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Wood G, Madsen TL, Kim WY, Lyhne MD. Increasing Levels of Positive End-expiratory Pressure Cause Stepwise Biventricular Stroke Work Reduction in a Porcine Model. Anesthesiology 2024; 140:240-250. [PMID: 37905995 DOI: 10.1097/aln.0000000000004821] [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: 11/02/2023]
Abstract
BACKGROUND Positive end-expiratory pressure (PEEP) is commonly applied to avoid atelectasis and improve oxygenation in patients during general anesthesia but affects cardiac pressures, volumes, and loading conditions through cardiorespiratory interactions. PEEP may therefore alter stroke work, which is the area enclosed by the pressure-volume loop and corresponds to the external work performed by the ventricles to eject blood. The low-pressure right ventricle may be even more susceptible to PEEP than the left ventricle. The authors hypothesized that increasing levels of PEEP would reduce stroke work in both ventricles. METHODS This was a prospective, observational, experimental study. Six healthy female pigs of approximately 60 kg were used. PEEP was stepwise increased from 0 to 5, 7, 9, 11, 13, 15, 17, and 20 cm H2O to cover the clinical spectrum of PEEP. Simultaneous, biventricular invasive pressure-volume loops, invasive blood pressures, and ventilator data were recorded. RESULTS Increasing PEEP resulted in stepwise reductions in left (5,740 ± 973 vs. 2,303 ± 1,154 mmHg · ml; P < 0.001) and right (2,064 ± 769 vs. 468 ± 133 mmHg · ml; P < 0.001) ventricular stroke work. The relative stroke work reduction was similar between the two ventricles. Left ventricular ejection fraction, afterload, and coupling were preserved. On the contrary, PEEP increased right ventricular afterload and caused right ventriculo-arterial uncoupling (0.74 ± 0.30 vs. 0.19 ± 0.13; P = 0.01) with right ventricular ejection fraction reduction (64 ± 8% vs. 37 ± 7%, P < 0.001). CONCLUSIONS A stepwise increase in PEEP caused stepwise reduction in biventricular stroke work. However, there are important interventricular differences in response to increased PEEP levels. PEEP increased right ventricular afterload leading to uncoupling and right ventricular ejection fraction decline. These findings may support clinical decision-making to further optimize PEEP as a means to balance between improving lung ventilation and preserving right ventricular function. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Gregory Wood
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Tobias Lynge Madsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Won Yong Kim
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Mads Dam Lyhne
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
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Pulmonary hypertension among children with in-hospital cardiac arrest: A multicenter study. Resuscitation 2021; 168:52-57. [PMID: 34536558 DOI: 10.1016/j.resuscitation.2021.09.009] [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: 08/02/2021] [Revised: 09/03/2021] [Accepted: 09/07/2021] [Indexed: 11/20/2022]
Abstract
AIMS To determine the prevalence of pulmonary hypertension (PH) among children with in-hospital cardiac arrest (IHCA) and its association with survival. METHODS Children (<18 years) admitted to ICUs participating in the Virtual Pediatric Systems multicenter registry between January 2011 and December 2017 who had an IHCA during their hospitalization were included. Patients were classified by whether they had a documented diagnosis of PH at the time of IHCA. Clinical characteristics were compared between patients with and without PH. After propensity score matching, conditional logistic regression within the matched cohort determined the association between PH and survival to hospital discharge. RESULTS Of 18,575 children with IHCA during the study period, 1,590 (8.6%) had a pre-arrest diagnosis of PH. Patients with PH were more likely to be 29 days to 2 years of age, female, Black/African American, and American Indian/Alaskan Native, and to be treated in a cardiac ICU or mixed PICU/cardiac ICU. At ICU admission, PH patients had a lower probability of death as determined by the Pediatric Index of Mortality 2 (PIM-2) score. Patients with PH were more likely to be receiving inhaled nitric oxide (13.0% vs. 2.1%; p < 0.001). Propensity score matching successfully matched 1,302 PH patients with 3,604 non-PH patients. Patients with PH were less likely to survive to hospital discharge (aOR 0.83; 95% CI: 0.72-0.95; p = 0.01) than non-PH patients. CONCLUSIONS In this large multicenter study, 8.6% of children with IHCA had pre-existing documented PH. These children were less likely to survive to hospital discharge than those without PH.
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Noori MAM, Rushdy A, Shah KK, Shamoon F, Naser M. Acute-Hypoxemia-Induced Right-To-Left Shunting in the Presence of Patent Foramen Ovale. Cureus 2021; 13:e16138. [PMID: 34262827 PMCID: PMC8260202 DOI: 10.7759/cureus.16138] [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] [Accepted: 07/02/2021] [Indexed: 12/01/2022] Open
Abstract
Patent foramen ovale (PFO) is a common congenital abnormality of the heart. It results from incomplete closure of foramen ovale that persists in adulthood. Most individuals with PFO are asymptomatic and are discovered incidentally. The left atrial pressure is generally higher than the right atrial pressure, which prevents blood flow against the gradient; however, any medical condition that increases the pulmonary artery pressure can lead to reversal of blood flow from right to left by elevating right atrial pressure. We present a case of a 59-year-old female who presented with complaints of shortness of breath associated with bilateral lower-extremity edema and was found to have acute decompensated heart failure and atrial fibrillation. Transesophageal echocardiogram (TEE) with cardioversion was performed. Propofol was given for conscious sedation; however, the procedure was terminated as patient became hypoxemic and was noted to have moderately dilated right ventricle (RV) with hypokinesia and PFO with right-to-left shunting. It also demonstrated mild mitral regurgitation, mild left ventricular hypertrophy, and a left ventricular ejection fraction of 55-60%. In contrast to TEE findings, while the patient was having normal oxygen saturation, transthoracic echocardiogram showed left-to-right shunting instead of right-to-left and no RV hypokinesia was noted. In conclusion, this case draws attention to the relationship between acute hypoxemia and right-to-left shunting in a patient with PFO. This case illustrates and highlights the need for more prospective studies to establish a relationship between acute hypoxemia and right-to-left shunting in the presence of PFO.
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Affiliation(s)
| | - Abanoub Rushdy
- Cardiology, Saint Joseph's University Medical Center, Paterson, USA
| | - Kalpesh K Shah
- Cardiology, Saint Joseph's University Medical Center, Paterson, USA
| | - Fayez Shamoon
- Cardiology, Saint Joseph's University Medical Center, Paterson, USA
| | - Mohammad Naser
- Cardiology, Saint Joseph's University Medical Center, Paterson, USA
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Morgan RW, Sutton RM, Himebauch AS, Roberts AL, Landis WP, Lin Y, Starr J, Ranganathan A, Delso N, Mavroudis CD, Volk L, Slovis J, Marquez AM, Nadkarni VM, Hefti M, Berg RA, Kilbaugh TJ. A randomized and blinded trial of inhaled nitric oxide in a piglet model of pediatric cardiopulmonary resuscitation. Resuscitation 2021; 162:274-283. [PMID: 33766668 DOI: 10.1016/j.resuscitation.2021.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 02/22/2021] [Accepted: 03/09/2021] [Indexed: 01/17/2023]
Abstract
AIM Inhaled nitric oxide (iNO) during cardiopulmonary resuscitation (CPR) improved systemic hemodynamics and outcomes in a preclinical model of adult in-hospital cardiac arrest (IHCA) and may also have a neuroprotective role following cardiac arrest. The primary objectives of this study were to determine if iNO during CPR would improve cerebral hemodynamics and mitochondrial function in a pediatric model of lipopolysaccharide-induced shock-associated IHCA. METHODS After lipopolysaccharide infusion and ventricular fibrillation induction, 20 1-month-old piglets received hemodynamic-directed CPR and were randomized to blinded treatment with or without iNO (80 ppm) during and after CPR. Defibrillation attempts began at 10 min with a 20-min maximum CPR duration. Cerebral tissue from animals surviving 1-h post-arrest underwent high-resolution respirometry to evaluate the mitochondrial electron transport system and immunohistochemical analyses to assess neuropathology. RESULTS During CPR, the iNO group had higher mean aortic pressure (41.6 ± 2.0 vs. 36.0 ± 1.4 mmHg; p = 0.005); diastolic BP (32.4 ± 2.4 vs. 27.1 ± 1.7 mmHg; p = 0.03); cerebral perfusion pressure (25.0 ± 2.6 vs. 19.1 ± 1.8 mmHg; p = 0.02); and cerebral blood flow relative to baseline (rCBF: 243.2 ± 54.1 vs. 115.5 ± 37.2%; p = 0.02). Among the 8/10 survivors in each group, the iNO group had higher mitochondrial Complex I oxidative phosphorylation in the cerebral cortex (3.60 [3.56, 3.99] vs. 3.23 [2.44, 3.46] pmol O2/s mg; p = 0.01) and hippocampus (4.79 [4.35, 5.18] vs. 3.17 [2.75, 4.58] pmol O2/s mg; p = 0.02). There were no other differences in mitochondrial respiration or brain injury between groups. CONCLUSIONS Treatment with iNO during CPR resulted in superior systemic hemodynamics, rCBF, and cerebral mitochondrial Complex I respiration in this pediatric cardiac arrest model.
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Affiliation(s)
- Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States; Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, United States.
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States; Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, United States
| | - Adam S Himebauch
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States; Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, United States
| | - Anna L Roberts
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States
| | - William P Landis
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States
| | - Yuxi Lin
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States
| | - Jonathan Starr
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States
| | - Abhay Ranganathan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States
| | - Nile Delso
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States
| | - Constantine D Mavroudis
- Department of Surgery, Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, United States
| | - Lindsay Volk
- Department of Surgery, Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, United States
| | - Julia Slovis
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States
| | - Alexandra M Marquez
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States; Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, United States
| | - Marco Hefti
- Department of Pathology, University of Iowa Carver College of Medicine, United States
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States; Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, United States
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States; Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, United States
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Bleakley C, Singh S, Garfield B, Morosin M, Surkova E, Mandalia MS, Dias B, Androulakis E, Price LC, McCabe C, Wort SJ, West C, Li W, Khattar R, Senior R, Patel BV, Price S. Right ventricular dysfunction in critically ill COVID-19 ARDS. Int J Cardiol 2020; 327:251-258. [PMID: 33242508 PMCID: PMC7681038 DOI: 10.1016/j.ijcard.2020.11.043] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 11/09/2020] [Accepted: 11/18/2020] [Indexed: 02/06/2023]
Abstract
Aims Comprehensive echocardiography assessment of right ventricular (RV) impairment has not been reported in critically ill patients with COVID-19. We detail the specific phenotype and clinical associations of RV impairment in COVID-19 acute respiratory distress syndrome (ARDS). Methods Transthoracic echocardiography (TTE) measures of RV function were collected in critically unwell patients for associations with clinical, ventilatory and laboratory data. Results Ninety patients (25.6% female), mean age 52.0 ± 10.8 years, veno-venous extracorporeal membrane oxygenation (VVECMO) (42.2%) were studied. A significantly higher proportion of patients were identified as having RV dysfunction by RV fractional area change (FAC) (72.0%,95% confidence interval (CI) 61.0–81.0) and RV velocity time integral (VTI) (86.4%, 95 CI 77.3–93.2) than by tricuspid annular plane systolic excursion (TAPSE) (23.8%, 95 CI 16.0–33.9), RVS’ (11.9%, 95% CI 6.6–20.5) or RV free wall strain (FWS) (35.3%, 95% CI 23.6–49.0). RV VTI correlated strongly with RV FAC (p ≤ 0.01). Multivariate regression demonstrated independent associations of RV FAC with NTpro-BNP and PVR. RV-PA coupling correlated with PVR (univariate p < 0.01), as well as RVEDAi (p < 0.01), and RVESAi (p < 0.01), and was associated with P/F ratio (p 0.026), PEEP (p 0.025), and ALT (p 0.028). Conclusions Severe COVID-19 ARDS is associated with a specific phenotype of RV radial impairment with sparing of longitudinal function. Clinicians should avoid interpretation of RV health purely on long-axis parameters in these patients. RV-PA coupling potentially provides important additional information above standard measures of RV performance in this cohort.
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Affiliation(s)
- Caroline Bleakley
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, London, UK; Department of Adult Critical Care, Royal Brompton Hospital, Sydney Street, London, UK
| | - Suveer Singh
- Department of Adult Critical Care, Royal Brompton Hospital, Sydney Street, London, UK
| | - Benjamin Garfield
- Department of Adult Critical Care, Royal Brompton Hospital, Sydney Street, London, UK
| | - Marco Morosin
- Department of Adult Critical Care, Royal Brompton Hospital, Sydney Street, London, UK
| | - Elena Surkova
- Department of Echocardiography, Royal Brompton Hospital, Sydney Street, London, UK
| | | | - Bernardo Dias
- Department of Echocardiography, Royal Brompton Hospital, Sydney Street, London, UK
| | | | - Laura C Price
- Pulmonary Hypertension Service, Royal Brompton Hospital, Sydney Street, London, UK
| | - Colm McCabe
- Pulmonary Hypertension Service, Royal Brompton Hospital, Sydney Street, London, UK
| | - Stephen John Wort
- Pulmonary Hypertension Service, Royal Brompton Hospital, Sydney Street, London, UK
| | - Cathy West
- Department of Echocardiography, Royal Brompton Hospital, Sydney Street, London, UK
| | - Wei Li
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, London, UK; Department of Echocardiography, Royal Brompton Hospital, Sydney Street, London, UK
| | - Rajdeep Khattar
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, London, UK; Department of Echocardiography, Royal Brompton Hospital, Sydney Street, London, UK
| | - Roxy Senior
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, London, UK; Department of Echocardiography, Royal Brompton Hospital, Sydney Street, London, UK
| | - Brijesh V Patel
- Department of Adult Critical Care, Royal Brompton Hospital, Sydney Street, London, UK
| | - Susanna Price
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, London, UK; Department of Adult Critical Care, Royal Brompton Hospital, Sydney Street, London, UK.
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6
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Nguyen‐Truong M, Liu W, Boon J, Nelson B, Easley J, Monnet E, Wang Z. Establishment of adult right ventricle failure in ovine using a graded, animal-specific pulmonary artery constriction model. Animal Model Exp Med 2020; 3:182-192. [PMID: 32613177 PMCID: PMC7323700 DOI: 10.1002/ame2.12124] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 05/05/2020] [Accepted: 05/20/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Right ventricle failure (RVF) is associated with serious cardiac and pulmonary diseases that contribute significantly to the morbidity and mortality of patients. Currently, the mechanisms of RVF are not fully understood and it is partly due to the lack of large animal models in adult RVF. In this study, we aim to establish a model of RVF in adult ovine and examine the structure and function relations in the RV. METHODS RV pressure overload was induced in adult male sheep by revised pulmonary artery constriction (PAC). Briefly, an adjustable hydraulic occluder was placed around the main pulmonary artery trunk. Then, repeated saline injection was performed at weeks 0, 1, and 4, where the amount of saline was determined in an animal-specific manner. Healthy, age-matched male sheep were used as additional controls. Echocardiography was performed bi-weekly and on week 11 post-PAC, hemodynamic and biological measurements were obtained. RESULTS This PAC methodology resulted in a marked increase in RV systolic pressure and decreases in stroke volume and tricuspid annular plane systolic excursion, indicating signs of RVF. Significant increases in RV chamber size, wall thickness, and Fulton's index were observed. Cardiomyocyte hypertrophy and collagen accumulation (particularly type III collagen) were evident, and these structural changes were correlated with RV dysfunction. CONCLUSION In summary, the animal-specific, repeated PAC provided a robust approach to induce adult RVF, and this ovine model will offer a useful tool to study the progression and treatment of adult RVF that is translatable to human diseases.
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Affiliation(s)
| | - Wenqiang Liu
- School of Biomedical EngineeringColorado State UniversityFort CollinsCOUSA
| | - June Boon
- Veterinary Teaching HospitalColorado State UniversityFort CollinsCOUSA
| | - Brad Nelson
- Veterinary Teaching HospitalColorado State UniversityFort CollinsCOUSA
| | - Jeremiah Easley
- Veterinary Teaching HospitalColorado State UniversityFort CollinsCOUSA
- Department of Clinical SciencesColorado State UniversityFort CollinsCOUSA
| | - Eric Monnet
- Veterinary Teaching HospitalColorado State UniversityFort CollinsCOUSA
- Department of Clinical SciencesColorado State UniversityFort CollinsCOUSA
| | - Zhijie Wang
- School of Biomedical EngineeringColorado State UniversityFort CollinsCOUSA
- Department of Mechanical EngineeringColorado State UniversityFort CollinsCOUSA
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Abstract
OBJECTIVES In adult in-hospital cardiac arrest, pulmonary hypertension is associated with worse outcomes, but pulmonary hypertension-associated in-hospital cardiac arrest has not been well studied in children. The objective of this study was to determine the prevalence of pulmonary hypertension among children with in-hospital cardiac arrest and its impact on outcomes. DESIGN Retrospective single-center cohort study. SETTING PICU of a quaternary care, academic children's hospital. PATIENTS Children (<18 yr old) receiving greater than or equal to 1 minute of cardiopulmonary resuscitation (cardiopulmonary resuscitation) for an index in-hospital cardiac arrest with an echocardiogram in the 48 hours preceding in-hospital cardiac arrest, excluding those with cyanotic congenital heart disease. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 284 in-hospital cardiac arrest subjects, 57 (20%) had evaluable echocardiograms, which were analyzed by a cardiologist blinded to patient characteristics. Pulmonary hypertension was present in 20 of 57 (35%); nine of 20 (45%) had no prior pulmonary hypertension history. Children with pulmonary hypertension had worse right ventricular systolic function, measured by fractional area change (p = 0.005) and right ventricular global longitudinal strain (p = 0.046); more right ventricular dilation (p = 0.010); and better left ventricular systolic function (p = 0.001). Children with pulmonary hypertension were more likely to have abnormal baseline functional status and a history of chronic lung disease or acyanotic congenital heart disease and less likely to have sepsis or acute kidney injury. Children with pulmonary hypertension were more likely to have an initial rhythm of pulseless electrical activity or asystole and were more frequently treated with inhaled nitric oxide (80% vs 32%; p < 0.001) at the time of cardiopulmonary resuscitation. On multivariable analysis, pulmonary hypertension was not associated with event survival (14/20 [70%] vs 24/37 [65%]; adjusted odds ratio, 1.30 [CI95, 0.25-6.69]; p = 0.77) or survival to discharge (8/20 [40%] vs 10/37 [27%]; adjusted odds ratio, 1.17 [CI95, 0.22-6.44]; p = 0.85). CONCLUSIONS Pulmonary hypertension physiology preceding pediatric in-hospital cardiac arrest may be more common than previously described. Among this cohort with a high frequency of inhaled nitric oxide treatment during cardiopulmonary resuscitation, pulmonary hypertension was not associated with survival outcomes.
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Bäcker H, Kyburz A, Bosshard A, Babst R, Beeres FJP. Dead or dying? Pulseless electrical activity during trauma resuscitation. Br J Anaesth 2018; 118:809. [PMID: 28510749 DOI: 10.1093/bja/aex105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Morgan RW, Sutton RM, Karlsson M, Lautz AJ, Mavroudis CD, Landis WP, Lin Y, Jeong S, Craig N, Nadkarni VM, Kilbaugh TJ, Berg RA. Pulmonary Vasodilator Therapy in Shock-associated Cardiac Arrest. Am J Respir Crit Care Med 2018; 197:905-912. [PMID: 29244522 PMCID: PMC6020403 DOI: 10.1164/rccm.201709-1818oc] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 12/15/2017] [Indexed: 12/24/2022] Open
Abstract
RATIONALE Many in-hospital cardiac arrests are precipitated by hypotension, often associated with systemic inflammation. These patients are less likely to be successfully resuscitated, and novel approaches to their treatment are needed. OBJECTIVES To determine if the addition of inhaled nitric oxide (iNO) to hemodynamic-directed cardiopulmonary resuscitation (HD-CPR) would improve short-term survival from cardiac arrest associated with shock and systemic inflammation. METHODS In 3-month-old swine (n = 21), LPS was intravenously infused, inducing systemic hypotension. Ventricular fibrillation was induced, and animals were randomized to blinded treatment with either: 1) HD-CPR with iNO, or 2) HD-CPR without iNO. During HD-CPR, chest compression depth was titrated to peak aortic compression pressure of 100 mm Hg, and vasopressor administration was titrated to coronary perfusion pressure greater than or equal to 20 mm Hg. Defibrillation attempts began after 10 minutes of resuscitation. The primary outcome was 45-minute survival. MEASUREMENTS AND MAIN RESULTS The iNO group had higher rates of 45-minute survival (10 of 10 vs. 3 of 11; P = 0.001). During cardiopulmonary resuscitation, the iNO group had lower pulmonary artery relaxation pressure (mean ± SEM, 10.9 ± 2.4 vs. 18.4 ± 2.4 mm Hg; P = 0.03), higher coronary perfusion pressure (21.1 ± 1.5 vs. 16.9 ± 1.0 mm Hg; P = 0.005), and higher aortic relaxation pressure (36.6 ± 1.6 vs. 30.4 ± 1.1 mm Hg; P < 0.001) despite shallower chest compressions (5.88 ± 0.25 vs. 6.46 ± 0.40 cm; P = 0.02) and fewer vasopressor doses in the first 10 minutes (median, 4 [interquartile range, 3-4] vs. 5 [interquartile range, 5-6], P = 0.03). CONCLUSIONS The addition of iNO to HD-CPR in LPS-induced shock-associated cardiac arrest improved short-term survival and intraarrest hemodynamics.
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Affiliation(s)
- Ryan W. Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Robert M. Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Michael Karlsson
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Andrew J. Lautz
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Constantine D. Mavroudis
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - William P. Landis
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Yuxi Lin
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Sejin Jeong
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Nancy Craig
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Vinay M. Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Todd J. Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
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