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A new paradigm for lung-conservative total liquid ventilation. EBioMedicine 2019; 52:102365. [PMID: 31447395 PMCID: PMC7033528 DOI: 10.1016/j.ebiom.2019.08.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 08/06/2019] [Accepted: 08/12/2019] [Indexed: 12/23/2022] Open
Abstract
Background Total liquid ventilation (TLV) of the lungs could provide radically new benefits in critically ill patients requiring lung lavage or ultra-fast cooling after cardiac arrest. It consists in an initial filling of the lungs with perfluorocarbons and subsequent tidal ventilation using a dedicated liquid ventilator. Here, we propose a new paradigm for a lung-conservative TLV using pulmonary volumes of perfluorocarbons below functional residual capacity (FRC). Methods and findings Using a dedicated technology, we showed that perfluorocarbon end-expiratory volumes could be maintained below expected FRC and lead to better respiratory recovery, preserved lung structure and accelerated evaporation of liquid residues as compared to complete lung filling in piglets. Such TLV below FRC prevented volutrauma through preservation of alveolar recruitment reserve. When used with temperature-controlled perfluorocarbons, this lung-conservative approach provided neuroprotective ultra-fast cooling in a model of hypoxic-ischemic encephalopathy. The scale-up and automating of the technology confirmed that incomplete initial lung filling during TLV was beneficial in human adult-sized pigs, despite larger size and maturity of the lungs. Our results were confirmed in aged non-human primates, confirming the safety of this lung-conservative approach. Interpretation This study demonstrated that TLV with an accurate control of perfluorocarbon volume below FRC could provide the full potential of TLV in an innovative and safe manner. This constitutes a new paradigm through the tidal liquid ventilation of incompletely filled lungs, which strongly differs from the previously known TLV approach, opening promising perspectives for a safer clinical translation. Fund ANR (COOLIVENT), FRM (DBS20140930781), SATT IdfInnov (project 273).
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Suppogu N, Panza GA, Kilic S, Gowdar S, Kallur KR, Jayaraman R, Lundbye J, Fernandez AB. The Effects of In-Hospital Intravenous Cold Saline in Postcardiac Arrest Patients Treated with Targeted Temperature Management. Ther Hypothermia Temp Manag 2018; 8:18-23. [DOI: 10.1089/ther.2017.0023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Nissi Suppogu
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Gregory A. Panza
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
- Department of Kinesiology, University of Connecticut, Storrs, Connecticut
| | - Sena Kilic
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Shreyas Gowdar
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Kamala R. Kallur
- Department of Medicine, St. Luke's-Roosevelt Hospital, New York, New York
| | - Ramya Jayaraman
- Department of Medicine, Saint Vincent's Hospital, Bridgeport, Connecticut
| | - Justin Lundbye
- Division of Cardiology, Hospital of Central Connecticut, New Britain, Connecticut
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Nadeau M, Sage M, Praud JP, Tissier R, Walti H, Micheau P. Optimal control of inspired perfluorocarbon temperature for induction of hypothermia by total liquid ventilation in juvenile lamb model. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2017; 2016:2704-2707. [PMID: 28268879 DOI: 10.1109/embc.2016.7591288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Mild hypothermia is well known for its therapeutic value in cardio- and neuroprotection. Many recent experimental studies have shown that the swiftness of the cooling offered by total liquid ventilation (TLV) holds great promise in achieving maximal therapeutic effect. TLV is an emerging ventilation technique in which the lungs are filled with breathable liquids, namely perfluorocarbons (PFCs). A liquid ventilator ensures subject ventilation by periodically renewing a volume of oxygenated, CO2-free and temperature-controlled breathable PFC. The substantial difference between breathing air and liquid is related to the fact that PFCs have over 500 times the volumetric thermal capacity of air 100% relative humidity. The PFC-filled lungs thus turn into an efficient heat exchanger with pulmonary circulation. The objective of the present study was to compute a posteriori the optimal inspired PFC temperature for ultrafast induction of mild hypothermia by TLV in a juvenile lamb experimentation using direct optimal control. The continuous time model and the discretized cycle-by-cycle model are presented. The control objectives of the direct optimal control are also presented and the results are compared with experimental data in order to validate the improved control performances. The computed direct optimal control showed that the inspired PFC temperature command can be improved to avoid temperature undershoots without altering the cooling performances.
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Nadeau M, Sage M, Kohlhauer M, Mousseau J, Vandamme J, Fortin-Pellerin E, Praud JP, Tissier R, Walti H, Micheau P. Optimal Control of Inspired Perfluorocarbon Temperature for Ultrafast Hypothermia Induction by Total Liquid Ventilation in an Adult Patient Model. IEEE Trans Biomed Eng 2017; 64:2760-2770. [PMID: 28237918 DOI: 10.1109/tbme.2017.2671741] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
GOAL Recent preclinical studies have shown that therapeutic hypothermia induced in less than 30 min by total liquid ventilation (TLV) strongly improves the survival rate after cardiac arrest. When the lung is ventilated with a breathable perfluorocarbon liquid, the inspired perfluorocarbon allows us to control efficiently the cooling process of the organs. While TLV can rapidly cool animals, the cooling speed in humans remains unknown. The objective is to predict the efficiency and safety of ultrafast cooling by TLV in adult humans. METHODS It is based on a previously published thermal model of ovines in TLV and the design of a direct optimal controller to compute the inspired perfluorocarbon temperature profile. The experimental results in an adult sheep are presented. The thermal model of sheep is subsequently projected to a human model to simulate the optimal hypothermia induction and its sensitivity to physiological parameter uncertainties. RESULTS The results in the sheep showed that the computed inspired perfluorocarbon temperature command can avoid arterial temperature undershoot. The projection to humans revealed that mild hypothermia should be ultrafast (reached in fewer than 3 min (-72 °C/h) for the brain and 20 min (-10 °C/h) for the entire body). CONCLUSION The projection to human model allows concluding that therapeutic hypothermia induction by TLV can be ultrafast and safe. SIGNIFICANCE This study is the first to simulate ultrafast cooling by TLV in a human model and is a strong motivation to translate TLV to humans to improve the quality of life of postcardiac arrest patients.
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Kohlhauer M, Berdeaux A, Kerber RE, Micheau P, Ghaleh B, Tissier R. Liquid Ventilation for the Induction of Ultrafast Hypothermia in Resuscitation Sciences: A Review. Ther Hypothermia Temp Manag 2016; 6:63-70. [DOI: 10.1089/ther.2015.0024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Matthias Kohlhauer
- Inserm, Unité 955, Equipe 03, Créteil, France
- Université Paris Est, UMR_S955, DHU A-TVB, UPEC, Créteil, France
- Université Paris Est, École Nationale Vétérinaire d'Alfort, Maisons-Alfort Cedex, France
| | - Alain Berdeaux
- Inserm, Unité 955, Equipe 03, Créteil, France
- Université Paris Est, UMR_S955, DHU A-TVB, UPEC, Créteil, France
- Université Paris Est, École Nationale Vétérinaire d'Alfort, Maisons-Alfort Cedex, France
| | - Richard E. Kerber
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Philippe Micheau
- Department of Mechanical Engineering, Université de Sherbrooke, Sherbrooke, Canada
| | - Bijan Ghaleh
- Inserm, Unité 955, Equipe 03, Créteil, France
- Université Paris Est, UMR_S955, DHU A-TVB, UPEC, Créteil, France
- Université Paris Est, École Nationale Vétérinaire d'Alfort, Maisons-Alfort Cedex, France
| | - Renaud Tissier
- Inserm, Unité 955, Equipe 03, Créteil, France
- Université Paris Est, UMR_S955, DHU A-TVB, UPEC, Créteil, France
- Université Paris Est, École Nationale Vétérinaire d'Alfort, Maisons-Alfort Cedex, France
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Nadeau M, Sage M, Kohlhauer M, Vandamme J, Mousseau J, Robert R, Tissier R, Praud JP, Walti H, Micheau P. Thermal Dynamics in Newborn and Juvenile Models Cooled by Total Liquid Ventilation. IEEE Trans Biomed Eng 2015; 63:1483-91. [PMID: 26552070 DOI: 10.1109/tbme.2015.2496938] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Total liquid ventilation (TLV) consists in filling the lungs with a perfluorocarbon (PFC) and using a liquid ventilator to ensure a tidal volume of oxygenated, CO 2 -free and temperature-controlled PFC. Having a much higher thermal capacity than air, liquid PFCs assume that the filled lungs become an efficient heat exchanger with pulmonary circulation. OBJECTIVE The objective of the present study was the development and validation of a parametric lumped thermal model of a subject in TLV. METHODS The lungs were modeled as one compartment in which the control volume varied as a function of the tidal volume. The heat transfer in the body was modeled as seven parallel compartments representing organs and tissues. The thermal model of the lungs and body was validated with two groups of lambs of different ages and weights (newborn and juvenile) undergoing an ultrafast mild therapeutic hypothermia induction by TLV. RESULTS The model error on all animals yielded a small mean error of -0.1 ±0.4 (°)C for the femoral artery and 0.0 ±0.1 (°)C for the pulmonary artery. CONCLUSION The resulting experimental validation attests that the model provided an accurate estimation of the systemic arterial temperature and the venous return temperature. SIGNIFICANCE This comprehensive thermal model of the lungs and body has the advantage of closely modeling the rapid thermal dynamics in TLV. The model can explain how the time to achieve mild hypothermia between newborn and juvenile lambs remained similar despite of highly different physiological and ventilatory parameters. The strength of the model is its strong relationship with the physiological parameters of the subjects, which suggests its suitability for projection to humans.
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Nadeau M, Sage M, Kohlhauer M, Robert R, Vandamne J, Mousseau J, Tissier R, Praud JP, Walti H, Micheau P. Liquid ventilator for ultrafast hypothermia induction in juvenile lambs: Preliminary results. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2015; 2015:1695-1698. [PMID: 26736603 DOI: 10.1109/embc.2015.7318703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Total liquid ventilation (TLV) is an emerging mechanical ventilation technique. In this technique, the lungs are filled with liquid perfluorocarbons (PFC) and a liquid ventilator assures ventilation by periodically renewing a volume of oxygenated, CO2 freed and temperature controlled PFC. A huge difference between conventional mechanical ventilation and TLV relates to the fact that PFCs are about 1500 times denser than air. Thus, the PFCs filled lungs turn into an efficient heat exchanger with the circulating blood. One of the most appealing utilization of the lungs as a heat exchanger in TLV is for ultrafast induction of mild therapeutic hypothermia (MTH) for neuroprotection and cardioprotection after ischemia-reperfusion injuries. This study aimed to perform ultrafast MTH induction by TLV in animals up to 25 kg, then perform a fast post-hypothermic rewarming while maintaining proper ventilation. A thermal model of the lamb and liquid ventilator was developed to predict the dynamic and the control strategy to adopt for MTH induction. Two juvenile lambs were instrumented with temperature sensors in the femoral artery, pulmonary artery, oesophagus, right eardrum and rectum. After stabilization in conventional mechanical ventilation, TLV was initiated with ultrafast MTH induction, followed by posthypothermic rewarming. Preliminary results in the two juvenile lambs reveal that the liquid ventilator Inolivent-6.0 can induce MTH by TLV in less than 2.5 min for systemic arterial blood and in less than 10 min for venous return, esophagus and eardrum. Rectal temperature reached MTH in respectively 19.4 and 17.0 min for both lambs. Experimental results were consistent with the model predictions. Moreover, blood gas analysis exhibited that the gas exchange in the lungs was maintained adequately for the entire experiments.
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Hutin A, Lidouren F, Kohlhauer M, Lotteau L, Seemann A, Mongardon N, Renaud B, Isabey D, Carli P, Vivien B, Ricard JD, Hauet T, Kerber RE, Berdeaux A, Ghaleh B, Tissier R. Total liquid ventilation offers ultra-fast and whole-body cooling in large animals in physiological conditions and during cardiac arrest. Resuscitation 2015; 93:69-73. [PMID: 26070832 DOI: 10.1016/j.resuscitation.2015.05.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 04/19/2015] [Accepted: 05/21/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Total liquid ventilation (TLV) can cool down the entire body within 10-15 min in small animals. Our goal was to determine whether it could also induce ultra-fast and whole-body cooling in large animals using a specifically dedicated liquid ventilator. Cooling efficiency was evaluated under physiological conditions (beating-heart) and during cardiac arrest with automated chest compressions (CC, intra-arrest). METHODS In a first set of experiments, beating-heart pigs were randomly submitted to conventional mechanical ventilation or hypothermic TLV with perfluoro-N-octane (between 15 and 32 °C). In a second set of experiments, pigs were submitted to ventricular fibrillation and CC. One group underwent continuous CC with asynchronous conventional ventilation (Control group). The other group was switched to TLV while pursuing CC for the investigation of cooling capacities and potential effects on cardiac massage efficiency. RESULTS Under physiological conditions, TLV significantly decreased the entire body temperatures below 34 °C within only 10 min. As examples, cooling rates averaged 0.54 and 0.94 °C/min in rectum and esophageous, respectively. During cardiac arrest, TLV did not alter CC efficiency and cooled the entire body below 34 °C within 20 min, the low-flow period slowing cooling during CC. CONCLUSION Using a specifically designed liquid ventilator, TLV induced a very rapid cooling of the entire body in large animals. This was confirmed in both physiological conditions and during cardiac arrest with CC. TLV could be relevant for ultra-rapid cooling independently of body weight.
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Affiliation(s)
- Alice Hutin
- Inserm, U955, Equipe 03, F-94000 Créteil, France; Université Paris Est, UMR_S955, DHU A-TVB, UPEC, F-94000 Créteil, France; Université Paris Est, Ecole Nationale Vétérinaire d'Alfort, F-94700 Maisons-Alfort, France; Hôpitaux Universitaires Paris Centre, Cochin Hôtel-Dieu, Université Paris Descartes - Paris V , F-75014 Paris France
| | - Fanny Lidouren
- Inserm, U955, Equipe 03, F-94000 Créteil, France; Université Paris Est, UMR_S955, DHU A-TVB, UPEC, F-94000 Créteil, France; Université Paris Est, Ecole Nationale Vétérinaire d'Alfort, F-94700 Maisons-Alfort, France
| | - Matthias Kohlhauer
- Inserm, U955, Equipe 03, F-94000 Créteil, France; Université Paris Est, UMR_S955, DHU A-TVB, UPEC, F-94000 Créteil, France; Université Paris Est, Ecole Nationale Vétérinaire d'Alfort, F-94700 Maisons-Alfort, France
| | - Luc Lotteau
- Bertin Technologies, Montigny le Bretonneux F-78180, France
| | - Aurélien Seemann
- Inserm, U955, Equipe 03, F-94000 Créteil, France; Université Paris Est, UMR_S955, DHU A-TVB, UPEC, F-94000 Créteil, France; Université Paris Est, Ecole Nationale Vétérinaire d'Alfort, F-94700 Maisons-Alfort, France
| | - Nicolas Mongardon
- Inserm, U955, Equipe 03, F-94000 Créteil, France; Université Paris Est, UMR_S955, DHU A-TVB, UPEC, F-94000 Créteil, France; Université Paris Est, Ecole Nationale Vétérinaire d'Alfort, F-94700 Maisons-Alfort, France
| | - Bertrand Renaud
- Hôpitaux Universitaires Paris Centre, Cochin Hôtel-Dieu, Université Paris Descartes - Paris V , F-75014 Paris France
| | - Daniel Isabey
- Université Paris Est, UMR_S955, DHU A-TVB, UPEC, F-94000 Créteil, France; Inserm, U955, Equipe 13, F-94000 Créteil, France
| | - Pierre Carli
- SAMU de Paris, Département d'Anesthésie Réanimation, Hôpital Universitaire Necker-Enfants Malades, Université Paris Descartes - Paris V, F-75015 Paris, France
| | - Benoit Vivien
- SAMU de Paris, Département d'Anesthésie Réanimation, Hôpital Universitaire Necker-Enfants Malades, Université Paris Descartes - Paris V, F-75015 Paris, France
| | - Jean-Damien Ricard
- Inserm, IAME, 1137, Univ Paris Diderot, Sorbonne Paris Cité, F-75018 Paris, France; Assistance Publique - Hôpitaux de Paris, Hôpital Louis Mourier, Service de Réanimation Médico-chirurgicale, F-92700 Colombes, France
| | | | - Richard E Kerber
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - Alain Berdeaux
- Inserm, U955, Equipe 03, F-94000 Créteil, France; Université Paris Est, UMR_S955, DHU A-TVB, UPEC, F-94000 Créteil, France; Université Paris Est, Ecole Nationale Vétérinaire d'Alfort, F-94700 Maisons-Alfort, France
| | - Bijan Ghaleh
- Inserm, U955, Equipe 03, F-94000 Créteil, France; Université Paris Est, UMR_S955, DHU A-TVB, UPEC, F-94000 Créteil, France; Université Paris Est, Ecole Nationale Vétérinaire d'Alfort, F-94700 Maisons-Alfort, France
| | - Renaud Tissier
- Inserm, U955, Equipe 03, F-94000 Créteil, France; Université Paris Est, UMR_S955, DHU A-TVB, UPEC, F-94000 Créteil, France; Université Paris Est, Ecole Nationale Vétérinaire d'Alfort, F-94700 Maisons-Alfort, France.
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Nadeau M, Micheau P, Robert R, Avoine O, Tissier R, Germim PS, Vandamme J, Praud JP, Walti H. Core Body Temperature Control by Total Liquid Ventilation Using a Virtual Lung Temperature Sensor. IEEE Trans Biomed Eng 2014; 61:2859-68. [DOI: 10.1109/tbme.2014.2332293] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Nadeau M, Micheau P, Robert R, Avoine O, Tissier R, Germim PS, Walti H. Control of rapid hypothermia induction by total liquid ventilation: preliminary results. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2013; 2013:3757-3760. [PMID: 24110548 DOI: 10.1109/embc.2013.6610361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Mild therapeutic hypothermia (MTH) consists in cooling the body temperature of a patient to between 32 and 34 °C. This technique helps to preserve tissues and neurological functions in multi-organ failure by preventing ischemic injury. Total liquid ventilation (TLV) ensures gas exchange in the lungs with a liquid, typically perfluorocarbon (PFC). A liquid ventilator is responsible for ensuring cyclic renewal of tidal volume of oxygenated and temperature-controlled PFC. Hence, TLV using the lung as a heat exchanger and PFC as a heat carrier allows ultra fast cooling of the whole body which can help improve outcome after ischemic injuries. The present study was aimed to evaluate the control performance and safety of automated ultrarapid MTH induction by TLV. Experimentation was conducted using the Inolivent-5.0 liquid ventilator equipped with a PFC treatment unit that allows PFC cooling and heating from the flow of energy carrier water inside a double wall installed on an oxygenator. A water circulating bath is used to manage water temperature. A feedback controller was developed to modulate inspired PFC temperature and control body temperature. Such a controller is important since, with MTH induction, heart temperature should not reach 28 °C because of a high risk of fibrillation. The in vivo experimental protocol was conducted on a male newborn lamb of 4.7 kg which, after anesthetization, was submitted to conventional gas ventilation and instrumented with temperature sensors at the femoral artery, oesophagus, right ear drum and rectum. After stabilization, TLV was initiated with fast automated MTH induction to 33.5 °C until stabilization of all temperatures. MTH could be reached safely in 3 minutes at the femoral artery, in 3.6 minutes at the esophagus, in 7.7 minutes at the eardrum and in 15 minutes at the rectum. All temperatures were stable at 33.5 ± 0.5 °C within 15 minutes. The present results reveal that ultra-fast MTH induction by TLV with Inolivent-5.0 is safe for the heart while maintaining esophageal and arterial temperature over 32.6 °C.
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Hale SL, Kloner RA. Mild Hypothermia as a Cardioprotective Approach for Acute Myocardial Infarction: Laboratory to Clinical Application. J Cardiovasc Pharmacol Ther 2010; 16:131-9. [DOI: 10.1177/1074248410387280] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In many animal models, mild therapeutic hypothermia is a powerful intervention, reducing myocardial infarct size, reducing the no-reflow phenomenon, and improving healing after infarction. Cooling in these models has been produced by various means including whole-body hypothermia, synchronized hypothermic coronary venous retro-perfusion, heat exchangers, and regional hypothermia targeting the heart alone. However, in humans, the most widely used techniques are surface cooling and cooling by endovascular heat-exchange catheters. The reduction in temperature necessary to produce cardioprotection is mild (32-34°C), appears to have no detrimental effects on left ventricular function or regional myocardial blood flow, and may improve microvascular reflow to previously ischemic heart tissue. It has been shown in experimental and clinical studies that for therapeutic hypothermia to be effective it must be (1) initiated as early as possible after the onset of ischemia and (2) initiated before reperfusion. This may require initiation of hypothermia in the ambulance, well before mechanical reperfusion occurs. The mechanisms of protection produced by hypothermia have yet to be conclusively determined but may include a decrease in tissue metabolic rate, preservation of high energy phosphates, a reduction in tissue apoptosis or induction of heat shock proteins.
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Affiliation(s)
- Sharon L. Hale
- The Heart Institute of Good Samaritan Hospital, Los Angeles, CA, USA,
| | - Robert A. Kloner
- The Heart Institute of Good Samaritan Hospital, Los Angeles, CA, USA, Keck School of Medicine, Division of Cardiovascular Medicine, University of Southern California, Los Angeles, CA, USA
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Abstract
This review briefly discusses induced therapeutic hypothermia (TH), which represents the intentional induction of a lowered core body temperature of 35 degrees C or less. The focus is on resuscitative or postarrest hypothermia, the data that support it, and the practical issues pertaining to TH implementation.
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Affiliation(s)
- C Jessica Dine
- Division of Pulmonary, Allergy and Critical Care, University of Pennsylvania, Philadelphia, PA 19104, USA
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Staffey KS, Dendi R, Brooks LA, Pretorius AM, Ackermann LW, Zamba KD, Dickson E, Kerber RE. Liquid ventilation with perfluorocarbons facilitates resumption of spontaneous circulation in a swine cardiac arrest model. Resuscitation 2008; 78:77-84. [PMID: 18406036 DOI: 10.1016/j.resuscitation.2008.02.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2007] [Revised: 02/05/2008] [Accepted: 02/13/2008] [Indexed: 10/22/2022]
Abstract
BACKGROUND Induced external hypothermia during ventricular fibrillation (VF) improves resuscitation outcomes. Our objectives were twofold (1) to determine if very rapid hypothermia could be achieved by intrapulmonary administration of cold perfluorocarbons (PFC), thereby using the lungs as a vehicle for targeted cardiopulmonary hypothermia, and (2) to determine if this improved resuscitation success. METHODS Part 1: Nine female swine underwent static intrapulmonary instillation of cold perfluorocarbons (PFC) during electrically induced VF. Part 2: Thirty-three female swine in VF were immediately ventilated via total liquid ventilation (TLV) with pre-oxygenated cold PFC (-15 degrees C) or warm PFC (33 degrees C), while control swine received no ventilation during VF. All swine in both Parts 1 and 2 underwent VF arrest for 11 min, then defibrillation, ventilation and closed chest massage until resumption of spontaneous circulation (ROSC). The endpoint was continued spontaneous circulation for 1h without pharmacologic support. RESULTS Static intrapulmonary instillation of cold PFC achieved rapid cardiopulmonary hypothermia; pulmonary artery (PA) temperature of 33.5+/-0.2 degrees C was achieved by 10 min. Nine of 9 achieved ROSC. Hypothermia was achieved faster using TLV: at 6 min VF, cold TLV temperature was 32.9+/-0.4 degrees C vs. cold static instillation temperature 34.3+/-0.2 degrees C. Nine of 11 cold TLV swine achieved ROSC for 1h vs. 3 of 11 control swine (p=0.03). Warm PFC also appeared to be beneficial, with a trend toward greater achievement of ROSC than control (ROSC; warm PFC 8 of 11 vs. control 3 of 11, p=0.09). CONCLUSION Targeted cardiopulmonary intra-arrest moderate hypothermia was achieved rapidly by static intrapulmonary administration of cold PFC and more rapidly by total liquid ventilation with cold PFC; resumption of spontaneous circulation was facilitated. Warm PFC showed a trend toward facilitating ROSC.
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Affiliation(s)
- Kimberly S Staffey
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA.
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Tissier R, Hamanaka K, Kuno A, Parker JC, Cohen MV, Downey JM. Total liquid ventilation provides ultra-fast cardioprotective cooling. J Am Coll Cardiol 2007; 49:601-5. [PMID: 17276185 DOI: 10.1016/j.jacc.2006.09.041] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2006] [Revised: 09/11/2006] [Accepted: 09/11/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVES We tested whether total liquid ventilation (TLV) can be used to rapidly cool and protect the infarcting heart. BACKGROUND Decreasing myocardial temperature during ischemia is a powerful cardioprotective strategy, but clinical application has been impaired by lack of practical methodology to quickly cool the heart. METHODS We performed 30-min coronary artery occlusion/3-h reperfusion in rabbits. Upon occlusion, rabbits underwent either oxygen (Gas), normothermic liquid (Liquid Warm), or cold liquid (Liquid Cool) ventilation. RESULTS Left atrial chamber temperature decreased to 32.4 degrees +/- 0.2 degrees C within 5 min of onset of cold TLV. Blood gases were within acceptable limits during TLV. In the Liquid Warm group, perfluorocarbon inhalation did not alter infarct size compared with Gas (37.7 +/- 1.3% and 42.5 +/- 4.9% of risk zone, respectively). However, infarction was significantly reduced in the Liquid Cool group (4.0 +/- 0.5%). Cooling only during the initial 30 min of reperfusion did not reduce infarction. CONCLUSIONS Total liquid ventilation can elicit rapid cardioprotective cooling during ischemia.
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Affiliation(s)
- Renaud Tissier
- Department of Physiology, University of South Alabama, College of Medicine, Mobile, Alabama 36688, USA
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Srinivasan V, Nadkarni VM, Yannopoulos D, Marino BS, Sigurdsson G, McKnite SH, Zook M, Benditt DG, Lurie KG. Rapid induction of cerebral hypothermia is enhanced with active compression-decompression plus inspiratory impedance threshold device cardiopulmonary resusitation in a porcine model of cardiac arrest. J Am Coll Cardiol 2006; 47:835-41. [PMID: 16487853 DOI: 10.1016/j.jacc.2005.09.062] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2005] [Revised: 09/08/2005] [Accepted: 09/19/2005] [Indexed: 11/30/2022]
Abstract
OBJECTIVES A rapid, ice-cold saline flush combined with active compression-decompression (ACD) plus an inspiratory impedance threshold device (ITD) cardiopulmonary resusitation (CPR) will cool brain tissue more effectively than with standard CPR (S-CPR) during cardiac arrest (CA). BACKGROUND Early institution of hypothermia after CPR and return of spontaneous circulation improves survival and outcomes after CA in humans. METHODS Ventricular fibrillation (VF) was induced for 8 min in anesthetized and tracheally intubated pigs. Pigs were randomized to receive either ACD + ITD CPR (n = 8) or S-CPR (n = 8). After 2 min of CPR, 30 ml/kg ice-cold saline (3 degrees C) was infused over the next 3 min of CPR via femoral vein followed by up to three defibrillation attempts (150 J, biphasic). If VF persisted, epinephrine (40 microg/kg) and vasopressin (0.3 U/kg) were administered followed by three additional defibrillation attempts. Hemodynamic variables and temperatures were continuously recorded. RESULTS All ACD + ITD CPR pigs (8 of 8) survived (defined as 15 min of return of spontaneous circulation [ROSC]) versus 3 of 8 pigs with S-CPR (p < 0.05). In survivors, brain temperature (degrees C) measured at 2-cm depth in brain cortex 1 min after ROSC decreased from 37.6 +/- 0.2 to 35.8 +/- 0.3 in ACD + ITD CPR versus 37.8 +/- 0.2 to 37.3 +/- 0.3 in S-CPR (p < 0.005). Immediately before defibrillation: 1) right atrial systolic/diastolic pressures (mm Hg) were lower (85 +/- 19, 4 +/- 1) in ACD + ITD CPR than S-CPR pigs (141 +/- 12, 8 +/- 3, p < 0.01); and 2) coronary perfusion pressures (mm Hg) were higher in ACD + ITD CPR (28.3 +/- 2) than S-CPR pigs (17.4 +/- 3, p < 0.01). CONCLUSIONS A rapid ice-cold saline infusion combined with ACD + ITD CPR during cardiac arrest induces cerebral hypothermia more rapidly immediately after ROSC than with S-CPR.
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Affiliation(s)
- Vijay Srinivasan
- Department of Anesthesia and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA
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Burkhardt W, Proquitté H, Krause S, Wauer RR, Rüdiger M. Changes in FiO2 affect PaO2 with minor alterations in cerebral concentration of oxygenated hemoglobin during liquid ventilation in healthy piglets. Intensive Care Med 2004; 30:315-320. [PMID: 14722641 DOI: 10.1007/s00134-003-2090-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2003] [Accepted: 10/31/2003] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To measure the impact of changes in the fraction of inspired oxygen (FiO2) on systemic and cerebral oxygen supply in gas and liquid ventilated healthy animals. DESIGN Interventional prospective animal study. SETTING University research laboratory. PARTICIPANTS Ten healthy, new-born piglets. INTERVENTIONS Variations in FiO2 during conventional mechanical ventilation (CMV) followed by partial liquid ventilation (PLV) with two different filling volumes of PF 5080 (10 vs. 30 ml/kg). MEASUREMENTS AND RESULTS Arterial blood gases were obtained 15 min after changing FiO2 and concentrations of cerebral oxygenated and total hemoglobin were determined with near infrared spectroscopy. During CMV an increase in FiO2 1.0 was associated with a constant rise in PaO2 but only a small increase in the cerebral concentration of oxygenated Hb. Initiation of PLV (at FiO2 of 1.0) caused a rapid drop in PaO2 towards values that were similar to CMV at FiO2 of 0.5. At FiO2 of 0.5 a reduction in oxygenated Hb was found in the 30 ml/kg filling group. Complete filling of the lungs with PFC caused a significant drop in total cerebral Hb concentration. CONCLUSIONS. According to our data, PLV in healthy lungs should be performed with a FiO2 of 1.0 and a small filling volume to avoid deterioration in cerebral oxygen supply.
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Affiliation(s)
- Wolfram Burkhardt
- Clinic of Neonatology, Charité-Mitte, Schumannstrasse 20, 10098, Berlin, Germany
| | - Hans Proquitté
- Clinic of Neonatology, Charité-Mitte, Schumannstrasse 20, 10098, Berlin, Germany
| | - Susann Krause
- Clinic of Neonatology, Charité-Mitte, Schumannstrasse 20, 10098, Berlin, Germany
| | - Roland R Wauer
- Clinic of Neonatology, Charité-Mitte, Schumannstrasse 20, 10098, Berlin, Germany
| | - Mario Rüdiger
- Clinic of Neonatology, Charité-Mitte, Schumannstrasse 20, 10098, Berlin, Germany.
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Burkhardt W, Proquitté H, Krause S, Wauer RR, Rüdiger M. Cerebral oxygenation is affected by filling mode and perfluorochemical volume in partial liquid ventilation of healthy piglets. Neonatology 2003; 82:250-6. [PMID: 12381933 DOI: 10.1159/000065886] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Intrapulmonary administration of perfluorochemicals (PFC) has been suggested for reasons other than respiratory insufficiency. PFC application has been described to affect cerebral Hb concentration, however, data for healthy lungs are missing. Newborn piglets were randomized into 3 groups (30-ml slow-filling, 10-ml slow-filling and 30-ml rapid-filling), orally intubated and mechanically ventilated. Partial liquid ventilation (PLV) was initiated by filling the lung with PF5080 (10 or 30 ml/kg) at a rate of 1.5 ml/min (slow filling) or within 45 s (rapid filling). Vital signs, blood gases, tidal volume (VT) and changes in the cerebral concentration of oxygenated hemoglobin (HbO(2)) and total Hb were determined for up to 20 min. Rapid administration of PFC caused an immediate drop in HbO(2), PaO(2) and VT. The concentration of oxygenated and total Hb increased thereafter and remained high. We found a slow increase in PaCO(2), HbO(2) and total Hb in the 30-ml slow-filling group, but almost no changes in the 10-ml slow filling group (except for a decrease in PaO(2)). According to our data, PLV with 10 ml/kg should be preferred since cerebral alterations are minimal. If complete filling of the lung is needed PFC should be administered slowly to minimize side effects.
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Ko AC, Hirsh E, Wong AC, Moore TM, Taylor AE, Hirschl RB, Younger JG. Segmental hemodynamics during partial liquid ventilation in isolated rat lungs. Resuscitation 2003; 57:85-91. [PMID: 12668304 PMCID: PMC3677028 DOI: 10.1016/s0300-9572(02)00439-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
UNLABELLED Partial liquid ventilation (PLV) is a means of ventilatory support in which gas ventilation is carried out in a lung partially filled with a perfluorocarbon liquid capable of supporting gas exchange. Recently, this technique has been proposed as an adjunctive therapy for cardiac arrest, during which PLV with cold perfluorocarbons might rapidly cool the intrathoracic contents and promote cerebral protective hypothermia while not interfering with gas exchange. A concern during such therapy will be the effect of PLV on pulmonary hemodynamics during very low blood flow conditions. In the current study, segmental (i.e. precapillary, capillary, and postcapillary) hemodynamics were studied in the rat lung using a standard isolated lung perfusion system at a flow rate of 6 ml/min ( approximately 5% normal cardiac output). Lungs received either gas ventilation or 5 or 10 ml/kg PLV. Segmental pressures and vascular resistances were determined, as was transcapillary fluid flux. The relationship between individual hemodynamic parameters and PLV dose was examined using linear regression, with n=5 in each study group. PLV at both the 5 and 10 ml/kg dose produced no detectable changes in pulmonary blood flow or in transcapillary fluid flux (all R(2) values<0.20). CONCLUSION In an isolated perfused lung model of low flow conditions, normal segmental hemodynamic behavior was preserved during liquid ventilation. These data support further investigation of this technique as an adjunct to cardiopulmonary resuscitation.
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Affiliation(s)
- Angela C. Ko
- Department of Emergency Medicine, Room 7679 Kresge Research Building I, 200 Zina Pitcher Place, University of Michigan, Ann Arbor, MI 48109-0522, USA
| | - Emily Hirsh
- Department of Emergency Medicine, Room 7679 Kresge Research Building I, 200 Zina Pitcher Place, University of Michigan, Ann Arbor, MI 48109-0522, USA
| | - Andrew C. Wong
- Department of Emergency Medicine, Room 7679 Kresge Research Building I, 200 Zina Pitcher Place, University of Michigan, Ann Arbor, MI 48109-0522, USA
| | - Timothy M. Moore
- Department of Physiology, University of South Alabama, Mobile, AL, USA
| | - Aubrey E. Taylor
- Department of Physiology, University of South Alabama, Mobile, AL, USA
| | - Ronald B. Hirschl
- Department of Surgery, Room 7679 Kresge Research Building I, 200 Zina Pitcher Place, Uniersity of Michigan, Ann Arbor, MI 48109-0522, USA
| | - John G. Younger
- Department of Emergency Medicine, Room 7679 Kresge Research Building I, 200 Zina Pitcher Place, University of Michigan, Ann Arbor, MI 48109-0522, USA
- Corresponding author. (J.G. Younger)
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