be administered early in the post-arrest course and provide broad cytoprotection, as ischemia-reperfusion injury affects all organ systems. Our understanding of the immune system contributions to the PCAS has expanded, with animal models detailing biologically plausible mechanisms of secondary injury, the protective effects of available immunomodulatory drugs, and how immune dysregulation underlies infection susceptibility after arrest. In this narrative review, we discuss the dysregulated immune response in PCAS, human trials of targeted immunomodulation therapies, and future directions for immunomodulation following cardiac arrest.
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Affiliation(s)
- Cody A Cunningham
- Mayo Clinic School of Graduate Medical Education, Department of Internal Medicine, Mayo Clinic, Scottsdale, AZ, USA.
| | - Patrick J Coppler
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Aaron B Skolnik
- Department of Critical Care Medicine, Mayo Clinic Hospital, Phoenix, AZ, USA
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19
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Wang C, Bischof E, Xu J, Guo Q, Zheng G, Ge W, Hu J, Georgescu Margarint EL, Bradley JL, Peberdy MA, Ornato JP, Zhu C, Tang W. Effects of Methylprednisolone on Myocardial Function and Microcirculation in Post-resuscitation: A Rat Model. Front Cardiovasc Med 2022; 9:894004. [PMID: 35872886 PMCID: PMC9301050 DOI: 10.3389/fcvm.2022.894004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPrevious studies have demonstrated that inflammation and impaired microcirculation are key factors in post-resuscitation syndromes. Here, we investigated whether methylprednisolone (MP) could improve myocardial function and microcirculation by suppressing the systemic inflammatory response following cardiopulmonary resuscitation (CPR) in a rat model of cardiac arrest (CA).MethodsSprague-Dawley rats were randomly assigned to (1) sham, (2) control, and (3) drug groups. Ventricular fibrillation was induced and then followed by CPR. The rats were infused with either MP or vehicle at the start of CPR. Myocardial function and microcirculation were assessed at baseline and after the restoration of spontaneous circulation. Blood samples were drawn at baseline and 60-min post-resuscitation to assess serum cytokine (TNF-α, IL-1β, and IL-6) levels.ResultsMyocardial function [estimated by the ejection fraction (EF), myocardial performance index (MPI), and cardiac output (CO)] improved post-ROSC in the MP group compared with those in the control group (p < 0.05). MP decreased the levels of the aforementioned pro-inflammatory cytokines and alleviated cerebral, sublingual, and intestinal microcirculation compared with the control (p < 0.05). A negative correlation emerged between the cytokine profile and microcirculatory blood flow.ConclusionMP treatment reduced post-resuscitation myocardial dysfunction, inhibited pro-inflammatory cytokines, and improved microcirculation in the initial recovery phase in a CA and resuscitation animal model. Therefore, MP could be a potential clinical target for CA patients in the early phase after CPR to alleviate myocardial dysfunction and improve prognosis.
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Affiliation(s)
- Changsheng Wang
- Department of Emergency Medicine, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, United States
| | - Evelyne Bischof
- Department of Basic and Clinical Medicine, Shanghai University of Medicine and Health Sciences, Shanghai, China
- Department of Medical Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jing Xu
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, United States
| | - Qinyue Guo
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, United States
| | - Guanghui Zheng
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, United States
| | - Weiwei Ge
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, United States
| | - Juntao Hu
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, United States
| | | | - Jennifer L. Bradley
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, United States
| | - Mary Ann Peberdy
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, United States
- Department of Internal Medicine and Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA, United States
| | - Joseph P. Ornato
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, United States
- Department of Internal Medicine and Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA, United States
| | - Changqing Zhu
- Department of Emergency Medicine, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Changqing Zhu,
| | - Wanchun Tang
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, United States
- Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA, United States
- Wanchun Tang,
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20
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Jentzer JC. Under pressure: pulmonary hypertension and right ventricular dysfunction in cardiac arrest. Resuscitation 2022; 177:38-40. [PMID: 35779799 DOI: 10.1016/j.resuscitation.2022.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 06/23/2022] [Indexed: 10/17/2022]
Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester MN.
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21
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Tabi M, Singam NSV, Wiley B, Anavekar N, Barsness G, Jentzer JC. Echocardiographic Characteristics of Cardiogenic Shock Patients with and Without Cardiac Arrest. J Intensive Care Med 2022; 38:51-59. [PMID: 35656768 DOI: 10.1177/08850666221105236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Cardiac arrest (CA) is associated with worse outcomes in patients with cardiogenic shock (CS). To better understand the contribution of CA on CS, we evaluated transthoracic echocardiography (TTE) parameters in CS patients with and without CA. Methods: We retrospectively identified CS patients with a TTE performed near cardiac intensive care unit admission between 2007 to 2018. We compared TTE measurements of left ventricular (LV) and right ventricular (RV) function in patients with and without CA. The primary outcome was all-cause in-hospital mortality, as determined using multivariable logistic regression. Results: We included 1085 patients, 35% of whom had CA. Median age was 70 years and 37% were females. CA patients had higher severity of illness, more invasive mechanical ventilation and greater vasopressor/inotrope use. In-hospital mortality was 31% and was higher in CA patients (45% vs. 23%, p <0.001). Although LV ejection fraction (LVEF) was similar (35% vs. 37%, p = 0.05), CA patients had lower cardiac index, mitral valve E wave peak velocity, E/A ratio and E/e' ratio. TTE variables that were associated with hospital mortality varied, among patients with CA, these included measures of RV pressure and function and among patients without CA, these included parameters reflecting LV systolic function. Conclusions: Doppler assessments of RV systolic dysfunction were the strongest TTE predictors of hospital mortality in CS patients with CA, unlike CS patients without CA in whom LV systolic function was more important. This emphasizes the importance of RV assessment for mortality risk stratification after CA.
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Affiliation(s)
- Meir Tabi
- Department of Cardiovascular Medicine, 6915Mayo Clinic, Rochester MN, US
| | - Narayana Sarma V Singam
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, 6915Mayo Clinic, Rochester MN, US
| | - Brandon Wiley
- Department of Cardiovascular Medicine, 6915Mayo Clinic, Rochester MN, US
| | - Nandan Anavekar
- Department of Cardiovascular Medicine, 6915Mayo Clinic, Rochester MN, US
| | - Gregory Barsness
- Department of Cardiovascular Medicine, 6915Mayo Clinic, Rochester MN, US
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, 6915Mayo Clinic, Rochester MN, US.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, 6915Mayo Clinic, Rochester MN, US
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22
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Wang F, Yuan Q, Cao S, Li R, Zhang J, Yang K, Xu F, Chen Y. Inhibition of Nitrosative Stress Attenuates Myocardial Injury and Improves Outcomes after Cardiac Arrest and Resuscitation. Shock 2022; 57:299-307. [PMID: 35703306 DOI: 10.1097/shk.0000000000001939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Nitrosative stress is widely involved in cell injury via inducing the nitration modification of a variety of proteins. This study aimed to investigate whether inhibition of nitrosative stress attenuated myocardial injury and improved outcomes in a rat model of cardiac arrest (CA) and cardiopulmonary resuscitation (CPR). METHODS Adult male Wistar rats were subjected to asphyxia-induced cardiac arrest and subsequently resuscitation. One minute after return of spontaneous circulation (ROSC), rats were randomized and administered the nitrosative stress inhibitor, FeTMPyP (1 or 3 mg/kg), or normal saline as a placebo. 3-Nitrotyrosine (3-NT), mean arterial pressure (MAP), heart rate (HR), mortality, electrocardiogram (ECG), left ventricular ejection fraction (EF) and fractional shortening (FS), and levels of myocardial apoptosis were evaluated. The concentrations of lactate, creatine kinase MB isoenzyme (CK-MB), and angiotensin II (Ang II), were measured in blood samples. RESULTS 3-NT level was significantly increased in the heart after ROSC. Administration of FeTMPyP (1 or 3 mg/kg) attenuated the increase of 3-NT in the myocardium. Inhibition of nitrosative stress improved survival and attenuated CA/CPR-induced reperfusion injury by maintaining the stability of MAP and HR, and reducing the accumulation of lactic acid. Post-cardiac arrest rats had higher serum CK-MB and Ang II than healthy rats, while EF and FS were lower in healthy rats. Inhibition of nitrosative stress not only alleviated ischemic heart injury but also reduced the occurrence of CA/CPR-induced of arrhythmias. Moreover, nitrosative stress mediated the upregulation of Cleaved caspase-3 and downregulation Bcl-2, which was abolished by FeTMPyP. CONCLUSIONS Inhibition of nitrosative stress is a novel molecular target to alleviate myocardial injury and improve outcomes in a rat model of CA/CPR.
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Affiliation(s)
- Fulin Wang
- Department of Emergency Medicine, Qilu Hospital, Shandong University, Jinan, China
- Chest Pain Center, Qilu Hospital, Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital, Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital, Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Shandong University, Jinan, China
| | - Qiuhuan Yuan
- Department of Emergency Medicine, Qilu Hospital, Shandong University, Jinan, China
- Chest Pain Center, Qilu Hospital, Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital, Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital, Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Shandong University, Jinan, China
| | - Shengchuan Cao
- Department of Emergency Medicine, Qilu Hospital, Shandong University, Jinan, China
- Chest Pain Center, Qilu Hospital, Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital, Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital, Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Shandong University, Jinan, China
| | - Ruochuan Li
- Department of Emergency Medicine, Qilu Hospital, Shandong University, Jinan, China
- Chest Pain Center, Qilu Hospital, Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital, Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital, Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Shandong University, Jinan, China
| | - Jian Zhang
- Department of Emergency Medicine, Qilu Hospital, Shandong University, Jinan, China
- Chest Pain Center, Qilu Hospital, Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital, Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital, Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Shandong University, Jinan, China
| | - Kehui Yang
- Department of Emergency Medicine, Qilu Hospital, Shandong University, Jinan, China
- Chest Pain Center, Qilu Hospital, Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital, Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital, Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Shandong University, Jinan, China
| | - Feng Xu
- Department of Emergency Medicine, Qilu Hospital, Shandong University, Jinan, China
- Chest Pain Center, Qilu Hospital, Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital, Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital, Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Shandong University, Jinan, China
| | - Yuguo Chen
- Department of Emergency Medicine, Qilu Hospital, Shandong University, Jinan, China
- Chest Pain Center, Qilu Hospital, Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital, Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital, Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Shandong University, Jinan, China
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23
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Ortuno S, Geri G, Bouguoin W, Cariou A, Aissaoui N. Myocardial dysfunction after cardiac arrest: tips and pitfalls. Eur J Emerg Med 2022; 29:188-194. [PMID: 35135980 DOI: 10.1097/mej.0000000000000904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Postcardiac arrest shock (PCAS) is defined by hemodynamic instability occurring in the first hours after cardiac arrest (CA) and is a major cause of mortality among patients hospitalized after CA. It includes vasoplegia and myocardial dysfunction. This postcardiac arrest myocardial dysfunction is supposed to recover within the 3 days. However, there are many unknowns regarding its definition, its prognosis value and its management. In this review dedicated to emergency physicians, we choose to address tips and pitfalls they should know regarding this prevalent syndrome.
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Affiliation(s)
- Sofia Ortuno
- Assistance Publique des Hôpitaux de Paris (APHP) Cochin, Intensive Care Medicine
- Université de Paris, Paris
| | - Guillaume Geri
- Department of Cardiology and Critical Care, Clinique Ambroise Paré, Neuilly-sur-Seine
- After-ROSC Network, Paris
| | - Wulfran Bouguoin
- After-ROSC Network, Paris
- Service de Médecine Intensive Réanimation, Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy
- INSERM U970
- Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital
- Paris Sudden-Death-Expertise-Centre, Paris, France
| | - Alain Cariou
- Assistance Publique des Hôpitaux de Paris (APHP) Cochin, Intensive Care Medicine
- Université de Paris, Paris
- After-ROSC Network, Paris
- INSERM U970
- Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital
- Paris Sudden-Death-Expertise-Centre, Paris, France
| | - Nadia Aissaoui
- Assistance Publique des Hôpitaux de Paris (APHP) Cochin, Intensive Care Medicine
- Université de Paris, Paris
- After-ROSC Network, Paris
- INSERM U970
- Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital
- Paris Sudden-Death-Expertise-Centre, Paris, France
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24
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You JS, Lee HS, Jeon S, Lee JW, Chung HS, Chung SP, Kong T. Thrombotic Microangiopathy Score as a New Predictor of Neurologic Outcomes in Patients after Out-of-Hospital Cardiac Arrest. Yonsei Med J 2022; 63:461-469. [PMID: 35512749 PMCID: PMC9086697 DOI: 10.3349/ymj.2022.63.5.461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 02/07/2022] [Accepted: 02/09/2022] [Indexed: 12/02/2022] Open
Abstract
PURPOSE Given the morphological characteristics of schistocytes, thrombotic microangiopathy (TMA) score can be beneficial as it can be automatically and accurately measured. This study aimed to investigate whether serial TMA scores until 48 h post admission are associated with clinical outcomes in patients undergoing targeted temperature management (TTM) after out-of-hospital cardiac arrest (OHCA). MATERIALS AND METHODS We retrospectively evaluated a cohort of 185 patients using a prospective registry. We analyzed TMA scores at admission and after 12, 24, and 48 hours. The primary outcome measures were poor neurological outcome at discharge and 30-day mortality. RESULTS Increased TMA scores at all measured time points were independent predictors of poor neurological outcomes and 30-day mortality, with TMA score at time-12 showing the strongest correlation [odds ratio (OR), 3.008; 95% confidence interval (CI), 1.707-5.300; p<0.001 and hazard ratio (HR), 1.517; 95% CI, 1.196-1.925; p<0.001]. Specifically, a TMA score ≥2 at time-12 was closely associated with an increased predictability of poor neurological outcomes (OR, 6.302; 95% CI, 2.841-13.976; p<0.001) and 30-day mortality (HR, 2.656; 95% CI, 1.675-4.211; p<0.001). CONCLUSION Increased TMA scores predicted neurological outcomes and 30-day mortality in patients undergoing TTM after OHCA. In addition to the benefit of being serially measured using an automated hematology analyzer, TMA score may be a helpful tool for rapid risk stratification and identification of the need for intensive care in patients with return of spontaneous circulation after OHCA.
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Affiliation(s)
- Je Sung You
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Sun Lee
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Soyoung Jeon
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Wook Lee
- Department of Laboratory Medicine, Konyang University Hospital, Daejeon, Korea
| | - Hyun Soo Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Taeyoung Kong
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea.
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25
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Jentzer JC, Tabi M, Wiley BM, Singam NSV, Anavekar NS. Echocardiographic Correlates of Mortality Among Cardiac Intensive Care Unit Patients With Cardiogenic Shock. Shock 2022; 57:336-343. [PMID: 34710882 DOI: 10.1097/shk.0000000000001877] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prior studies have shown worse outcomes in patients with cardiogenic shock (CS) who have reduced left ventricular ejection fraction (LVEF), but the association between other transthoracic echocardiogram (TTE) findings and mortality in CS patients remains uncertain. We hypothesized that Doppler TTE measurements would outperform LVEF for risk stratification. METHODS Retrospective analysis of cardiac intensive care unit patients with an admission diagnosis of CS and a TTE within 1 day of admission. Hospital survivors and inpatient deaths were compared, and multivariable logistic regression was used to analyze the associations between TTE variables and hospital mortality. RESULTS We included 1,085 patients, with a median age of 69.5 (59.6, 77.5) years; 37% were females and 62% had an acute coronary syndrome. Most patients (66%) had moderate or severe left ventricular (LV) systolic dysfunction, and 48% had moderate or severe right ventricular (RV) systolic dysfunction. Hospital mortality occurred in 31%, and inpatient deaths had a lower median LVEF (29% vs. 35%, P < 0.001). Patients with mild or no LV or RV dysfunction were at lower risk of adjusted hospital mortality (P < 0.01). The LV outflow tract (LVOT) velocity-time integral (VTI) was the single best predictor of hospital mortality. After multivariable adjustment, both the LVEF and LVOT VTI remained strongly associated with hospital mortality (P < 0.001). CONCLUSIONS Early comprehensive Doppler TTE can provide important prognostic insights in CS patients, highlighting its potential utility in clinical practice. The LVOT VTI, reflecting forward flow, is an important measurement to obtain on bedside TTE.
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Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Meir Tabi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Brandon M Wiley
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Narayana S V Singam
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Nandan S Anavekar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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26
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Wu SN, Tsai MS, Huang CH, Chen WJ. Omecamtiv mecarbil treatment improves post-resuscitation cardiac function and neurological outcome in a rat model. PLoS One 2022; 17:e0264165. [PMID: 35176110 PMCID: PMC8853579 DOI: 10.1371/journal.pone.0264165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 02/02/2022] [Indexed: 11/29/2022] Open
Abstract
Background Myocardial dysfunction is a major cause of poor outcomes in the post-cardiac arrest period. Omecamtiv mecarbil (OM) is a selective small molecule activator of cardiac myosin that prolongs myocardial systole and increases stroke volume without apparent effects on myocardial oxygen demand. OM administration is safe and improves cardiac function in patients with acute heart failure. Whether OM improves post-resuscitation myocardial dysfunction remains unclear. This study investigated the effect of OM treatment on post-resuscitation myocardial dysfunction and outcomes. Methods and results Adult male rats were resuscitated after 9.5 min of asphyxia-induced cardiac arrest. OM and normal saline was continuously intravenously infused after return of spontaneous circulation (ROSC) at 0.25 mg/kg/h for 4 h in the experimental group and control group, respectively (n = 20 in each group). Hemodynamic parameters were measured hourly and monitored for 4 h after cardiac arrest. Recovery of neurological function was evaluated by neurological functioning scores (0–12; favorable: 11–12) for rats 72 h after cardiac arrest. OM treatment prolonged left ventricular ejection time and improved post-resuscitation cardiac output. Post-resuscitation heart rate and left ventricular systolic function (dp/dt40) were not different between groups. Kaplan-Meier analysis showed non-statistically higher 72-h survival in the OM group (72.2% [13/18] and 58.8% [10/17], p = 0.386). The OM group had a higher chance of having favorable neurological outcomes in surviving rats 72 h after cardiac arrest (84.6% [11/13] vs. 40% [4/10], p = 0.026). The percentage of damaged neurons was lower in the OM group in a histology study at 72 h after cardiac arrest (55.5±2.3% vs. 76.2±10.2%, p = 0.004). Conclusions OM treatment improved post-resuscitation myocardial dysfunction and neurological outcome in an animal model. These findings support further pre-clinical studies to improve outcomes in post-cardiac arrest care.
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Affiliation(s)
- Shih-Ni Wu
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Min-Shan Tsai
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
- * E-mail:
| | - Wen-Jone Chen
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
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27
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Bhardwaj A, Alwakeel M, Duggal A, Abi Fadel F, Abella BS. Post resuscitation myocardial dysfunction and echocardiographic characteristics following COVID-19 cardiac arrest. Resuscitation 2022; 173:57-58. [PMID: 35176402 PMCID: PMC8843318 DOI: 10.1016/j.resuscitation.2022.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 02/04/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Abhishek Bhardwaj
- Department of Pulmonary & Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Mahmoud Alwakeel
- Department of Internal Medicine, Cleveland Clinic Fairview Hospital, Cleveland, OH, USA
| | - Abhijit Duggal
- Department of Pulmonary & Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Francois Abi Fadel
- Department of Pulmonary & Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Benjamin S Abella
- Department of Emergency Medicine and Center for Resuscitation Science, University of Pennsylvania, Philadelphia, PA, USA
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28
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Concomitant Sepsis Diagnoses in Acute Myocardial Infarction-Cardiogenic Shock: 15-Year National Temporal Trends, Management, and Outcomes. Crit Care Explor 2022; 4:e0637. [PMID: 35141527 PMCID: PMC8820909 DOI: 10.1097/cce.0000000000000637] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES: DESIGN: SETTING: PARTICIPANTS: INTERVENTIONS: MEASUREMENTS AND MAIN RESULTS: CONCLUSIONS:
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29
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Saghafi F, Bagheri N, Salehi-Abargouei A, Sahebnasagh A. Efficacy of combination triple therapy with vasopressin, steroid, and epinephrine in cardiac arrest: a systematic review and meta-analysis of randomized-controlled trials. J Intensive Care 2022; 10:5. [PMID: 35109925 PMCID: PMC8809021 DOI: 10.1186/s40560-022-00597-5] [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: 12/04/2021] [Accepted: 01/16/2022] [Indexed: 11/10/2022] Open
Abstract
Background This study investigated whether combination therapy with vasopressin, steroid, and epinephrine (VSE) improves in-hospital survival and return of spontaneous circulation (ROSC) during and after resuscitation in-hospital cardiac arrest (CA). Materials and methods Various databases were explored from inception until October 2021 for relevant published clinical trials and cohort studies. Results Three clinical trials were included. Pooled analysis suggested that VSE was significantly associated with increased ROSC in patients with in-hospital CA (IHCA) (odds ratio (OR): 2.281, 95% confidence interval (CI): 1.304–3.989, P value = 0.004). Meta-analysis of two studies (368 patients) demonstrated a significant difference in the reduction of mean arterial pressure (MAP) during and 15–20 min after cardiopulmonary resuscitation (standardized mean difference (SMD): 1.069, 95% CI: 0.851–1.288, P value < 0.001), renal failure free days (SMD = 0.590; 95% CI: 0.312–0.869 days; P value < 0.001), and coagulation failure free days (SMD = 0.403; 95% CI: 0.128–0.679, P value = 0.004). However, no significant difference was observed for survival-to-discharge ratio (OR: 2.082, 95% CI: 0.638–6.796, P value = 0.225) and ventilator free days (SMD = 0.201, 95% CI: − 0.677, 1.079 days; P value = 0.838). Conclusions VSE combination therapy during and after IHCA may have beneficial effects in terms of the ROSC, renal and circulatory failure free days, and MAP. Prospero registration: CRD42020178297 (05/07/2020). Supplementary Information The online version contains supplementary material available at 10.1186/s40560-022-00597-5.
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Affiliation(s)
- Fatemeh Saghafi
- Department of Clinical Pharmacy, Faculty of Pharmacy and Pharmaceutical Sciences Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Negar Bagheri
- Pharmaceutical Sciences Research Center, School of Pharmacy, Student Research Committee, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Amin Salehi-Abargouei
- Nutrition and Food Security Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.,Department of Nutrition, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Adeleh Sahebnasagh
- Clinical Research Center, Department of Internal Medicine, School of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran.
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30
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Sarma D, Tabi M, Jentzer JC. Society for Cardiovascular Angiography and Intervention Shock Classification Predicts Mortality After Out-of-Hospital Cardiac Arrest. Resuscitation 2022; 172:101-105. [PMID: 35122891 DOI: 10.1016/j.resuscitation.2022.01.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/14/2022] [Accepted: 01/24/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Shock is common in patients resuscitated from out-of-hospital-cardiac arrest (OHCA). Shock severity can be classified using the Society for Cardiovascular Angiography and Intervention (SCAI) Shock Classification. We aimed to examine the association of SCAI Shock Stage with in-hospital mortality and neurological outcome in comatose OHCA patients undergoing targeted temperature management (TTM). METHODS This study included 213 comatose adult patients who underwent TTM after OHCA between January 2007 and December 2017. SCAI shock stage (A through E) was assigned using data from the first 24 hours, with shock defined as SCAI shock stage C/D/E. Good neurological outcome was defined as a modified Rankin Scale (mRS) less than 3. RESULTS In-hospital mortality was higher in the 144 (67.6%) patients with shock (46.5% v. 23.2%, unadjusted OR 2.88, 95% CI 1.51-5.51, p = 0.001). After multivariable adjustment, each SCAI shock stage was incrementally associated with an increased risk of in-hospital mortality (adjusted OR 1.80 per stage, 95% CI 1.20-2.71, p = 0.003). Good neurological outcome was less likely in patients with shock (31.9% vs. 53.6%, unadjusted OR 0.41, 95% CI 0.23-0.73, p = 0.002) and a higher SCAI shock stage was incrementally associated with a lower likelihood of good neurological outcome after multivariable adjustment (adjusted OR 0.67 per stage, 95% CI 0.48-0.93, p = 0.015). CONCLUSION Higher shock severity, defined using the SCAI Shock Classification, was associated with increased in-hospital mortality and a lower likelihood of good neurological outcome in OHCA patients treated with TTM.
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Affiliation(s)
- Dhruv Sarma
- Department of Internal Medicine, Mayo Clinic, Rochester, MN.
| | - Meir Tabi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.
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31
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Langeland H, Bergum D, Løberg M, Bjørnstad K, Skaug TR, Nordseth T, Klepstad P, Skjærvold NK. Characteristics of circulatory failure after out-of-hospital cardiac arrest: a prospective cohort study. Open Heart 2022; 9:openhrt-2021-001890. [PMID: 35046124 PMCID: PMC8772457 DOI: 10.1136/openhrt-2021-001890] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/31/2021] [Indexed: 12/02/2022] Open
Abstract
Background Circulatory failure after out-of-hospital cardiac arrest (OHCA) as part of the postcardiac arrest syndrome (PCAS) is believed to be caused by an initial myocardial depression that later subsides into a superimposed vasodilatation. However, the relative contribution of myocardial dysfunction and systemic inflammation has not been established. Our objective was to describe the macrocirculatory and microcirculatory failure in PCAS in more detail. Methods We included 42 comatose patients after OHCA where circulatory variables were invasively monitored from admission until day 5. We measured the development in cardiac power output (CPO), stroke work (SW), aortic elastance, microcirculatory metabolism, inflammatory and cardiac biomarkers and need for vasoactive medications. We used survival analysis and Cox regression to assess time to norepinephrine discontinuation and negative fluid balance, stratified by inflammatory and cardiac biomarkers. Results CPO, SW and oxygen delivery increased during the first 48 hours. Although the estimated afterload fell, the blood pressure was kept above 65 mmHg with a diminishing need for norepinephrine, indicating a gradually re-established macrocirculatory homoeostasis. Time to norepinephrine discontinuation was longer for patients with higher pro-brain natriuretic peptide concentration (HR 0.45, 95% CI 0.21 to 0.96), while inflammatory biomarkers and other cardiac biomarkers did not predict the duration of vasoactive pressure support. Markers of microcirculatory distress, such as lactate and venous-to-arterial carbon dioxide difference, were normalised within 24 hours. Conclusion The circulatory failure was initially characterised by reduced CPO and SW, however, microcirculatory and macrocirculatory homoeostasis was restored within 48 hours. We found that biomarkers indicating acute heart failure, and not inflammation, predicted longer circulatory support with norepinephrine. Taken together, this indicates an early and resolving, rather than a late and emerging vasodilatation. Trial registration NCT02648061.
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Affiliation(s)
- Halvor Langeland
- Department of Anesthesiology and Intensive Care Medicine, St. Olav's University Hospital, Trondheim, Norway .,Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Daniel Bergum
- Department of Anesthesiology and Intensive Care Medicine, St. Olav's University Hospital, Trondheim, Norway
| | - Magnus Løberg
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway.,Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Knut Bjørnstad
- Department of Cardiology, St. Olav's University Hospital, Trondheim, Norway
| | - Thomas R Skaug
- Department of Cardiology, St. Olav's University Hospital, Trondheim, Norway
| | - Trond Nordseth
- Department of Anesthesiology and Intensive Care Medicine, St. Olav's University Hospital, Trondheim, Norway.,Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Pål Klepstad
- Department of Anesthesiology and Intensive Care Medicine, St. Olav's University Hospital, Trondheim, Norway.,Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Nils Kristian Skjærvold
- Department of Anesthesiology and Intensive Care Medicine, St. Olav's University Hospital, Trondheim, Norway.,Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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An Overview of Therapy Guidelines for Cardiac Arrest and the Potential Benefits of Hemoglobin-Based Oxygen Carriers. CARDIOGENETICS 2022. [DOI: 10.3390/cardiogenetics12010004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/10/2022] Open
Abstract
Currently, there is an unmet therapeutic need for the medical management of cardiac arrest, as is evident from the high mortality rate associated with this condition. These dire outcomes can be attributed to the severe nature and poor prognosis of this disorder. However, the current treatment modalities, while helping to augment survival, are limited and do not offer adequate improvements to outcomes. Treatment modalities are particularly lacking when considering the underlying pathophysiology of the metabolic phase of cardiac arrest. In this study, we explore the three phases of cardiac arrest and assess the factors related to positive clinical outcomes and survival for these events. Furthermore, we evaluate the present guidelines for resuscitation and recovery, the issues related to ischemia and tissue reperfusion, and the benefit of oxygen-delivery therapeutic methods including blood transfusion therapy and synthetic hemoglobins (HBOCs). The current therapy protocols are limited specifically by the lack of an efficient method of oxygen delivery to address the metabolic phase of cardiac arrest. In this article, we investigate the next generation of HBOCs and review their properties that make them attractive for their potential application in the treatment of cardiac arrest. These products may be a viable solution to address complications associated with ischemia, reperfusion injury, and organ damage.
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Sarma D, Pareek N, Kanyal R, Cannata A, Dworakowski R, Webb I, Barash J, Emezu G, Melikian N, Hill J, Shah AM, MacCarthy P, Byrne J. Clinical Significance of Early Echocardiographic Changes after Resuscitated Out-of-Hospital Cardiac Arrest. Resuscitation 2021; 172:117-126. [PMID: 34923035 DOI: 10.1016/j.resuscitation.2021.12.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 11/26/2021] [Accepted: 12/12/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Left Ventricular Systolic Dysfunction (LVSD) is common after out-of-hospital cardiac arrest (OOHCA) and can manifest globally or regionally, although its clinical significance has not been robustly studied. This study evaluates the association between LVSD, extent of coronary artery disease (CAD) and outcome in those undergoing early echocardiography and coronary angiography after OOHCA. METHODS Trans-thoracic echocardiography (TTE) was performed in OOHCA patients on arrival to our centre between May 2012 and December 2017. Rates of cardiogenic shock and extent of CAD, respectively classified by SCAI grade and the SYNTAX score, were measured. The primary end-point was 12-month mortality. RESULTS From 398 patients in the King's Out of Hospital Cardiac Arrest Registry (KOCAR), 266 patients (median age 61 [53-71], 76% male) underwent both TTE and coronary angiography on arrival. 96 patients (36%) had significant LVSD (Left Ventricular Ejection Fraction [LVEF]<40%) and 139 (52.2%) patients had regional wall motion abnormalities (RWMAs). Patients with LVEF<40% had more SCAI grade C-E shock (65.3% vs. 34.5%, p<0.001) and higher 12-month mortality (55.2% vs 31.8%, p<0.001) which was more likely to be due to a cardiac aetiology (27.3% vs 5.3%, p<0.001). Patients with RWMAs had higher median SYNTAX scores (14.75 vs 7, p=0.001), culprit coronary lesions (83.5% vs. 45.3%, p <0.001) and lower 12-month mortality (29.5% vs 52%, p<0.001). CONCLUSIONS Patients with LVEF <40% at presentation have an increased mortality, driven by cardiac aetiology death, while the presence of RWMAs is associated with a higher rate of culprit coronary lesions, representing a potentially reversible cause of the arrest, and improved survival at 1 year.
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Affiliation(s)
- Dhruv Sarma
- King's College Hospital NHS Foundation Trust, London, U.K
| | - Nilesh Pareek
- King's College Hospital NHS Foundation Trust, London, U.K; School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, U.K.
| | - Ritesh Kanyal
- King's College Hospital NHS Foundation Trust, London, U.K; School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, U.K
| | - Antonio Cannata
- King's College Hospital NHS Foundation Trust, London, U.K; School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, U.K
| | - Rafal Dworakowski
- King's College Hospital NHS Foundation Trust, London, U.K; School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, U.K
| | - Ian Webb
- King's College Hospital NHS Foundation Trust, London, U.K; School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, U.K
| | - Jemma Barash
- King's College Hospital NHS Foundation Trust, London, U.K
| | - Gift Emezu
- King's College Hospital NHS Foundation Trust, London, U.K
| | - Narbeh Melikian
- King's College Hospital NHS Foundation Trust, London, U.K; School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, U.K
| | - Jonathan Hill
- King's College Hospital NHS Foundation Trust, London, U.K; School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, U.K
| | - Ajay M Shah
- King's College Hospital NHS Foundation Trust, London, U.K; School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, U.K
| | - Philip MacCarthy
- King's College Hospital NHS Foundation Trust, London, U.K; School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, U.K
| | - Jonathan Byrne
- King's College Hospital NHS Foundation Trust, London, U.K; School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, U.K
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Kim SE, Shin HY, Lee EY, Yoo YJ, Kim RH, Cho JH, Lee TK, Ahn D, Park BY, Yoon JC, Hong S, Kim IS, Tae HJ, Won MH. Effect of therapeutic hypothermia against renal injury in a rat model of asphyxial cardiac arrest: Α focus on the survival rate, pathophysiology and antioxidant enzymes. Mol Med Rep 2021; 25:19. [PMID: 34796906 PMCID: PMC8628291 DOI: 10.3892/mmr.2021.12535] [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: 09/03/2021] [Accepted: 10/27/2021] [Indexed: 11/21/2022] Open
Abstract
Although multi-organ dysfunction is associated with the survival rate following cardiac arrest (CA), the majority of studies to date have focused on hearts and brains, and few studies have considered renal failure. The objective of the present study, therefore, was to examine the effects of therapeutic hypothermia on the survival rate, pathophysiology and antioxidant enzymes in rat kidneys following asphyxial CA. Rats were sacrificed one day following CA. The survival rate, which was estimated using Kaplan-Meier analysis, was 42.9% one day following CA. However, hypothermia, which was induced following CA, significantly increased the survival rate (71.4%). In normothermia rats with CA, the serum blood urea nitrogen level was significantly increased one day post-CA. In addition, the serum creatinine level was significantly increased one day post-CA. However, in CA rats exposed to hypothermia, the levels of urea nitrogen and creatinine significantly decreased following CA. Histochemical staining revealed a significant temporal increase in renal injury after the normothermia group was subjected to CA. However, renal injury was significantly decreased in the hypothermia group. Immunohistochemical analysis of the kidney revealed a significant decrease in antioxidant enzymes (copper-zinc superoxide dismutase, manganese superoxide dismutase, glutathione peroxidase and catalase) with time in the normothermia group. However, in the hypothermia group, these enzymes were significantly elevated following CA. Collectively, the results revealed that renal dysfunction following asphyxial CA was strongly associated with the early survival rate and therapeutic hypothermia reduced renal injury via effective antioxidant mechanisms.
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Affiliation(s)
- So Eun Kim
- Department of Emergency Medicine, Research Institute of Clinical Medicine of Jeonbuk National University, Jeonju, Jeollabuk‑do 54907, Republic of Korea
| | - Ha-Young Shin
- College of Veterinary Medicine and Biosafety Research Institute, Jeonbuk National University, Iksan, Jeollabuk‑do 54596, Republic of Korea
| | - Eui-Yong Lee
- College of Veterinary Medicine and Biosafety Research Institute, Jeonbuk National University, Iksan, Jeollabuk‑do 54596, Republic of Korea
| | - Yeo-Jin Yoo
- College of Veterinary Medicine and Biosafety Research Institute, Jeonbuk National University, Iksan, Jeollabuk‑do 54596, Republic of Korea
| | - Ryun-Hee Kim
- College of Veterinary Medicine and Biosafety Research Institute, Jeonbuk National University, Iksan, Jeollabuk‑do 54596, Republic of Korea
| | - Jeong-Hwi Cho
- College of Veterinary Medicine and Biosafety Research Institute, Jeonbuk National University, Iksan, Jeollabuk‑do 54596, Republic of Korea
| | - Tae-Kyeong Lee
- Department of Biomedical Science and Research Institute for Bioscience and Biotechnology, Hallym University, Chuncheon, Gangwon‑do 24252, Republic of Korea
| | - Dongchoon Ahn
- College of Veterinary Medicine and Biosafety Research Institute, Jeonbuk National University, Iksan, Jeollabuk‑do 54596, Republic of Korea
| | - Byung-Yong Park
- College of Veterinary Medicine and Biosafety Research Institute, Jeonbuk National University, Iksan, Jeollabuk‑do 54596, Republic of Korea
| | - Jae Chol Yoon
- Department of Emergency Medicine, Research Institute of Clinical Medicine of Jeonbuk National University, Jeonju, Jeollabuk‑do 54907, Republic of Korea
| | - Seongkweon Hong
- Department of Surgery, Kangwon National University Hospital, School of Medicine, Kangwon National University, Chuncheon, Gangwon‑do 24289, Republic of Korea
| | - In-Shik Kim
- College of Veterinary Medicine and Biosafety Research Institute, Jeonbuk National University, Iksan, Jeollabuk‑do 54596, Republic of Korea
| | - Hyun-Jin Tae
- College of Veterinary Medicine and Biosafety Research Institute, Jeonbuk National University, Iksan, Jeollabuk‑do 54596, Republic of Korea
| | - Moo-Ho Won
- Department of Neurobiology, School of Medicine, Kangwon National University, Chuncheon, Gangwon‑do 24341, Republic of Korea
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Doan TN, Prior M, Vollbon W, Rogers B, Rashford S, Bosley E. Survival after Resuscitated Out-of-Hospital Cardiac Arrest in Patients with Paramedic-Identified ST-Segment Elevation Myocardial Infarction Treated with Primary Percutaneous Coronary Intervention. PREHOSP EMERG CARE 2021; 26:764-771. [PMID: 34731063 DOI: 10.1080/10903127.2021.1992054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Background: ST-segment elevation myocardial infarction (STEMI) is a common cause of out-of-hospital cardiac arrest (OHCA). For these patients, urgent angiography and revascularization is an important treatment goal. There is a lack of data on the prognosis of STEMI patients after OHCA, who are diagnosed and treated by paramedics prior to hospital transport for primary percutaneous coronary intervention (PCI).Methods: Included were adult STEMI patients identified and treated by paramedics in Queensland (Australia) from January 2016 to December 2019, transported to a hospital for primary PCI, and receiving primary PCI. Patients were grouped into those with resuscitated OHCA and those without OHCA. Clinically-important time intervals, angiographic and clinical profiles, and survival were described.Results: Patients with OHCA had longer time intervals from prehospital STEMI identification to reperfusion than those without OHCA (median 97 versus 87 mins, p = 0.001). The former had higher rates of cardiac arrhythmia history (50.5 versus 12.4%, p < 0.001), classified low left ventricular ejection fraction on admission (64.9 versus 50.1%, p = 0.006), and cardiogenic shock (5.2 versus 1.2%, p = 0.011) than the latter. A significantly higher proportion of patients with OHCA had multiple diseased vessels (16.9 versus 8.3%, p = 0.005). In-hospital, 30-day, and one-year mortality was low, being 4.1%, 4.1% and 5.2%, respectively, for STEMI patients with OHCA. The corresponding figures for those without OHCA were 1.6%, 1.8% and 3.3%, respectively.Conclusions: Survival in paramedic-identified STEMI patients treated with primary PCI following OHCA resuscitation was high. Rapid angiography and reperfusion are critical in these patients.
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Liang L, Zhang G, Cheng C, Li H, Jin T, Su C, Xiao Y, Bradley J, Peberdy MA, Ornato JP, Mangino MJ, Tang W. High-resolution respirometry for evaluation of mitochondrial function on brain and heart homogenates in a rat model of cardiac arrest and cardiopulmonary resuscitation. Biomed Pharmacother 2021; 142:111935. [PMID: 34467895 DOI: 10.1016/j.biopha.2021.111935] [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: 12/10/2020] [Revised: 07/12/2021] [Accepted: 07/14/2021] [Indexed: 10/20/2022] Open
Abstract
The physiology and physiopathology process of mitochondrial function following cardiac arrest remains poorly understood. We aimed to assess mitochondrial respiratory function on the heart and brain homogenates from cardiac arrest rats. The expression level of SIRT1/PGC-1α pathway was measured by immunoblotting. 30 rats were assigned to the CA group and the sham group. Rats of CA were subjected to 6 min of untreated ventricular fibrillation (VF) followed by 8 min of cardiopulmonary resuscitation (CPR). Mitochondrial respiratory function was compromised following CA and I/R injury, as indicated by CIL (451.46 ± 71.48 vs. 909.91 ± 5.51 pmol/min*mg for the heart and 464.14 ± 8.22 vs. 570.53 ± 56.33 pmol/min*mg for the brain), CI (564.04 ± 64.34 vs. 2729.52 ± 347.39 pmol/min*mg for the heart and 726.07 ± 85.78 vs. 1762.82 ± 262.04 pmol/min*mg for the brain), RCR (1.88 ± 0.46 vs. 3.57 ± 0.38 for the heart and 2.05 ± 0.19 vs. 3.49 ± 0.19, for the brain) and OXPHOS coupling efficiency (0.45 ± 0.11 vs. 0.72 ± 0.03 for the heart and 0.52 ± 0.05 vs. 0.71 ± 0.01 for the brain). However, routine respiration was lower in the heart and comparable in the brain after CA. CIV did not change in the heart but was enhanced in the brain. Furthermore, both SIRT1 and PGC-1α were downregulated concurrently in the heart and brain. The mitochondrial respiratory function was compromised following CA and I/R injury, and the major affected respiratory state is complex I-linked respiration. Furthermore, the heart and the brain respond differently to the global I/R injury after CA in mitochondrial respiratory function. Inhibition of the SIRT1/PGC-1α pathway may be a major contributor to the impaired mitochondrial respiratory function.
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Affiliation(s)
- Lian Liang
- Department of Emergency, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China; Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, USA; Institute of Cardiopulmonary Cerebral Resuscitation, Sun Yat-Sen University, Guangzhou, China
| | - Guozhen Zhang
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, USA; Department of Intensive Care Medicine, Tianjin Cancer Hospital Airport Free Trade Zone Hospital, Tianjin, China
| | - Cheng Cheng
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, USA; Department of Intensive Care Medicine, The Second Hospital of Anhui Medical University, Hefei, China
| | - Hui Li
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, USA; Department of Intensive Care Medicine, The Second Hospital of Anhui Medical University, Hefei, China
| | - Tao Jin
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, USA
| | - Chenglei Su
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, USA
| | - Yan Xiao
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, USA
| | - Jennifer Bradley
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, USA
| | - Mary A Peberdy
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, USA; Department of Internal Medicine and Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Joseph P Ornato
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, USA; Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Martin J Mangino
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, USA; Department of Surgery, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Wanchun Tang
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, USA; Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA, USA.
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Su C, Xiao Y, Zhang G, Liang L, Li H, Cheng C, Jin T, Bradley J, Peberdy MA, Ornato JP, Mangino MJ, Tang W. Exogenous Nicotinamide Adenine Dinucleotide Attenuates Postresuscitation Myocardial and Neurologic Dysfunction in a Rat Model of Cardiac Arrest. Crit Care Med 2021; 50:e189-e198. [PMID: 34637412 DOI: 10.1097/ccm.0000000000005268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To investigate the therapeutic potential and underlying mechanisms of exogenous nicotinamide adenine dinucleotide+ on postresuscitation myocardial and neurologic dysfunction in a rat model of cardiac arrest. DESIGN Thirty-eight rats were randomized into three groups: 1) Sham, 2) Control, and 3) NAD. Except for the sham group, untreated ventricular fibrillation for 6 minutes followed by cardiopulmonary resuscitation was performed in the control and NAD groups. Nicotinamide adenine dinucleotide+ (20 mg/kg) was IV administered at the onset of return of spontaneous circulation. SETTING University-affiliated research laboratory. SUBJECTS Sprague-Dawley rats. INTERVENTIONS Nicotinamide adenine dinucleotide+. MEASUREMENTS AND MAIN RESULTS Hemodynamic and myocardial function were measured at baseline and within 4 hours following return of spontaneous circulation. Survival analysis and Neurologic Deficit Score were performed up to 72 hours after return of spontaneous circulation. Adenosine triphosphate (adenosine triphosphate) level was measured in both brain and heart tissue. Mitochondrial respiratory chain function, acetylation level, and expression of Sirtuin3 and NADH dehydrogenase (ubiquinone) 1 alpha subcomplex, 9 (NDUFA9) in isolated mitochondrial protein from both brain and heart tissue were evaluated at 4 hours following return of spontaneous circulation. The results demonstrated that nicotinamide adenine dinucleotide+ treatment improved mean arterial pressure (at 1 hr following return of spontaneous circulation, 94.69 ± 4.25 mm Hg vs 89.57 ± 7.71 mm Hg; p < 0.05), ejection fraction (at 1 hr following return of spontaneous circulation, 62.67% ± 6.71% vs 52.96% ± 9.37%; p < 0.05), Neurologic Deficit Score (at 24 hr following return of spontaneous circulation, 449.50 ± 82.58 vs 339.50 ± 90.66; p < 0.05), and survival rate compared with that of the control group. The adenosine triphosphate level and complex I respiratory were significantly restored in the NAD group compared with those of the control group. In addition, nicotinamide adenine dinucleotide+ treatment activated the Sirtuin3 pathway, down-regulating acetylated-NDUFA9 in the isolated mitochondria protein. CONCLUSIONS Exogenous nicotinamide adenine dinucleotide+ treatment attenuated postresuscitation myocardial and neurologic dysfunction. The responsible mechanisms may involve the preservation of mitochondrial complex I respiratory capacity and adenosine triphosphate production, which involves the Sirtuin3-NDUFA9 deacetylation.
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Affiliation(s)
- Chenglei Su
- Department of Emergency Medicine Center, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China. Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA. Department of Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China. Department of Emergency Medicine, The Second Affiliated Hospital of Soochow University, Soochow, China. Departments of Internal Medicine and Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA. Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA. Department of Surgery, Virginia Commonwealth University Health System, Richmond, VA
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Nakajima J, Sawada Y, Isshiki Y, Ichikawa Y, Fukushima K, Aramaki Y, Oshima K. Influence of the prehospital administered dosage of epinephrine on the plasma levels of catecholamines in patients with out-of-hospital cardiac arrest. Heliyon 2021; 7:e07708. [PMID: 34401588 PMCID: PMC8353485 DOI: 10.1016/j.heliyon.2021.e07708] [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: 03/06/2021] [Revised: 07/07/2021] [Accepted: 07/30/2021] [Indexed: 11/27/2022] Open
Abstract
Aim This study evaluated whether the prehospital administered dosage of epinephrine (Ep) influences the plasma levels of catecholamines in patients with out-of-hospital cardiac arrest (OHCA). Methods This was a prospective, observational clinical study. Patients with OHCA transferred to our hospital between July 2014 and July 2017 were analyzed. The plasma levels of catecholamines were measured using blood samples obtained immediately upon arrival at the hospital and before the administration of Ep. Patients were divided into three groups based on the prehospital administered dosage of Ep: no prehospital administration (group Z); 1 mg of Ep (group O); and 2 mg of Ep (group T). The levels of catecholamines, as well as the conditions of resuscitation prior to and after arrival at the hospital were compared between the three groups. Results We analyzed 145 patients with OHCA (96, 38, and 11 patients in groups Z, O, and T, respectively). Group T exhibited the highest plasma levels of Ep with a statistically significant difference, however, there were no significant differences in the plasma levels of norepinephrine (Nep), dopamine (DOA) and vasopressin (ADH) among the three groups. Conclusion The prehospital administered dosage of Ep influences the plasma levels of Ep; however, it does not contribute to the plasma levels of Nep, DOA and ADH in patients with OHCA.
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Affiliation(s)
- Jun Nakajima
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Yusuke Sawada
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Yuta Isshiki
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Yumi Ichikawa
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Kazunori Fukushima
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Yuto Aramaki
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Kiyohiro Oshima
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
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Molar Sodium Lactate Attenuates the Severity of Postcardiac Arrest Syndrome: A Preclinical Study. Crit Care Med 2021; 50:e71-e79. [PMID: 34473656 DOI: 10.1097/ccm.0000000000005233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine whether continuous IV infusion of molar sodium lactate would limit cardiac arrest-induced neurologic injury and cardiovascular failure. DESIGN Randomized blinded study (animal model). SETTING University animal research facility. SUBJECTS Twenty-four adult male "New Zealand White" rabbits. INTERVENTIONS Anesthetized rabbits underwent 12.5 minutes of asphyxial cardiac arrest and were randomized to receive either normal saline (control group, n = 12) or molar sodium lactate (molar sodium lactate group, n = 12) at a rate of 5 mL/kg/hr during the whole 120-minute reperfusion period. MEASUREMENTS AND MAIN RESULTS Pupillary reactivity (primary outcome), levels of S100β protein, in vitro brain mitochondria functions, cardiovascular function, and fluid balance were assessed. Molar sodium lactate reduced brain injury, with a higher proportion of animals exhibiting pupillary reactivity to light (83% vs 25% in the CTRL group, p = 0.01) and lower S100β protein levels (189 ± 42 vs 412 ± 63 pg/mL, p < 0.01) at the end of the protocol. Molar sodium lactate significantly prevented cardiac arrest-induced decrease in oxidative phosphorylation and mitochondrial calcium-retention capacity compared with controls. At 120 minutes of reperfusion, survival did not significantly differ between the groups (10/12, 83% in the molar sodium lactate group vs nine of 12, 75% in the control group; p > 0.99), but hemodynamics were significantly improved in the molar sodium lactate group compared with the control group (higher mean arterial pressure [49 ± 2 vs 29 ± 3 mm Hg; p < 0.05], higher cardiac output [108 ± 4 vs 58 ± 9 mL/min; p < 0.05], higher left ventricle surface shortening fraction [38% ± 3% vs 19% ± 3%; p < 0.05], and lower left ventricular end-diastolic pressure [3 ± 1 vs 8 ± 2 mm Hg; p < 0.01]). While fluid intake was similar in both groups, fluid balance was higher in control animals (11 ± 1 mL/kg) than that in molar sodium lactate-treated rabbits (1 ± 3 mL/kg; p < 0.01) due to lower diuresis. CONCLUSIONS Molar sodium lactate was effective in limiting the severity of the postcardiac arrest syndrome. This preclinical study opens up new perspectives for the treatment of cardiac arrest.
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Zhu Z, Zou B, Gao S, Zhang D, Guo J, Chen B, Hou H, Zhu X. CD14 Involvement in Third-degree Skin Burn-induced Myocardial Injury via the MAPK Signaling Pathway. Cell Biochem Biophys 2021; 80:139-150. [PMID: 34297270 DOI: 10.1007/s12013-021-00995-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2021] [Indexed: 10/20/2022]
Abstract
This study investigated the potential genes and related pathways in burn-induced myocardial injury. Rat myocardial injury induced by third-degree burn and the histopathological structures, apoptosis, and cardiac injury markers were then identified using hematoxylin & eosin staining, terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling staining, and enzyme-linked immunosorbent assay. Next, differentially expressed mRNAs were screened through next-generation sequencing (NGS), followed by functional annotation and key gene validation through quantitative reverse transcription-polymerase chain reaction. Subsequently, CD14 was screened out, and small interfering RNAs against CD14 were transfected to H9C2 cells to further verify the role of CD14 in burn-induced injury. The results showed that third-degree burn could markedly damage the structure of myocardial tissue, induce the apoptosis of myocardial cells, and increase the levels of myocardial injury-related markers, suggesting that burns could induce myocardial injury in rats. Besides, NGS data discovered that third-degree burn could result in 416 differentially upregulated mRNAs and 285 differentially downregulated mRNAs in myocardial tissue. It was also disclosed that differentially expressed mRNAs were mainly enriched in the phosphatidylinositol 3-kinase/Akt, mitogen-activated protein kinase (MAPK), and tumor necrosis factor signaling pathways. Furthermore, cell viability was significantly decreased in H9C2 cells treated with 10% rat burn serum. CD14 was significantly differentially expressed and screened out for further studies. Treatment with burn serum can significantly upregulate the phosphorylation level of extracellular signal-regulated kinase, p38, and c-Jun N-terminal kinase and the expression of cleaved caspase-3 and downregulate the expression of Bcl2 when compared with those in negative control of small interfering RNA transfected H9C2 cells, whereas interfering with CD14 expression reversed the effects of burn serum. The study demonstrated that burn serum treatment could activate the MAPK signaling pathway to promote cell apoptosis, and it can be reversed by interfering with the expression of CD14.
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Affiliation(s)
- Zhensen Zhu
- The Department of Plastic and Burn Surgery, Shenzhen Hospital, Southern Medical University, Shenzhen, China
| | - Ben Zou
- The Department of Plastic and Burn Surgery, Shenzhen Hospital, Southern Medical University, Shenzhen, China
| | - Songying Gao
- The Department of Plastic and Burn Surgery, Shenzhen Hospital, Southern Medical University, Shenzhen, China
| | - Dongmei Zhang
- The Department of Plastic and Burn Surgery, Shenzhen Hospital, Southern Medical University, Shenzhen, China
| | - Jingdong Guo
- The Department of Plastic and Burn Surgery, Shenzhen Hospital, Southern Medical University, Shenzhen, China
| | - Bo Chen
- The Department of Plastic and Burn Surgery, Shenzhen Hospital, Southern Medical University, Shenzhen, China
| | - Haixin Hou
- The Department of Plastic and Burn Surgery, Shenzhen Hospital, Southern Medical University, Shenzhen, China
| | - Xiongxiang Zhu
- The Department of Plastic and Burn Surgery, Shenzhen Hospital, Southern Medical University, Shenzhen, China.
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Abstract
This article describes evidence-based nursing practices for detecting pediatric decompensation and prevention of cardiopulmonary arrest and outlines the process for effective and high-quality pediatric resuscitation and postresuscitation care. Primary concepts include pediatric decompensation signs and symptoms, pediatric resuscitation essential practices, and postresuscitation care, monitoring, and outcomes. Pediatric-specific considerations for family presence during resuscitation, ensuring good outcomes for medically complex children in community settings, and the role of targeted temperature management, continuous electroencephalography, and the use of extracorporeal membrane oxygenation in pediatric resuscitation are also discussed.
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Affiliation(s)
- Amanda P Bettencourt
- Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, 400 North Ingalls Building, Room #4304, Ann Arbor, MI 48109-5482, USA.
| | - Melissa Gorman
- Shriners Hospitals for Children-Boston, 51 Blossom Street, Boston, MA 02114, USA
| | - Jodi E Mullen
- Pediatric Intensive Care Unit, UF Health Shands Children's Hospital, 1600 SW Archer Rd., Gainesville FL 32608, USA
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Tabi M, Burstein BJ, Anavekar NS, Kashani KB, Jentzer JC. Associations of Vasopressor Requirements With Echocardiographic Parameters After Out-of-Hospital Cardiac Arrest. J Intensive Care Med 2021; 37:518-527. [PMID: 34044666 DOI: 10.1177/0885066621998936] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Post-arrest hypotension is common after out of hospital cardiac arrest (OHCA) and many patients resuscitated after OHCA will require vasopressors. We sought to determine the associations between echocardiographic parameters and vasopressor requirements in OHCA patients. METHODS We retrospectively analyzed adult patients with OHCA treated with targeted temperature management between December 2005 and September 2016 who underwent a transthoracic echocardiogram (TTE). Categorical variables were compared using 2-tailed Fisher's exact and Pearson's correlation coefficients and variance (r2) values were used to assess relationships between continuous variables. RESULTS Among 217 included patients, the mean age was 62 ± 12 years, including 74% males. The arrest was witnessed in 90%, the initial rhythm was shockable in 88%, and 58% received bystander CPR. At the time of TTE, 41% of patients were receiving vasopressors; this group of patients was older, had greater severity of illness, higher inpatient mortality and left ventricular ejection fraction (LVEF) was modestly lower (36.8 ± 17.1% vs. 41.4 ± 16.4%, P = 0.04). Stroke volume, cardiac power output and left ventricular stroke work index correlated with number of vasopressors (Pearson r -0.24 to -0.34, all P < 0.002), but the correlation with LVEF was weak (Pearson r -0.13, P = 0.06). CONCLUSIONS In patients after OHCA, left ventricular systolic dysfunction was associated with the need for vasopressors, and Doppler TTE hemodynamic parameters had higher correlation coefficients compared with vasopressor requirements than LVEF. This emphasizes the complex nature of shock after OHCA, including pathophysiologic processes not captured by TTE assessment alone.
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Affiliation(s)
- Meir Tabi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Barry J Burstein
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nandan S Anavekar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kianoush B Kashani
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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43
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Liang L, Zhang G, Li H, Cheng C, Jin T, Su C, Xiao Y, Bradley J, Peberdy MA, Ornato JP, Mangino MJ, Tang W. Combined Therapy With Polyethylene Glycol-20k and MCC950 Preserves Post-Resuscitated Myocardial Function in a Rat Model of Cardiac Arrest and Cardiopulmonary Resuscitation. J Am Heart Assoc 2021; 10:e019177. [PMID: 33884887 PMCID: PMC8200739 DOI: 10.1161/jaha.120.019177] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background To investigate the therapeutic potential of combined therapy with polyethylene glycol-20k (PEG-20k) and MCC950 on post-resuscitation myocardial function in a rat model of cardiac arrest. Methods and Results Thirty rats were randomized into 5 groups: Sham, Control, PEG-20k, MCC950, PEG-20k+ MCC950. Except for sham, animals were subjected to 6 minutes of ventricular fibrillation followed by 8 minutes cardiopulmonary resuscitation. Two milliliters PEG-20k was administered by intravenous injection coincident with the start of cardiopulmonary resuscitation; MCC950 (10 mg/kg), a highly selective NLRP3 inflammasome inhibitor, was delivered immediately after restoration of spontaneous circulation. Myocardial function, sublingual microcirculation, mitochondrial function, plasma cardiac troponin I, and interleukin-1β, expression of proteins in SIRT1 (sirtuin 1)/PGC-1α (peroxisome proliferator-activated receptor gamma coactivator 1-alpha) and NLRP3 (the NOD-like receptor family protein 3) inflammasome pathways were evaluated. Following cardiopulmonary resuscitation, myocardial function was compromised with a significantly decreased cardiac output, ejection fraction, and increased myocardial performance index, cardiac troponin I. Sublingual microcirculation was disturbed with impaired perfused vessel density and microvascular flow index. Cardiac arrest reduced mitochondrial routine respiration, Complex I-linked respiration, respiratory control rates and oxidative phosphorylation coupling efficiency. PEG-20k or MCC950 alone restored mitochondrial respiratory function, restituted sublingual microcirculation, and preserved myocardial function, whereas a combination of PEG-20k and MCC950 further improved these aspects. PEG-20k restored the expression of SIRT1 and PGC-1α, and blunted activation of NLRP3 inflammasomes. MCC950 suppressed expression of cleaved-caspase-1/pro-caspase-1, ASC (apoptosis-associated speck-like protein), GSDMD [gasdermin d], and interleukin-1β. Conclusions Combined therapy with PEG-20k and MCC950 is superior to either therapy alone for preserving post-resuscitated myocardial function, restituting sublingual microcirculation at restoration of spontaneous circulation at 6 hours. The responsible mechanisms involve upregulated expression of SIRT1/PGC1-α in tandem with inhibition of NLRP3 inflammasomes.
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Affiliation(s)
- Lian Liang
- Department of Emergency Sun Yat-sen Memorial Hospital, Sun Yat-sen University Guangzhou China.,Weil Institute of Emergency and Critical Care Research Virginia Commonwealth University Richmond VA.,Institute of Cardiopulmonary Cerebral Resuscitation Sun Yat-sen University Guangzhou China
| | - Guozhen Zhang
- Weil Institute of Emergency and Critical Care Research Virginia Commonwealth University Richmond VA
| | - Hui Li
- Weil Institute of Emergency and Critical Care Research Virginia Commonwealth University Richmond VA
| | - Cheng Cheng
- Weil Institute of Emergency and Critical Care Research Virginia Commonwealth University Richmond VA
| | - Tao Jin
- Weil Institute of Emergency and Critical Care Research Virginia Commonwealth University Richmond VA
| | - Chenglei Su
- Weil Institute of Emergency and Critical Care Research Virginia Commonwealth University Richmond VA
| | - Yan Xiao
- Weil Institute of Emergency and Critical Care Research Virginia Commonwealth University Richmond VA
| | - Jennifer Bradley
- Weil Institute of Emergency and Critical Care Research Virginia Commonwealth University Richmond VA
| | - Mary A Peberdy
- Weil Institute of Emergency and Critical Care Research Virginia Commonwealth University Richmond VA.,Departments of Internal Medicine and Emergency Medicine Virginia Commonwealth University Health System Richmond VA
| | - Joseph P Ornato
- Weil Institute of Emergency and Critical Care Research Virginia Commonwealth University Richmond VA.,Department of Emergency Medicine Virginia Commonwealth University Health System Richmond VA
| | - Martin J Mangino
- Weil Institute of Emergency and Critical Care Research Virginia Commonwealth University Richmond VA.,Department of Surgery Virginia Commonwealth University Health System Richmond VA
| | - Wanchun Tang
- Weil Institute of Emergency and Critical Care Research Virginia Commonwealth University Richmond VA
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Hansen FB, Secher N, Mattson T, Løfgren B, Simonsen U, Granfeldt A. Effect of the KCa3.1 blocker, senicapoc, on cerebral edema and cardiovascular function after cardiac arrest - A randomized experimental rat study. Resusc Plus 2021; 6:100111. [PMID: 34223371 PMCID: PMC8244250 DOI: 10.1016/j.resplu.2021.100111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/05/2021] [Accepted: 03/05/2021] [Indexed: 11/30/2022] Open
Abstract
Senicapoc was successfully administered intravenously. Senicapoc did not reduce cerebral edema 4 h after cardiac arrest. Senicapoc did not increase mean arterial pressure within 4 h from resuscitation.
Aim Formation of cerebral edema and cardiovascular dysfunction may worsen brain injury following cardiac arrest. We hypothesized that administration of the intermediate calcium-activated potassium (KCa3.1) channel blocker, senicapoc, would reduce cerebral edema and augment mean arterial pressure in the early post-resuscitation period. Method Male Sprague-Dawley rats, aged 11–15 weeks, were utilized in the study. Rats were exposed to 8 min of asphyxial cardiac arrest. Shortly after resuscitation, rats were randomized to receive either vehicle or senicapoc (10 mg/kg) intravenously. The primary outcome was cerebral wet to dry weight ratio 4 h after resuscitation. Secondary outcomes included mean arterial pressure, cardiac output, norepinephrine dose, inflammatory cytokines and neuron specific enolase levels. Additionally, a sub-study was conducted to validate intravenous administration of senicapoc. Results The sub-study revealed that senicapoc-treated rats maintained a significantly higher mean arterial pressure during administration of SKA-31 (a KCa3.1 channel opener). The plasma concentration of senicapoc was 1060 ± 303 ng/ml 4 h after administration. Senicapoc did not reduce cerebral edema or augment mean arterial pressure 4 h after resuscitation. Likewise, cardiac function and norepinephrine dose did not vary between groups. Inflammatory cytokines and neuron specific enolase levels increased in both groups after resuscitation with no difference between groups. Senicapoc enhanced the PaO2/FiO2 ratio significantly 4 h after resuscitation. Conclusion Senicapoc was successfully administered intravenously after resuscitation, but did not reduce cerebral edema or increase mean arterial pressure in the early post-resuscitation period.
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Affiliation(s)
- Frederik Boe Hansen
- Department of Biomedicine, Aarhus University, Ole Worms Allé 4, 8000 Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Blvd. 82, 8200 Aarhus N, Denmark
| | - Niels Secher
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
| | - Thomas Mattson
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
| | - Bo Løfgren
- Department of Internal Medicine, Randers Regional Hospital, Skovlyvej 15, 8930 Randers NE, Denmark.,Research Center for Emergency Medicine, Aarhus University Hospital, Palle Juul-Jensens Blvd. 161, 8200 Aarhus N, Denmark
| | - Ulf Simonsen
- Department of Biomedicine, Aarhus University, Ole Worms Allé 4, 8000 Aarhus, Denmark
| | - Asger Granfeldt
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Blvd. 82, 8200 Aarhus N, Denmark.,Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
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45
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Wang P, Zhang F, Pan L, Tan Y, Song F, Ge Q, Huang Z, Yao L. Inhibiting Cardiac Mitochondrial Fatty Acid Oxidation Attenuates Myocardial Injury in a Rat Model of Cardiac Arrest. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2021; 2021:6622232. [PMID: 33728022 PMCID: PMC7939742 DOI: 10.1155/2021/6622232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 01/26/2021] [Accepted: 02/16/2021] [Indexed: 11/17/2022]
Abstract
Mitochondrial fatty acid oxidation (FAO) is involved in myocardial damage after cardiopulmonary resuscitation (CPR). This study is aimed at investigating the effect of inhibiting mitochondrial FAO on myocardial injury and the underlying mechanisms of postresuscitation myocardial dysfunction. Rats were induced, subjected to 8 min of ventricular fibrillation, and underwent 6 min of CPR. Rats with return of spontaneous circulation (ROSC) were randomly divided into the Sham group, CPR group, and CPR + Trimetazidine (TMZ) group. Rats in the CPR + TMZ group were administered TMZ (10 mg/kg) at the onset of ROSC via the right external jugular vein, while rats in the CPR group were injected with equivalent volumes of vehicle. The sham rats were only administered equivalent volumes of vehicle. We found that the activities of enzymes related to cardiac mitochondrial FAO were partly improved after ROSC. TMZ, as a reversible inhibitor of 3-ketoacyl CoA thiolase, inhibited myocardial mitochondrial FAO after ROSC. In the CPR + TMZ group, the levels of mitochondrial injury in cardiac tissue were alleviated following attenuated myocardial damage and oxidative stress after ROSC. In addition, the disorder of cardiac mitochondrial metabolism was ameliorated, and specifically, the superfluous succinate related to mitochondrial reactive oxygen species (ROS) generation was decreased by inhibiting myocardial mitochondrial FAO with TMZ administration after ROSC. In conclusion, in the early period after ROSC, inhibiting cardiac mitochondrial FAO attenuated excessive cardiac ROS generation and preserved myocardial function, probably by alleviating the dysfunction of cardiac mitochondrial metabolism in a rat model of cardiac arrest.
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Affiliation(s)
- Peng Wang
- Department of Emergency Medicine, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
- Institute of Cardiopulmonary Cerebral Resuscitation, Sun Yat-sen University, Guangzhou, China
| | - Fan Zhang
- Department of Emergency Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, China
| | - Liming Pan
- Department of Emergency Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, China
| | - Yunke Tan
- Department of Emergency Medicine, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
- Institute of Cardiopulmonary Cerebral Resuscitation, Sun Yat-sen University, Guangzhou, China
| | - Fengqing Song
- Department of Emergency Medicine, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
- Institute of Cardiopulmonary Cerebral Resuscitation, Sun Yat-sen University, Guangzhou, China
| | - Qiulin Ge
- Department of Emergency Medicine, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
- Institute of Cardiopulmonary Cerebral Resuscitation, Sun Yat-sen University, Guangzhou, China
| | - Zitong Huang
- Department of Emergency Medicine, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
- Institute of Cardiopulmonary Cerebral Resuscitation, Sun Yat-sen University, Guangzhou, China
| | - Lan Yao
- Department of Emergency Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, China
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46
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Coppler PJ, Elmer J. Mitochondrial resuscitation after cardiac arrest. Resuscitation 2021; 162:433-434. [PMID: 33662525 DOI: 10.1016/j.resuscitation.2021.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 02/18/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Patrick J Coppler
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA.
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Biventricular Unloading with Impella and Venoarterial Extracorporeal Membrane Oxygenation in Severe Refractory Cardiogenic Shock: Implications from the Combined Use of the Devices and Prognostic Risk Factors of Survival. J Clin Med 2021; 10:jcm10040747. [PMID: 33668590 PMCID: PMC7918629 DOI: 10.3390/jcm10040747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 02/07/2021] [Accepted: 02/08/2021] [Indexed: 12/01/2022] Open
Abstract
Since mechanical circulatory support (MCS) devices have become integral component in the therapy of refractory cardiogenic shock (RCS), we identified 67 patients in biventricular support with Impella and venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) for RCS between February 2013 and December 2019 and evaluated the risk factors of mortality in this setting. Mean age was 61.07 ± 10.7 and 54 (80.6%) patients were male. Main cause of RCS was acute myocardial infarction (AMI) (74.6%), while 44 (65.7%) were resuscitated prior to admission. The mean Simplified Acute Physiology Score II (SAPS II) and Sequential Organ Failure Assessment Score (SOFA) score on admission was 73.54 ± 16.03 and 12.25 ± 2.71, respectively, corresponding to an expected mortality of higher than 80%. Vasopressor doses and lactate levels were significantly decreased within 72 h on biventricular support (p < 0.05 for both). Overall, 17 (25.4%) patients were discharged to cardiac rehabilitation and 5 patients (7.5%) were bridged successfully to ventricular assist device implantation, leading to a total of 32.8% survival on hospital discharge. The 6-month survival was 31.3%. Lactate > 6 mmol/L, vasoactive score > 100 and pH < 7.26 on initiation of biventricular support, as well as Charlson comorbity index > 3 and prior resuscitation were independent predictors of survival. In conclusion, biventricular support with Impella and VA-ECMO in patients with RCS is feasible and efficient leading to a better survival than predicted through traditional risk scores, mainly via significant hemodynamic improvement and reduction in lactate levels.
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48
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Review of Hypothermia Protocol and Timing of the Echocardiogram. Curr Probl Cardiol 2021; 46:100786. [PMID: 33516091 DOI: 10.1016/j.cpcardiol.2021.100786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 12/30/2020] [Indexed: 11/24/2022]
Abstract
Targeted temperature management, also known as therapeutic hypothermia (TH), is recommended for out-of-hospital cardiac arrest (OHCA). Both internal or external methods of cooling can be applied. Individuals resuscitated from OHCA frequently develop postarrest myocardial dysfunction resulting in decreased cardiac output and left ventricular systolic function. This dysfunction is usually transient and improves with spontaneous recovery over time. Echocardiogram (ECHO) can be a vital tool for the assessment and management of these patients. This manuscript reviewed methods available for TH after OHCA and reviews role of ECHO in the diagnosis and prognosis in this setting.
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49
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Baldi E, Schnaubelt S, Caputo ML, Klersy C, Clodi C, Bruno J, Compagnoni S, Benvenuti C, Domanovits H, Burkart R, Fracchia R, Primi R, Ruzicka G, Holzer M, Auricchio A, Savastano S. Association of Timing of Electrocardiogram Acquisition After Return of Spontaneous Circulation With Coronary Angiography Findings in Patients With Out-of-Hospital Cardiac Arrest. JAMA Netw Open 2021; 4:e2032875. [PMID: 33427885 PMCID: PMC7801935 DOI: 10.1001/jamanetworkopen.2020.32875] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE Electrocardiography (ECG) is an important tool to triage patients with out-of-hospital cardiac arrest (OHCA) after return of spontaneous circulation (ROSC). An immediate coronary angiography after ROSC is recommended only in patients with an ECG that is diagnostic of ST-segment elevation myocardial infarction (STEMI). To date, the benefit of this approach has not been demonstrated in patients with a post-ROSC ECG that is not diagnostic of STEMI. OBJECTIVE To assess whether the time from ROSC to ECG acquisition is associated with the diagnostic accuracy of ECG for STEMI. DESIGN, SETTING, AND PARTICIPANTS This retrospective, multicenter cohort study (the Post-ROSC Electrocardiogram After Cardiac Arrest study) analyzed consecutive patients older than 18 years who were resuscitated from OHCA between January 1, 2015, and December 31, 2018, and were admitted to 1 of the 3 participating centers in Europe (Pavia, Italy; Lugano, Switzerland; and Vienna, Austria). EXPOSURE Only patients who underwent coronary angiography during hospitalization and who acquired a post-ROSC ECG before the angiography were enrolled. Patients with a nonmedical cause of OHCAs were excluded. MAIN OUTCOMES AND MEASURES The primary end point was false-positive ECG findings, defined as the percentage of patients with post-ROSC ECG findings that met STEMI criteria but who did not show obstructive coronary artery disease on angiography that was worthy of percutaneous coronary angioplasty. RESULTS Of 586 consecutive patients who were admitted to the 3 participating centers, 370 were included in the analysis (287 men [77.6%]; median age, 62 years [interquartile range, 53-70 years]); 121 (32.7%) were enrolled in the participating center in Pavia, Italy; 38 (10.3%) in Lugano, Switzerland; and 211 (57.0%) in Vienna, Austria. The percentage of false-positive ECG findings in the first tertile of ROSC to ECG time (≤7 minutes) was significantly higher than that in the second (8-33 minutes) and third (>33 minutes) tertiles: 18.5% in the first tertile vs 7.2% in the second (odds ratio [OR], 0.34; 95% CI, 0.13-0.87; P = .02) and 5.8% in the third (OR, 0.27; 95% CI, 0.15-0.47; P < .001). These differences remained significant when adjusting for sex (≤7 minutes: reference; 8-33 minutes: OR, 0.32; 95% CI, 0.12-0.85; P = .02; >33 minutes: OR, 0.26; 95% CI, 0.14-0.47; P < .001), age (≤7 minutes: reference; 8-33 minutes: OR, 0.34; 95% CI, 0.13-0.89; P = .03; >33 minutes: OR, 0.27; 95% CI, 0.15-0.46; P < .001), number of segments with ST-elevation (≤7 minutes: reference; 8-33 minutes: OR, 0.35; 95% CI, 0.15-0.81; P = .01; >33 minutes: OR, 0.28; 95% CI, 0.15-0.52; P < .001), QRS duration (≤7 minutes: reference; 8-33 minutes: OR, 0.35; 95% CI, 0.14-0.87; P = .02; >33 minutes: OR, 0.27; 95% CI, 0.15-0.48; P < .001), heart rate (≤7 minutes: reference; 8-33 minutes: OR, 0.35; 95% CI, 0.13-0.93; P = .04; >33 minutes: OR, 0.29; 95% CI, 0.15-0.55; P < .001), epinephrine administered (≤7 minutes: reference; 8-33 minutes: OR, 0.35; 95% CI, 0.13-0.98; P = .045; >33 minutes: OR, 0.27; 95% CI, 0.16-0.48; P < .001), shockable initial rhythm (≤7 minutes: reference; 8-33 minutes: OR, 0.35; 95% CI, 0.13-0.96; P = .04; >33 minutes: OR, 0.26; 95% CI, 0.15-0.46; P < .001), and 3 or more shocks administered (≤7 minutes: reference; 8-33 minutes: OR, 0.36; 95% CI, 0.13-1.00; P = .05; >33 minutes: OR, 0.27; 95% CI, 0.16-0.48; P < .001) in bivariable analyses. CONCLUSIONS AND RELEVANCE This study suggests that early ECG acquisition after ROSC in patients with OHCA is associated with a higher percentage of false-positive ECG findings for STEMI. It may be reasonable to delay post-ROSC ECG by at least 8 minutes after ROSC or repeat the acquisition if the first ECG is diagnostic of STEMI and is acquired early after ROSC.
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Affiliation(s)
- Enrico Baldi
- Department of Molecular Medicine, Section of Cardiology, University of Pavia, Pavia, Italy
- Cardiac Intensive Care Unit, Arrhythmia and Electrophysiology and Experimental Cardiology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy
| | | | - Maria Luce Caputo
- Department of Molecular Medicine, Section of Cardiology, University of Pavia, Pavia, Italy
- Division of Cardiology, Cardiocentro Ticino, Lugano, Switzerland
| | - Catherine Klersy
- Service of Clinical Epidemiology and Biometry, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Christian Clodi
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Jolie Bruno
- Division of Cardiology, Cardiocentro Ticino, Lugano, Switzerland
| | - Sara Compagnoni
- Department of Molecular Medicine, Section of Cardiology, University of Pavia, Pavia, Italy
- Cardiac Intensive Care Unit, Arrhythmia and Electrophysiology and Experimental Cardiology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy
| | | | - Hans Domanovits
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Rosa Fracchia
- Department of Molecular Medicine, Section of Cardiology, University of Pavia, Pavia, Italy
| | - Roberto Primi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Gerhard Ruzicka
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Michael Holzer
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Angelo Auricchio
- Division of Cardiology, Cardiocentro Ticino, Lugano, Switzerland
| | - Simone Savastano
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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50
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Conner CM, Perucki WH, Gabriel A, O'Sullivan DM, Fernandez AB. Heart Rate and Neurological Outcomes in Patients Undergoing Targeted Temperature Management. J Intensive Care Med 2020; 36:1392-1397. [PMID: 33380239 DOI: 10.1177/0885066620982502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION There is a paucity of data evaluating the impact of heart rate (HR) during Targeted Temperature Management (TTM) and neurologic outcomes. Current resuscitation guidelines do not specify a HR goal during TTM. We sought to determine the relationship between HR and neurologic outcomes in a single-center registry dataset. METHODS We retrospectively studied 432 consecutive patients who completed TTM (33°C) after cardiac arrest from 2008 to 2017. We evaluated the relationship between neurologic outcomes and HR during TTM. Pittsburgh Cerebral Performance Categories (CPC) at discharge were used to determine neurological recovery. Statistical analysis included chi square, Student's t-test and Mann-Whitney U. A logistic regression model was created to evaluate the strength of contribution of selected variables on the outcome of interest. RESULTS Approximately 94,000 HR data points from 432 patients were retrospectively analyzed; the mean HR was 82.17 bpm over the duration of TTM. Favorable neurological outcomes were seen in 160 (37%) patients. The mean HR in the patients with a favorable outcome was lower than the mean HR of those with an unfavorable outcome (79.98 bpm vs 85.67 bpm p < 0.001). Patients with an average HR of 60-91 bpm were 2.4 times more likely to have a favorable neurological outcome compared to than HR's < 60 or > 91 (odds ratio [OR] = 2.36, 95% confidence interval [CI] 1.61-3.46, p < 0.001). Specifically, mean HR's in the 73-82 bpm range had the greatest rate of favorable outcomes (OR 3.56, 95% CI 1.95-6.50), p < 0.001. Administration of epinephrine, a history of diabetes mellitus and hypertension all were associated with worse neurological outcomes independent of HR. CONCLUSION During TTM, mean HRs between 60-91 showed a positive association with favorable outcomes. It is unclear whether a specific HR should be targeted during TTM or if heart rates between 60-91 bpm might be a sign of less neurological damage.
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Affiliation(s)
- Chad M Conner
- University of Connecticut School of Medicine, Farmington, CT, USA
| | | | - Andre Gabriel
- University of Connecticut School of Medicine, Farmington, CT, USA
| | | | - Antonio B Fernandez
- University of Connecticut School of Medicine, Farmington, CT, USA.,Division of Cardiology, Hartford Hospital, Hartford, CT, USA
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