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Obling LER, Beske RP, Meyer MAS, Grand J, Wiberg S, Mohr T, Damm-Hejmdal A, Forman JL, Frikke-Schmidt R, Folke F, Møller JE, Kjaergaard J, Hassager C. Effect of prehospital high-dose glucocorticoid on hemodynamics in patients resuscitated from out-of-hospital cardiac arrest: a sub-study of the STEROHCA trial. Crit Care 2024; 28:28. [PMID: 38254130 PMCID: PMC10801994 DOI: 10.1186/s13054-024-04808-3] [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: 12/04/2023] [Accepted: 01/12/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Following resuscitated out-of-hospital cardiac arrest (OHCA), inflammatory markers are significantly elevated and associated with hemodynamic instability and organ dysfunction. Vasopressor support is recommended to maintain a mean arterial pressure (MAP) above 65 mmHg. Glucocorticoids have anti-inflammatory effects and may lower the need for vasopressors. This study aimed to assess the hemodynamic effects of prehospital high-dose glucocorticoid treatment in resuscitated comatose OHCA patients. METHODS The STEROHCA trial was a randomized, placebo-controlled, phase 2 trial comparing one prehospital injection of methylprednisolone 250 mg with placebo immediately after resuscitated OHCA. In this sub-study, we included patients who remained comatose at admission and survived until intensive care unit (ICU) admission. The primary outcome was cumulated norepinephrine use from ICU admission until 48 h reported as mcg/kg/min. Secondary outcomes included hemodynamic status characterized by MAP, heart rate, vasoactive-inotropic score (VIS), and the VIS/MAP-ratio as well as cardiac function assessed by pulmonary artery catheter measurements. Linear mixed-model analyses were performed to evaluate mean differences between treatment groups at all follow-up times. RESULTS A total of 114 comatose OHCA patients were included (glucocorticoid: n = 56, placebo: n = 58) in the sub-study. There were no differences in outcomes at ICU admission. From the time of ICU admission up to 48 h post-admission, patients in the glucocorticoid group cumulated a lower norepinephrine use (mean difference - 0.04 mcg/kg/min, 95% CI - 0.07 to - 0.01, p = 0.02). Moreover, after 12-24 h post-admission, the glucocorticoid group demonstrated a higher MAP with mean differences ranging from 6 to 7 mmHg (95% CIs from 1 to 12), a lower VIS (mean differences from - 4.2 to - 3.8, 95% CIs from - 8.1 to 0.3), and a lower VIS/MAP ratio (mean differences from - 0.10 to - 0.07, 95% CIs from - 0.16 to - 0.01), while there were no major differences in heart rate (mean differences from - 4 to - 3, 95% CIs from - 11 to 3). These treatment differences between groups were also present 30-48 h post-admission but to a smaller extent and with increased statistical uncertainty. No differences were found in pulmonary artery catheter measurements between groups. CONCLUSIONS Prehospital treatment with high-dose glucocorticoid was associated with reduced norepinephrine use in resuscitated OHCA patients. TRIAL REGISTRATION EudraCT number: 2020-000855-11; submitted March 30, 2020. URL: https://www. CLINICALTRIALS gov ; Unique Identifier: NCT04624776.
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Affiliation(s)
- Laust E R Obling
- Department of Cardiology, Rigshospitalet - Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, OE, Denmark.
| | - Rasmus P Beske
- Department of Cardiology, Rigshospitalet - Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, OE, Denmark
| | - Martin A S Meyer
- Department of Cardiology, Rigshospitalet - Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, OE, Denmark
| | - Johannes Grand
- Department of Cardiology, Rigshospitalet - Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, OE, Denmark
| | - Sebastian Wiberg
- Department of Cardiology, Rigshospitalet - Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, OE, Denmark
- Department of Thoracic Anesthesiology, Rigshospitalet - Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Mohr
- Department of Intensive Care, Herlev-Gentofte Hospital - Copenhagen University Hospital, Copenhagen, Denmark
| | - Anders Damm-Hejmdal
- Copenhagen Emergency Services, Capital Region of Denmark, Copenhagen, Denmark
| | - Julie L Forman
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Ruth Frikke-Schmidt
- Department of Clinical Biochemistry, Rigshospitalet - Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Fredrik Folke
- Copenhagen Emergency Services, Capital Region of Denmark, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Herlev-Gentofte Hospital - Copenhagen University Hospital, Copenhagen, Denmark
| | - Jacob E Møller
- Department of Cardiology, Rigshospitalet - Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, OE, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, Rigshospitalet - Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, OE, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet - Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, OE, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Chalkias A, Adamos G, Mentzelopoulos SD. General Critical Care, Temperature Control, and End-of-Life Decision Making in Patients Resuscitated from Cardiac Arrest. J Clin Med 2023; 12:4118. [PMID: 37373812 DOI: 10.3390/jcm12124118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/02/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Cardiac arrest affects millions of people per year worldwide. Although advances in cardiopulmonary resuscitation and intensive care have improved outcomes over time, neurologic impairment and multiple organ dysfunction continue to be associated with a high mortality rate. The pathophysiologic mechanisms underlying the post-resuscitation disease are complex, and a coordinated, evidence-based approach to post-resuscitation care has significant potential to improve survival. Critical care management of patients resuscitated from cardiac arrest focuses on the identification and treatment of the underlying cause(s), hemodynamic and respiratory support, organ protection, and active temperature control. This review provides a state-of-the-art appraisal of critical care management of the post-cardiac arrest patient.
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Affiliation(s)
- Athanasios Chalkias
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, 41500 Larisa, Greece
- Outcomes Research Consortium, Cleveland, OH 44195, USA
| | - Georgios Adamos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, 10675 Athens, Greece
| | - Spyros D Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, 10675 Athens, Greece
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3
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Lazzarin T, Tonon CR, Martins D, Fávero EL, Baumgratz TD, Pereira FWL, Pinheiro VR, Ballarin RS, Queiroz DAR, Azevedo PS, Polegato BF, Okoshi MP, Zornoff L, Rupp de Paiva SA, Minicucci MF. Post-Cardiac Arrest: Mechanisms, Management, and Future Perspectives. J Clin Med 2022; 12:jcm12010259. [PMID: 36615059 PMCID: PMC9820907 DOI: 10.3390/jcm12010259] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 12/22/2022] [Accepted: 12/23/2022] [Indexed: 12/31/2022] Open
Abstract
Cardiac arrest is an important public health issue, with a survival rate of approximately 15 to 22%. A great proportion of these deaths occur after resuscitation due to post-cardiac arrest syndrome, which is characterized by the ischemia-reperfusion injury that affects the role body. Understanding physiopathology is mandatory to discover new treatment strategies and obtain better results. Besides improvements in cardiopulmonary resuscitation maneuvers, the great increase in survival rates observed in recent decades is due to new approaches to post-cardiac arrest care. In this review, we will discuss physiopathology, etiologies, and post-resuscitation care, emphasizing targeted temperature management, early coronary angiography, and rehabilitation.
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Yu Y, Tang Z, Xie M, Li J, Hang CC, An L, Li C. Glucocorticoid receptor expression in patients with cardiac arrest in the early period after the return of spontaneous circulation: a prospective observational single-centre study. BMJ Open 2022; 12:e060246. [PMID: 36691201 PMCID: PMC9462114 DOI: 10.1136/bmjopen-2021-060246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 08/15/2022] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES Rapid changes in glucocorticoid (GC) levels and adrenal insufficiency are related to the development of post-cardiac arrest (CA) syndrome. However, GC receptor (GR) expression changes have not been studied. Hence, this study aimed to investigate the association of early changes in GR expression and prognosis and immune response in patients who experienced CA. DESIGN Prospective observational study. SETTING Emergency department. PARTICIPANTS Patients (85) in the early period of return of spontaneous circulation (ROSC) after CA were admitted between October 2018 and October 2019. After a physical examination, age-matched and sex-matched healthy individuals (40) were recruited for the control group. PRIMARY AND SECONDARY OUTCOME MEASURES GR expression and cell counts of circulatory T and B lymphocytes, natural killer cells and regulatory T (Treg) cells were assessed. Plasma total cortisol and adrenocorticotrophic hormone (ACTH) levels were also tested. RESULTS All cell counts were lower, and plasma total cortisol levels were higher (p<0.001) in patients who experienced CA than in the healthy control group. GR expression in Treg cells and CD3+CD4+ T lymphocytes were not significantly different, but the mean fluorescence intensity and GR expression in other cells were lower in patients who experienced CA (p<0.05) than in the healthy control group. ACTH levels were not different. There were no significant differences between survivors and non-survivors. CONCLUSIONS This study revealed that GR expression and cell counts rapidly decreased, whereas plasma total cortisol levels increased in the early period after ROSC among patients who experienced CA. Our findings provide important information about GR level and function, and immunosuppressive status in these patients. Assessing GR expression in patients who experienced CA may help screening for those who are more sensitive to GC therapy.
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Affiliation(s)
- Yanan Yu
- Department of Emergency Medicine, Beijing Chao-Yang Hospital Capital Medical University, Beijing, Beijing, China
| | - Ziren Tang
- Department of Emergency Medicine, Beijing Chao-Yang Hospital Capital Medical University, Beijing, Beijing, China
| | - Miaorong Xie
- Department of Emergency Medicine, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, Beijing, China
| | - Jiabao Li
- Department of Critical Care, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, Beijing, China
| | - Chen-Chen Hang
- Department of Emergency Medicine, Beijing Chao-Yang Hospital Capital Medical University, Beijing, Beijing, China
| | - Le An
- Department of Emergency Medicine, Beijing Chao-Yang Hospital Capital Medical University, Beijing, Beijing, China
| | - Chunsheng Li
- Department of Emergency Medicine, Beijing Chao-Yang Hospital Capital Medical University, Beijing, Beijing, China
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5
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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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6
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Narvaez Linares N, Munelith-Souksanh K, Tanguay A, Plamondon H. The impact of myocardial infarction on basal and stress-induced heart rate variability and cortisol secretion in women: A pilot study. COMPREHENSIVE PSYCHONEUROENDOCRINOLOGY 2022; 9:100113. [PMID: 35755922 PMCID: PMC9216611 DOI: 10.1016/j.cpnec.2022.100113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/07/2022] [Accepted: 01/07/2022] [Indexed: 10/24/2022] Open
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7
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Sahebnasagh A, Nejad PS, Salehi-Abargouei A, Dehghani MH, Saghafi F. A characterization of cortisol level and adrenal reservation in human cardiopulmonary arrest: systematic review and meta-analysis. Syst Rev 2021; 10:266. [PMID: 34625103 PMCID: PMC8499554 DOI: 10.1186/s13643-021-01820-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 09/25/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Cardiopulmonary arrest (CPA) is an urgency, which is associated with high mortality. This systematic review evaluated the relationship between baseline cortisol level and the outcome of resuscitated CPA patients. METHODS We searched the following databases: PubMed, Scopus, ISI Web of Science, and Google Scholar. Relevant observational and controlled trials were explored from inception by April 2020. The quality of the articles was assessed using the Newcastle-Ottawa Scale (NOS). RESULTS Finally, five cohort studies (n = 201 participants in total) were eligible for including in the meta-analysis. The results of this meta-analysis showed that although the baseline serum cortisol levels were higher in survivors of cardiac arrest compared with non-survivors, the differences between groups do not reach a significance level (Hedges' g = 0.371, 95% CI, -0.727, 1.469, P value = 0.508). Between-study heterogeneity was statistically significant (Cochrane Q test: P value < 0.001, I2 = 89.323). CONCLUSIONS The result of the present meta-analysis was suggestive of a higher baseline serum cortisol levels in survivors of CPA. Future randomized controlled studies with a large sample size will determine the exact relationship between adrenal reservation and the eventual outcome of patients with CPA. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018085468.
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Affiliation(s)
- Adeleh Sahebnasagh
- Clinical Research Center, Department of Internal Medicine, School of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Paria Soltani Nejad
- 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
| | - Mohammad Hossein Dehghani
- Department of Anesthesiology and Critical Care, Shahid Rahnemoun Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Fatemeh Saghafi
- Department of Clinical Pharmacy, Faculty of Pharmacy and Pharmaceutical Sciences Research Center, Shahid Sadoughi University of Medical Sciences, Professor Hesabi Blvd, Yazd, Iran.
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8
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Pantazopoulos I, Boutsikos I, Mavrovounis G, Graikou T, Faa G, Barouxis D, Kesidou E, Mavridis T, Chalkias A, Xanthos T. Stress hormones kinetics in ventricular fibrillation cardiac arrest and resuscitation: Translational and therapeutic implications. Am J Emerg Med 2021; 50:14-21. [PMID: 34265731 DOI: 10.1016/j.ajem.2021.07.016] [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: 05/26/2021] [Revised: 06/24/2021] [Accepted: 07/01/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Knowing the kinetics of endogenous stress hormones during cardiac arrest and cardiopulmonary resuscitation (CRP) will help to optimize personalized physiology-guided treatment. The aim of this study was to examine the dynamic changes in stress hormones in a swine model of ventricular fibrillation (VF) cardiac arrest. METHODS Ventricular fibrillation was induced in 10 healthy Landrace/Large White piglets, which were subsequently left untreated for 8 min. All animals were resuscitated according to the 2015 European Resuscitation Council guidelines. The concentration of adrenalin, noradrenalin, and cortisol was measured at baseline and at the 4th and 8th minute of VF-cardiac arrest, as well as at 30-min, 60-min, 24 h and 48 h post-ROSC. RESULTS By the end of the 4th min of VF, the animals of the ROSC group exhibited significantly higher adrenaline levels compared to those of the no-ROSC group (7264 pg/ml vs. 1648 pg/ml, p = 0.03). Noradrenaline was higher in the ROSC group at the 4th min of VF (3021 pg/ml vs. 1626 pg/ml, p = 0.02). Cortisol levels in the ROSC group were significantly lower by the end of the 8th min of VF [16.25 ng/ml vs. 92.82 ng/ml, p = 0.03]. With a cut-off point of 5970 pg/ml, adrenaline at the 4th min of VF exhibited 100% sensitivity and 80% specificity for predicting ROSC. CONCLUSION Higher endogenous adrenaline and lower endogenous cortisol levels were associated with ROSC.
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Affiliation(s)
- Ioannis Pantazopoulos
- University of Thessaly, School of Health Sciences, Faculty of Medicine, Department of Emergency Medicine, 41110 Larissa, Greece
| | | | - Georgios Mavrovounis
- University of Thessaly, School of Health Sciences, Faculty of Medicine, Department of Emergency Medicine, 41110 Larissa, Greece.
| | - Themis Graikou
- European University Cyprus, School of Medicine, Engomi 1516, Cyprus
| | - Gavino Faa
- Division of Pathology, Department of Surgical Sciences, Università degli Studi di Cagliari, Cagliari, Italy
| | | | - Evangelia Kesidou
- Laboratory of Experimental Physiology, Department of Physiology and Pharmacology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodoros Mavridis
- First Neurology Department, Aeginiteio Hospital Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - Athanasios Chalkias
- University of Thessaly, School of Health Sciences, Faculty of Medicine, Department of Anesthesiology, 41110 Larissa, Greece
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9
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Sahebnasagh A, Najmeddin F, Najafi A, Saghafi F, Salehi-Abargouei A, Ahmadi A, Amini S, Mojtahedzadeh M, Sharifnia H. Efficacy of Glucocorticoid Administration in Patients with Cardiac Arrest: A Systematic Review of Clinical Studies. Curr Med Chem 2021; 29:136-151. [PMID: 34060997 DOI: 10.2174/0929867328666210531145617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/31/2021] [Accepted: 04/05/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND The pathophysiology of cardiac arrest (CA) involves over-activation of systemic inflammatory responses, relative adrenal insufficiency, and glycocalyx damage. Corticosteroids have beneficial effects in preventing the perturbation of the endothelial glycocalyx. OBJECTIVES The aim of this systematic review was to determine the efficacy of glucocorticoids in patients with cardiac arrest. METHODS We searched PubMed, Scopus, ISI Web of Science, Google Scholar and Cochrane central register for relevant clinical trials and cohort studies until September 2019. RESULTS We retrieved 7 peer-reviewed published studies for the systematic review. Two studies were clinical trials evaluating 147 patients, while five illustrated cohort design, evaluating 196,192 patients. In total, 196,339 patients were assessed. There was limited evidence and conflicting results to establish a correlation between glucocorticoids and the survival of patients suffering from cardiac arrest. However, the link between these medications and survival-to-admission, survival-to discharge, and 1-year survival rates was strong and consistent in observational studies. CONCLUSION The clinical evidence regarding the efficacy and safety of glucocorticoids in CA is limited to observational studies with inconsistent methodology and few clinical trials with small sample size. Nevertheless, it seems that glucocorticoid supplementation during and after cardiopulmonary resuscitation (CPR) may have significant effects in terms of survival-to-admission, survival to discharge, 1-year survival rates and an improved return of spontaneous circulation (ROSC) rate, especially in patients with hemodynamic instability and cardiovascular diseases (i.e., refractory hemodynamic shock). Future studies with high-quality, large-scale, long-term intervention and precise baseline characteristics are needed to evaluate the exact effective dose, duration, and efficacy of glucocorticoids in CA.
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Affiliation(s)
- Adeleh Sahebnasagh
- Clinical Research Center, Department of Internal Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Farhad Najmeddin
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Atabak Najafi
- Department of Anesthesiology and Critical Care Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Saghafi
- Department of Clinical Pharmacy, Faculty of Pharmacy and Pharmaceutical Sciences Research Center, 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
| | - Arezoo Ahmadi
- Department of Anesthesiology and Critical Care Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahideh Amini
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mojtaba Mojtahedzadeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Sharifnia
- Department of Anesthesiology and Critical Care Medicine, Sina Hospital, Tehran University of Medical Sciences, Iran
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10
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Okuma Y, Aoki T, Miyara SJ, Hayashida K, Nishikimi M, Takegawa R, Yin T, Kim J, Becker LB, Shinozaki K. The evaluation of pituitary damage associated with cardiac arrest: An experimental rodent model. Sci Rep 2021; 11:629. [PMID: 33436714 PMCID: PMC7804952 DOI: 10.1038/s41598-020-79780-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 11/24/2020] [Indexed: 11/11/2022] Open
Abstract
The pituitary gland plays an important endocrinal role, however its damage after cardiac arrest (CA) has not been well elucidated. The aim of this study was to determine a pituitary gland damage induced by CA. Rats were subjected to 10-min asphyxia and cardiopulmonary resuscitation (CPR). Immunohistochemistry and ELISA assays were used to evaluate the pituitary damage and endocrine function. Samples were collected at pre-CA, and 30 and 120 min after cardio pulmonary resuscitation. Triphenyltetrazolium chloride (TTC) staining demonstrated the expansion of the pituitary damage over time. There was phenotypic validity between the pars distalis and nervosa. Both CT-proAVP (pars nervosa hormone) and GH/IGF-1 (pars distalis hormone) decreased over time, and a different expression pattern corresponding to the damaged areas was noted (CT-proAVP, 30.2 ± 6.2, 31.5 ± 5.9, and 16.3 ± 7.6 pg/mg protein, p < 0.01; GH/IGF-1, 2.63 ± 0.61, 0.62 ± 0.36, and 2.01 ± 0.41 ng/mg protein, p < 0.01 respectively). Similarly, the expression pattern between these hormones in the end-organ systems showed phenotypic validity. Plasma CT-proAVP (r = 0.771, p = 0.025) and IGF-1 (r = −0.775, p = 0.024) demonstrated a strong correlation with TTC staining area. Our data suggested that CA induces pathological and functional damage to the pituitary gland.
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Affiliation(s)
- Yu Okuma
- The Feinstein Institutes for Medical Research, Northwell Health, 350 Community Dr., Manhasset, NY, 11030, USA
| | - Tomoaki Aoki
- The Feinstein Institutes for Medical Research, Northwell Health, 350 Community Dr., Manhasset, NY, 11030, USA
| | - Santiago J Miyara
- The Feinstein Institutes for Medical Research, Northwell Health, 350 Community Dr., Manhasset, NY, 11030, USA.,Elmezzi Graduate School of Molecular Medicine at Northwell Health, Manhasset, NY, USA
| | - Kei Hayashida
- The Feinstein Institutes for Medical Research, Northwell Health, 350 Community Dr., Manhasset, NY, 11030, USA
| | - Mitsuaki Nishikimi
- The Feinstein Institutes for Medical Research, Northwell Health, 350 Community Dr., Manhasset, NY, 11030, USA
| | - Ryosuke Takegawa
- The Feinstein Institutes for Medical Research, Northwell Health, 350 Community Dr., Manhasset, NY, 11030, USA
| | - Tai Yin
- The Feinstein Institutes for Medical Research, Northwell Health, 350 Community Dr., Manhasset, NY, 11030, USA
| | - Junhwan Kim
- The Feinstein Institutes for Medical Research, Northwell Health, 350 Community Dr., Manhasset, NY, 11030, USA
| | - Lance B Becker
- The Feinstein Institutes for Medical Research, Northwell Health, 350 Community Dr., Manhasset, NY, 11030, USA.,Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Koichiro Shinozaki
- The Feinstein Institutes for Medical Research, Northwell Health, 350 Community Dr., Manhasset, NY, 11030, USA. .,Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
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11
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Tassopoulos A, Chalkias A, Papalois A, Karlovasiti P, Zanda JSA, Chatzidakis S, Gazouli M, Iacovidou N, Fanni D, Xanthos T. Assessment of Post-Resuscitation Intestinal Injury and Timing of Bacterial Translocation in Swine Anaesthetized With Propofol-Based Total Intravenous Anaesthesia. Cureus 2020; 12:e10362. [PMID: 33062485 PMCID: PMC7549874 DOI: 10.7759/cureus.10362] [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] [Indexed: 11/05/2022] Open
Abstract
Introduction and objectives Bacterial translocation (BT) is the passage of viable bacteria or endotoxins from the gastrointestinal lumen to extra-luminal tissues and is usually observed after intestinal ischaemia-reperfusion injury. The aim of this study was to investigate post-resuscitation BT after cardiac arrest and resuscitation in a swine anaesthetized with propofol-based total intravenous anaesthesia. Materials and methods Eighteen female Landrace/Large White piglets were randomly divided into control (CON), cardiac arrest (CA) and cardiac arrest-cardiopulmonary resuscitation (CA-CPR) groups. In the CON group, the animals were only monitored for two hours. In the CA group, the animals were not resuscitated and underwent necropsy immediately after cardiac arrest. In the CA-CPR group, the animals were resuscitated until the return of spontaneous circulation (ROSC) and were monitored for two hours. The animals of the CON and CA-CPR groups underwent necropsy 24 hours later. Bacterial translocation was assessed by blood and tissue cultures and endotoxin measurement in the portal and systemic circulation. Malondialdehyde content calculation and histological analysis of the intestine were performed in order to estimate ischemia and reperfusion (I/R) tissue damage. Results Malondialdehyde content, an indicator of oxidative stress, was significantly higher in the CA-CPR group compared to the CA in homogenized ileum (p=0.016). Malondialdehyde content in homogenized colon revealed significantly higher levels in the CA-CPR group compared to the CON (p=0.004) and the CA group (p=0.016). We found significantly higher levels of portal endotoxin in the CA-CPR group compared to the CON (p=0.026) and the CA group (p=0.026). The number of positive mesenteric lymph nodes cultures for E. coli was greater in the CA-CPR group, followed by the CA and CON groups, although the difference was not significant (67%, 33%, and 33%, respectively; p=0.407). Conclusions Malondialdehyde content and portal endotoxin levels do not increase during the cardiac arrest interval, but only after CPR and ROSC. Although the number of positive MLNs cultures was greater in the CA-CPR animals, no statistically significant differences were observed between the three groups due to the short monitoring period.
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Affiliation(s)
| | - Athanasios Chalkias
- Department of Anesthesiology, University of Thessaly, School of Health Sciences, Faculty of Medicine, Larisa, GRC
| | - Apostolos Papalois
- Translational Research and Training, ELPEN Research & Experimental Center, Athens, GRC
| | - Paraskevi Karlovasiti
- Department of Biopathology - Microbiology and Biochemistry, Medical School, National and Kapodistrian University of Athens, Athens, GRC
| | | | - Stefanos Chatzidakis
- Department of Medicine, European University Cyprus, School of Medicine, Nicosia, CYP
| | - Maria Gazouli
- Laboratory of Biology, Medical School, National and Kapodistrian University of Athens, Athens, GRC
| | - Nicoletta Iacovidou
- Department of Neonatology, Medical School, National and Kapodistrian University of Athens, Athens, GRC
| | - Daniela Fanni
- Division of Pathology, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, ITA
| | - Theodoros Xanthos
- Department of Physiology and Pathophysiology, European University Cyprus, School of Medicine, Nicosia, CYP
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Jentzer JC, Clements CM, Murphy JG, Scott Wright R. Recent developments in the management of patients resuscitated from cardiac arrest. J Crit Care 2017; 39:97-107. [PMID: 28242531 DOI: 10.1016/j.jcrc.2017.02.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 01/18/2017] [Accepted: 02/01/2017] [Indexed: 01/31/2023]
Abstract
Cardiac arrest is the leading cause of death in Europe and the United States. Many patients who are initially resuscitated die in the hospital, and hospital survivors often have substantial neurologic dysfunction. Most cardiac arrests are caused by coronary artery disease; patients with coronary artery disease likely benefit from early coronary angiography and intervention. After resuscitation, cardiac arrest patients remain critically ill and frequently suffer cardiogenic shock and multiorgan failure. Early cardiopulmonary stabilization is important to prevent worsening organ injury. To achieve best patient outcomes, comprehensive critical care management is needed, with primary goals of stabilizing hemodynamics and preventing progressive brain injury. Targeted temperature management is frequently recommended for comatose survivors of cardiac arrest to mitigate the neurologic injury that drives outcomes. Accurate neurologic assessment is central to managing care of cardiac arrest survivors and should combine physical examination with objective neurologic testing, with the caveat that delaying neurologic prognosis is essential to avoid premature withdrawal of supportive care. A combination of clinical findings and diagnostic results should be used to estimate the likelihood of functional recovery. This review focuses on recent advances in care and specific cardiac intensive care strategies that may improve morbidity and mortality for patients after cardiac arrest.
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Affiliation(s)
- Jacob C Jentzer
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
| | | | - Joseph G Murphy
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - R Scott Wright
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
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Effect of Erythropoietin on Postresuscitation Renal Function in a Swine Model of Ventricular Fibrillation. BIOMED RESEARCH INTERNATIONAL 2016; 2016:3567275. [PMID: 27847811 PMCID: PMC5099488 DOI: 10.1155/2016/3567275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 09/13/2016] [Accepted: 09/21/2016] [Indexed: 12/26/2022]
Abstract
Purpose. To investigate the effect of EPO administration on postresuscitation renal function. Methods. Twenty-four female Landrace/Large-White piglets aged 10–15 weeks with average weight of 19 ± 2 kg were randomly assigned to 2 different groups of 12 subjects each. After the end of an 8-minute ventricular fibrillation, the control group (Group C) received saline as placebo, whereas the EPO group (Group E) received EPO 5000 U/kg. The animals were resuscitated according to the 2010 European Resuscitation Council Guidelines for Resuscitation. Results. Five animals (41.67%) from Group C and 11 animals (91.67%) from Group E achieved ROSC (p = 0.027). Eight animals (66.67%, 5 surviving and 3 nonsurviving) from Group C suffered severe kidney damage or AKI compared to animals from Group E, in which none of the swine had evidence of severe kidney damage or AKI (p = 0.001). There was a statistically significant difference in all tested biochemical markers between the two groups, as well as a positive correlation of creatinine with NGAL, L-FABP, and IL-18 (summed mean values' p = 0.049, 0.01, and 0.004, resp.). Conclusions. Administration of EPO protected swine from postresuscitation acute kidney injury.
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Tsai MS, Chuang PY, Yu PH, Huang CH, Tang CH, Chang WT, Chen WJ. Glucocorticoid use during cardiopulmonary resuscitation may be beneficial for cardiac arrest. Int J Cardiol 2016; 222:629-635. [PMID: 27517652 DOI: 10.1016/j.ijcard.2016.08.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 08/01/2016] [Accepted: 08/02/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Various studies have indicated that glucocorticoid supplementation during cardiopulmonary resuscitation (CPR), in conjunction with vasopressors, may improve outcomes in instances of cardiac arrest. However, further population-based analysis is warranted with respect to resuscitative and long-term survival benefits conferred by administering glucocorticoids in this setting. METHODS A total of 145,644 adult patients who experienced non-traumatic, cardiac arrest occurred at emergency room during years 2004-2011 were selected for study from the Taiwan National Health Insurance Research database. These patients were grouped as steroid and non-steroid recipients during CPR, and group members were matched in terms of patient characteristics, including presenting complaint, prior steroid use, resuscitative drugs and shocks delivered, treatment setting (medical center or not), socioeconomic status, and year that cardiac arrest occurred, through propensity scoring. Logistic regression analysis was performed to determine the impact of steroid usage on survival to admission, survival to discharge, and 1-year survival. RESULTS Compared with matched non-steroid group members (n=8628), patients given steroid (n=2876) displayed significantly higher rates of survival to admission (38.32% vs 18.67%; adjusted OR=2.97, 95% CI 2.69-3.29; p<0.0001), survival to discharge (14.50% vs 5.61%; adjusted OR=1.71, 95% CI 1.42-2.05; p<0.0001), and 1-year overall survival (10.81% vs 4.74%; adjusted OR=1.48, 95% CI 1.22-1.79; p<0.0001). Steroid use proved more beneficial in patients with COPD or asthma and in the absence of shockable rhythm during CPR. CONCLUSION Glucocorticoid use during CPR is associated with improved survival-to-admission, survival-to-discharge, and 1-year survival rates.
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Affiliation(s)
- Min-Shan Tsai
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan.
| | - Po-Ya Chuang
- School of Health Care Administration, Taipei Medical University, Taipei, Taiwan.
| | - Ping-Hsun Yu
- Department of Emergency Medicine, Taipei Hospital, Ministry of Health and Welfare, Taipei, Taiwan.
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan.
| | - Chao-Hsiun Tang
- School of Health Care Administration, Taipei Medical University, Taipei, Taiwan.
| | - Wei-Tien Chang
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan.
| | - Wen-Jone Chen
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan; Department of Emergency Medicine, Lotung Poh-Ai Hospital, Yilan County, Taiwan.
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Corticosteroid therapy in refractory shock following cardiac arrest: a randomized, double-blind, placebo-controlled, trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:82. [PMID: 27038920 PMCID: PMC4818959 DOI: 10.1186/s13054-016-1257-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 02/26/2016] [Indexed: 12/17/2022]
Abstract
Background The purpose of this study was to determine whether the provision of corticosteroids improves time to shock reversal and outcomes in patients with post-cardiac arrest shock. Methods We conducted a randomized, double-blind trial of post-cardiac arrest patients in shock, defined as vasopressor support for a minimum of 1 hour. Patients were randomized to intravenous hydrocortisone 100 mg or placebo every 8 hours for 7 days or until shock reversal. The primary endpoint was time to shock reversal. Results Fifty patients were included with 25 in each group. There was no difference in time to shock reversal between groups (hazard ratio: 0.83 [95 % CI: 0.40–1.75], p = 0.63). We found no difference in secondary outcomes including shock reversal (52 % vs. 60 %, p = 0.57), good neurological outcome (24 % vs. 32 %, p = 0.53) or survival to discharge (28 % vs. 36 %, p = 0.54) between the hydrocortisone and placebo groups. Of the patients with a baseline cortisol < 15 ug/dL, 100 % (6/6) in the hydrocortisone group achieved shock reversal compared to 33 % (1/3) in the placebo group (p = 0.08). All patients in the placebo group died (100 %; 3/3) whereas 50 % (3/6) died in the hydrocortisone group (p = 0.43). Conclusions In a population of cardiac arrest patients with vasopressor-dependent shock, treatment with hydrocortisone did not improve time to shock reversal, rate of shock reversal, or clinical outcomes when compared to placebo. Clinical trial registration Clinicaltrials.gov: NCT00676585, registration date: May 9, 2008.
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Varvarousi G, Stefaniotou A, Varvaroussis D, Xanthos T. Glucocorticoids as an emerging pharmacologic agent for cardiopulmonary resuscitation. Cardiovasc Drugs Ther 2015; 28:477-88. [PMID: 25163464 PMCID: PMC4163188 DOI: 10.1007/s10557-014-6547-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Although cardiac arrest (CA) constitutes a major health problem with dismal prognosis, no specific drug therapy has been shown to improve survival to hospital discharge. CA causes adrenal insufficiency which is associated with poor outcome and increased mortality. Adrenal insufficiency may manifest as an inability to increase cortisol secretion during and after cardiopulmonary resuscitation (CPR). Several studies suggest that glucocorticoids during and after CPR seem to confer benefits with respect to return of spontaneous circulation (ROSC) rates and long term survival. They have beneficial hemodynamic effects that may favor their use during CPR and in the early post-resuscitation period. Moreover, they have anti-inflammatory and anti-apoptotic properties that improve organ function by reducing ischemia/reperfusion (I/R) injury. However, glucocorticoid supplementation has shown conflicting results with regard to survival to hospital discharge and neurological outcome. The purpose of this article is to review the pathophysiology of hypothalamic-pituitary-adrenal (HPA) axis during CPR. Furthermore, this article reviews the effects of glucocorticoids use during CRP and the post-resuscitation phase.
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Affiliation(s)
- Giolanda Varvarousi
- National and Kapodistrian University of Athens, Medical School, MSc "Cardiopulmonary Resuscitation", Athens, Greece,
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