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Ichinose F, Hindle A. Sulfide catabolism in hibernation and neuroprotection. Nitric Oxide 2024; 146:19-23. [PMID: 38521487 PMCID: PMC11055667 DOI: 10.1016/j.niox.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 02/27/2024] [Accepted: 03/17/2024] [Indexed: 03/25/2024]
Abstract
The mammalian brain is exquisitely vulnerable to lack of oxygen. However, the mechanism underlying the brain's sensitivity to hypoxia is incompletely understood. In this narrative review, we present a case for sulfide catabolism as a key defense mechanism of the brain against acute oxygen shortage. We will examine literature on the role of sulfide in hypoxia/ischemia, deep hibernation, and leigh syndrome patients, and present our recent data that support the neuroprotective effects of sulfide catabolism and persulfide production. When oxygen levels become low, hydrogen sulfide (H2S) accumulates in brain cells and impairs the ability of these cells to use the remaining, available oxygen to produce energy. In recent studies, we found that hibernating ground squirrels, which can withstand very low levels of oxygen, have high levels of sulfide:quinone oxidoreductase (SQOR) and the capacity to catabolize hydrogen sulfide in the brain. Silencing SQOR increased the sensitivity of the brain of squirrels and mice to hypoxia, whereas neuron-specific SQOR expression prevented hypoxia-induced sulfide accumulation, bioenergetic failure, and ischemic brain injury in mice. Excluding SQOR from mitochondria increased sensitivity to hypoxia not only in the brain but also in heart and liver. Pharmacological agents that scavenge sulfide and/or increase persulfide maintained mitochondrial respiration in hypoxic neurons and made mice resistant to ischemic injury to the brain or spinal cord. Drugs that oxidize hydrogen sulfide and/or increase persulfide may prove to be an effective approach to the treatment of patients experiencing brain injury caused by oxygen deprivation or mitochondrial dysfunction.
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Affiliation(s)
- Fumito Ichinose
- Anesthesia Center for Critical Care Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
| | - Allyson Hindle
- Anesthesia Center for Critical Care Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; School of Life Sciences, University of Nevada Las Vegas, Las Vegas, NV, USA
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2
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Marutani E, Morita M, Hirai S, Kai S, Grange RMH, Miyazaki Y, Nagashima F, Traeger L, Magliocca A, Ida T, Matsunaga T, Flicker DR, Corman B, Mori N, Yamazaki Y, Batten A, Li R, Tanaka T, Ikeda T, Nakagawa A, Atochin DN, Ihara H, Olenchock BA, Shen X, Nishida M, Hanaoka K, Kevil CG, Xian M, Bloch DB, Akaike T, Hindle AG, Motohashi H, Ichinose F. Sulfide catabolism ameliorates hypoxic brain injury. Nat Commun 2021; 12:3108. [PMID: 34035265 PMCID: PMC8149856 DOI: 10.1038/s41467-021-23363-x] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 04/27/2021] [Indexed: 01/09/2023] Open
Abstract
The mammalian brain is highly vulnerable to oxygen deprivation, yet the mechanism underlying the brain's sensitivity to hypoxia is incompletely understood. Hypoxia induces accumulation of hydrogen sulfide, a gas that inhibits mitochondrial respiration. Here, we show that, in mice, rats, and naturally hypoxia-tolerant ground squirrels, the sensitivity of the brain to hypoxia is inversely related to the levels of sulfide:quinone oxidoreductase (SQOR) and the capacity to catabolize sulfide. Silencing SQOR increased the sensitivity of the brain to hypoxia, whereas neuron-specific SQOR expression prevented hypoxia-induced sulfide accumulation, bioenergetic failure, and ischemic brain injury. Excluding SQOR from mitochondria increased sensitivity to hypoxia not only in the brain but also in heart and liver. Pharmacological scavenging of sulfide maintained mitochondrial respiration in hypoxic neurons and made mice resistant to hypoxia. These results illuminate the critical role of sulfide catabolism in energy homeostasis during hypoxia and identify a therapeutic target for ischemic brain injury.
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Affiliation(s)
- Eizo Marutani
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Masanobu Morita
- Department of Environmental Medicine and Molecular Toxicology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shuichi Hirai
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Shinichi Kai
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Robert M H Grange
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Yusuke Miyazaki
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Fumiaki Nagashima
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Lisa Traeger
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Aurora Magliocca
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Tomoaki Ida
- Department of Environmental Medicine and Molecular Toxicology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tetsuro Matsunaga
- Department of Environmental Medicine and Molecular Toxicology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Daniel R Flicker
- Department of Systems Biology, Harvard Medical School, Boston, MA, USA
- Howard Hughes Medical Institute and Department of Molecular Biology, Massachusetts General Hospital, Boston, MA, USA
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Benjamin Corman
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Naohiro Mori
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Yumiko Yamazaki
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Annabelle Batten
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Rebecca Li
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Tomohiro Tanaka
- Division of Cardiocirculatory Signaling, National Institute for Physiological Sciences & Exploratory Research Center on Life and Living Systems & Center for Novel Science Initiatives, National Institutes of Natural Sciences, Okazaki, Japan
| | - Takamitsu Ikeda
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Akito Nakagawa
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Dmitriy N Atochin
- Harvard Medical School, Boston, MA, USA
- Cardiovascular Research Center, Division of Cardiology, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Charlestown, MA, USA
| | - Hideshi Ihara
- Department of Biological Science, Graduate School of Science, Osaka Prefecture University, Osaka, Japan
| | - Benjamin A Olenchock
- Harvard Medical School, Boston, MA, USA
- Division of Cardiovascular Medicine, Department of Medicine, The Brigham and Women's Hospital, Boston, MA, USA
| | - Xinggui Shen
- Department of Pathology and Translational Pathobiology, Louisiana State University Health Sciences Center-Shreveport, Shreveport, LA, USA
| | - Motohiro Nishida
- Division of Cardiocirculatory Signaling, National Institute for Physiological Sciences & Exploratory Research Center on Life and Living Systems & Center for Novel Science Initiatives, National Institutes of Natural Sciences, Okazaki, Japan
- Department of Physiology, Graduate School of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan
| | - Kenjiro Hanaoka
- Graduate School of Pharmaceutical Sciences, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Christopher G Kevil
- Department of Pathology and Translational Pathobiology, Louisiana State University Health Sciences Center-Shreveport, Shreveport, LA, USA
| | - Ming Xian
- Department of Chemistry, Brown University, Providence, RI, USA
| | - Donald B Bloch
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Takaaki Akaike
- Department of Environmental Medicine and Molecular Toxicology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Allyson G Hindle
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- School of Life Sciences, University of Nevada Las Vegas, Las Vegas, NV, USA
| | - Hozumi Motohashi
- Department of Gene Expression Regulation, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan.
| | - Fumito Ichinose
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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The Effect of Asphyxia Arrest Duration on a Pediatric End-Tidal CO2-Guided Chest Compression Delivery Model. Pediatr Crit Care Med 2019; 20:e352-e361. [PMID: 31149967 PMCID: PMC6612600 DOI: 10.1097/pcc.0000000000001968] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine the effect of the duration of asphyxial arrest on the survival benefit previously seen with end-tidal CO2-guided chest compression delivery. DESIGN Preclinical randomized controlled study. SETTING University animal research laboratory. SUBJECTS Two-week-old swine. INTERVENTIONS After either 17 or 23 minutes of asphyxial arrest, animals were randomized to standard cardiopulmonary resuscitation or end-tidal CO2-guided chest compression delivery. Standard cardiopulmonary resuscitation was optimized by marker, monitor, and verbal feedback about compression rate, depth, and release. End-tidal CO2-guided delivery used adjustments to chest compression rate and depth to maximize end-tidal CO2 level without other feedback. Cardiopulmonary resuscitation for both groups proceeded from 10 minutes of basic life support to 10 minutes of advanced life support or return of spontaneous circulation. MEASUREMENTS AND MAIN RESULTS After 17 minutes of asphyxial arrest, mean end-tidal CO2 during 10 minutes of cardiopulmonary resuscitation was 18 ± 9 torr in the standard group and 33 ± 15 torr in the end-tidal CO2 group (p = 0.004). The rate of return of spontaneous circulation was three of 14 (21%) in the standard group rate and nine of 14 (64%) in the end-tidal CO2 group (p = 0.05). After a 23-minute asphyxial arrest, neither end-tidal CO2 values (20 vs 26) nor return of spontaneous circulation rate (3/14 vs 1/14) differed between the standard and end-tidal CO2-guided groups. CONCLUSIONS Our previously observed survival benefit of end-tidal CO2-guided chest compression delivery after 20 minutes of asphyxial arrest was confirmed after 17 minutes of asphyxial arrest. The poor survival after 23 minutes of asphyxia shows that the benefit of end-tidal CO2-guided chest compression delivery is limited by severe asphyxia duration.
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Abstract
Although the occurrence of sudden cardiac death (SCD) in a young person is a rare event, it is traumatic and often widely publicized. In recent years, SCD in this population has been increasingly seen as a public health and safety issue. This review presents current knowledge relevant to the epidemiology of SCD and to strategies for prevention, resuscitation, and identification of those at greatest risk. Areas of active research and controversy include the development of best practices in screening, risk stratification approaches and postmortem evaluation, and identification of modifiable barriers to providing better outcomes after resuscitation of young SCD patients. Institution of a national registry of SCD in the young will provide data that will help to answer these questions.
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Affiliation(s)
- Michael Ackerman
- From Departments of Internal Medicine, Pediatrics, and Molecular Pharmacology & Experimental Therapeutics; Divisions of Cardiovascular Diseases and Pediatric Cardiology; Windland Smith Rice Sudden Death Genomics Laboratory; Mayo Clinic, Rochester, MN (M.A.);Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa, City (D.L.A.); andDepartment of Cardiology, Boston Children's Hospital, MA (J.K.T.)
| | - Dianne L Atkins
- From Departments of Internal Medicine, Pediatrics, and Molecular Pharmacology & Experimental Therapeutics; Divisions of Cardiovascular Diseases and Pediatric Cardiology; Windland Smith Rice Sudden Death Genomics Laboratory; Mayo Clinic, Rochester, MN (M.A.);Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa, City (D.L.A.); andDepartment of Cardiology, Boston Children's Hospital, MA (J.K.T.)
| | - John K Triedman
- From Departments of Internal Medicine, Pediatrics, and Molecular Pharmacology & Experimental Therapeutics; Divisions of Cardiovascular Diseases and Pediatric Cardiology; Windland Smith Rice Sudden Death Genomics Laboratory; Mayo Clinic, Rochester, MN (M.A.);Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa, City (D.L.A.); andDepartment of Cardiology, Boston Children's Hospital, MA (J.K.T.).
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Gabrielli A, Layon AJ, Cole P, Holbert R, Modell JH. Prolonged cardiopulmonary resuscitation with preservation of cerebral function in an elderly patient with asystole after electroconvulsive therapy. J Clin Anesth 2002; 14:234-40. [PMID: 12031760 DOI: 10.1016/s0952-8180(02)00344-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
This case report describes a patient who became asystolic after electroconvulsive therapy. The report describes the prolonged resuscitative events that lasted 54 minutes and discusses the effectiveness of chest compressions and the importance of monitoring the acid-base balance. The report also stresses the importance of being able to establish effective cardiac pacing in this patient. The updated resuscitation guidelines published by the American Heart Association are also discussed.
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Affiliation(s)
- Andrea Gabrielli
- Department of Anesthesiology, College of Medicine, University of Florida, Gainesville, FL 32610-0254, USA
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7
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Angelos MG, Menegazzi JJ, Callaway CW. Bench to bedside: resuscitation from prolonged ventricular fibrillation. Acad Emerg Med 2001; 8:909-24. [PMID: 11535487 DOI: 10.1111/j.1553-2712.2001.tb01155.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Ventricular fibrillation (VF) remains the most common cardiac arrest heart rhythm. Defibrillation is the primary treatment and is very effective if delivered early within a few minutes of onset of VF. However, successful treatment of VF becomes increasingly more difficult when the duration of VF exceeds 4 minutes. Classically, successful cardiac arrest resuscitation has been thought of as simply achieving restoration of spontaneous circulation (ROSC). However, this traditional approach fails to consider the high early post-cardiac arrest mortality and morbidity and ignores the reperfusion injuries, which are manifest in the heart and brain. More recently, resuscitation from cardiac arrest has been divided into two phases; phase I, achieving ROSC, and phase II, treatment of reperfusion injury. The focus in both phases of resuscitation remains the heart and brain, as prolonged VF remains primarily a two-organ disease. These two organs are most sensitive to oxygen and substrate deprivation and account for the vast majority of early post-resuscitation mortality and morbidity. This review focuses first on the initial resuscitation (achieving ROSC) and then on the reperfusion issues affecting the heart and brain.
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Affiliation(s)
- M G Angelos
- Department of Emergency Medicine, Ohio State University, Columbus, OH 43210-1270, USA.
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8
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Abstract
Due to the relative ineffectiveness of standard resuscitation techniques, alternative methods have been explored for many years. The aim of new methods is to improve haemodynamics and increase survival rates. In spite of some encouraging haemodynamic results, all but one study failed to show an increase in long-term survival rates with an alternative method in a convincingly large group of patients (hospital discharge without neurological damage, and 1-year survival). In this study active compression-decompression resuscitation (ACD-CPR) increased long-term survival compared to standard-CPR. The results from certain individual studies, which showed a significant increase in short-term survival rate, could not be reproduced in other trials. This may be attributed in part to the fact that the alternative methods are not significantly superior, but also due to logistical and statistical problems in the conduct of the studies and differences in application within and between the study sites. ACD-CPR has been the most studied method amongst the alternatives and can be recommended for patients with asystole in centres with special training and where outcome quality is regularly verified and evaluated.
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Affiliation(s)
- D Mauer
- The Clinic of Anaesthesiology, Johannes Gutenberg University, Langenbeckstrasse, Mainz, Germany.
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Shaffner DH, Eleff SM, Brambrink AM, Sugimoto H, Izuta M, Koehler RC, Traystman RJ. Effect of arrest time and cerebral perfusion pressure during cardiopulmonary resuscitation on cerebral blood flow, metabolism, adenosine triphosphate recovery, and pH in dogs. Crit Care Med 1999; 27:1335-42. [PMID: 10446829 DOI: 10.1097/00003246-199907000-00026] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To test the hypothesis that greater cerebral perfusion pressure (CPP) is required to restore cerebral blood flow (CBF), oxygen metabolism, adenosine triphosphate (ATP), and intracellular pH (pHi) levels after variable periods of no-flow than to maintain them when cardiopulmonary resuscitation (CPR) is started immediately. DESIGN Prospective, randomized, comparison of three arrest times and two perfusion pressures during CPR in 24 anesthetized dogs. SETTING University cerebral resuscitation laboratory. INTERVENTIONS We used radiolabeled microspheres to determine CBF and magnetic resonance spectroscopy to derive ATP and pHi levels before and during CPR. Ventricular fibrillation was induced, epinephrine administered, and thoracic vest CPR adjusted to provide a CPP of 25 or 35 mm Hg after arrest times of O, 6, or 12 mins. MEASUREMENTS AND MAIN RESULTS When CPR was started immediately after arrest with a CPP of 25 mm Hg, CBF and ATP were 57 +/- 10% and 64 +/- 14% of prearrest (at 10 mins of CPR). In contrast, CBF and ATP were minimally restored with a CPP at 25 mm Hg after a 6-min arrest time (23 +/- 5%, 16 +/- 5%, respectively). With a CPP of 35 mm Hg, extending the no-flow arrest time from 6 to 12 mins reduced reflow from 71 +/- 11% to 37 +/- 7% of pre-arrest and reduced ATP recovery from 60 +/- 11% to 2 +/- 1% of pre-arrest. After 6- or 12-min arrest times, brainstem blood flow was restored more than supratentorial blood flow, but cerebral pHi was never restored. CONCLUSIONS A CPP of 25 mm Hg maintains supratentorial blood flow and ATP at 60% to 70% when CPR starts immediately on arrest, but not after a 6-min delay. A higher CPP of 35 mm Hg is required to restore CBF and ATP when CPR is delayed for 6 mins. After a 12-min delay, even the CPP of 35 mm Hg is unable to restore CBF and ATP. Therefore, increasing the arrest time at these perfusion pressures increases the resistance to reflow sufficient to impair restoration of cerebral ATP.
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Affiliation(s)
- D H Shaffner
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
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Affiliation(s)
- C W Callaway
- Department of Emergency Medicine, University of Pittsburgh Medical Center, PA 15213, USA.
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Brown C, Wiklund L, Bar-Joseph G, Miller B, Bircher N, Paradis N, Menegazzi J, von Planta M, Kramer GC, Gisvold SE. Future directions for resuscitation research. IV. Innovative advanced life support pharmacology. Resuscitation 1996; 33:163-77. [PMID: 9025133 DOI: 10.1016/s0300-9572(96)01017-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The topics discussed in this session include a partial review of laboratory and clinical studies examining the effects of adrenergic agonists on restoration of spontaneous circulation after cardiac arrest, the effects of varying doses of epinephrine, and the effects of novel vasopressors, buffer agents (NaHCO3, THAM, 'Carbicarb') and anti-arrhythmics (lidocaine, bretylium, amiodarone) in refractory ventricular fibrillation. Novel therapeutic approaches include titrating electric countershocks against electrocardiographic power spectra and of preceding the first countershocks with single or multiple drug treatments. These approaches need to be investigated further in controlled animal and patient studies. Epidemiologic data from randomized clinical outcome studies can give clues, but cannot document pharmacologic mechanisms in the dynamically changing events during attempts to achieve restoration of spontaneous circulation from prolonged cardiac arrest. Also, rapid drug administration by the intraosseous route was compared with intratracheal and intravenous (i.v.) drug administration. Many studies on the above treatments have yielded conflicting results because of differences between healthy hearts of animals and sick hearts of patients, differences in arrest (no-flow) times and cardiopulmonary resuscitation (CPR) (low-flow) times, different pharmacokinetics, different dose/response requirements, and different timing of drug administration during low-flow CPR versus during spontaneous circulation. The need to stabilize normotension and prevent rearrest by titrated novel drug administration, once spontaneous circulation has been restored, requires research. Most of the above topics require some re-evaluation in clinically realistic animal models and in cardiac arrest patients, especially by titration of old and new drug treatments against variables that can be monitored continuously during resuscitation.
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12
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Hum PD, Traystman RJ. pH-associated Brain Injury in Cerebral Ischemia and Circulatory Arrest. J Intensive Care Med 1996. [DOI: 10.1177/088506669601100403] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Neuronal injury remains a major limitation in therapies directed toward cardiopulmonary resuscitation and cerebral ischemia. We summarize clinical and experimental information regarding pH-modulated mechanisms of cerebral ischemic injury and the status of antiacidosis therapies relative to the brain. A large body of evidence in animals and humans indicates that cerebral pH can modulate, and perhaps mediate, ischemic brain pathology and influence functional outcome. The importance of low pH and brain bicarbonate levels during reperfusion as a secondary injury remains an open question of therapeutic importance. Under specific conditions, acidosis may be neuroprotective, but this is an area of current controversy. Effective antiacidosis therapy must address the possibility of synergism and competition among multiple injury mechanisms.
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Affiliation(s)
- Patricia D. Hum
- From the Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Richard J. Traystman
- From the Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, MD
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13
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Halperin HR, Chandra NC, Levin HR, Rayburn BK, Tsitlik JE. Newer methods of improving blood flow during CPR. Ann Emerg Med 1996; 27:553-62. [PMID: 8629775 DOI: 10.1016/s0196-0644(96)70157-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- H R Halperin
- Peter Belfer Cardiac Mechanics Laboratory, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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14
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Schmitz B, Fischer M, Bockhorst K, Hoehn-Berlage M, Hossmann KA. Resuscitation from cardiac arrest in cats: influence of epinephrine dosage on brain recovery. Resuscitation 1995; 30:251-62. [PMID: 8867715 DOI: 10.1016/0300-9572(95)00891-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The quality of brain recovery after cardiac arrest depends crucially on the speed of cardiac resuscitation because the low cerebral perfusion pressure during the resuscitation procedure facilitates the development of no-reflow. To accelerate return of spontaneous circulation, high dose epinephrine has been recommended but the effect on the dynamics of early brain recovery is still unknown. We, therefore, studied the dynamics of brain resuscitation after cardiopulmonary resuscitation (CPR) with standard and high dose epinephrine using non-invasive NMR techniques. Fifteen min cardiac arrest was induced in normothermic cats by ventricular fibrillation. CPR was performed using an inflatable pneumatic vest for cyclic chest compression. With the beginning of CPR the standard dose group received 0.02 mg/kg epinephrine (n = 6) and the high dose group received 0.2 mg/kg (n = 8). Brain recovery was monitored by magnetic resonance imaging of the apparent diffusion coefficient (ADC) of water for 3 h. Although high dose epinephrine treatment led to a significantly higher blood pressure during early reperfusion, rapidly changing heterogeneities of early brain recovery were observed in both groups. High dose epinephrine thus does not improve the quality of post-cardiac arrest brain recovery during the first 3 h of reperfusion.
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Affiliation(s)
- B Schmitz
- Department of Experimental Neurology, Max-Planck-Institute for Neurological Research, Cologne, Germany
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15
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Strange K, Jackson PS. Swelling-activated organic osmolyte efflux: a new role for anion channels. Kidney Int 1995; 48:994-1003. [PMID: 8569109 DOI: 10.1038/ki.1995.381] [Citation(s) in RCA: 117] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- K Strange
- Department of Medicine, Nephrology, Children's Hospital, Boston, Massachusetts, USA
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16
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Eleff SM, Sugimoto H, Shaffner DH, Traystman RJ, Koehler RC. Acidemia and brain pH during prolonged cardiopulmonary resuscitation in dogs. Stroke 1995; 26:1028-34. [PMID: 7762019 DOI: 10.1161/01.str.26.6.1028] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND PURPOSE Cardiopulmonary resuscitation (CPR) generating low perfusion pressures and beginning immediately after cardiac arrest maintains cerebral ATP but not cerebral pH or arterial pH. We tested the hypothesis that preventing severe arterial acidemia prevents cerebral acidosis, whereas augmenting arterial acidemia augments cerebral acidosis. METHODS In dogs anesthetized with pentobarbital and fentanyl, cerebral pH and ATP were measured with 31P MR spectroscopy and blood flow was measured with radiolabeled microspheres. A pneumatically controlled vest was placed around the thorax, and chest compressions were begun immediately after electrically induced cardiac arrest. Cerebral perfusion pressure was maintained with epinephrine at 30 mm Hg for 90 minutes. The arterial acidemia observed during CPR was untreated in a control group, corrected to a pH of 7.3 with the use of sodium bicarbonate, or maintained below pH 6.5 with intravenous lactic acid after 14 minutes of CPR. RESULTS At 10 minutes of CPR, cerebral ATP (99 +/- 1.5%, control), blood flow (35 +/- 3 mL/min per 100 g), O2 consumption (4.0 +/- 0.2 mL/min per 100 g), and cerebral pH (7.05 +/- .03) were unchanged from prearrest values (mean +/- SEM). After 10 minutes of CPR in the control group, cerebral pH progressively fell (6.43 +/- 0.10 at 90 minutes) in parallel with cerebral venous pH. In the bicarbonate group cerebral pH was maintained higher (6.91 +/- 0.08). Cerebral blood flow, O2 consumption, and ATP were sustained near prearrest values in both groups. In the lactate group, however, the rate of decrease of cerebral pH was augmented (6.47 +/- 0.06 by 30 minutes), and cerebral blood flow and metabolism were significantly reduced. CONCLUSIONS Cerebral pH decreased in parallel with blood pH when resuscitation was started immediately upon arrest even when cerebral O2 consumption and blood flow were near normal. Although cerebral metabolism was near normal during the first hour of CPR, systemic bicarbonate administration ameliorated the cerebral acidosis. This finding indicates that the blood-brain pH gradient is important at the subnormal cerebral perfusion pressures seen in CPR.
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Affiliation(s)
- S M Eleff
- Department of Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, Md, USA
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Zwemer CF, Whitesall SE, D'Alecy LG. Cardiopulmonary-cerebral resuscitation with 100% oxygen exacerbates neurological dysfunction following nine minutes of normothermic cardiac arrest in dogs. Resuscitation 1994; 27:159-70. [PMID: 8086011 DOI: 10.1016/0300-9572(94)90009-4] [Citation(s) in RCA: 145] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
This study investigated the effects of normoxic (FIO2 = 0.21), hyperoxic (FIO2 = 1.0), and hyperoxic (FIO2 = 1.0) plus antioxidant pretreatment (tirilazad mesylate) [corrected] resuscitation on neurologic outcome following 9 min of normothermic (39 +/- 1.0 degrees C) cardiac arrest. Physiologic variables including arterial blood gases and neurologic outcome, which was assessed using a standardized scoring system, were followed over a 24-h period following resuscitation from cardiac arrest. Hyperoxically resuscitated dogs sustained significantly worse neurological deficit at 12 and 24 h (mean scores: 39 +/- 3 and 49 +/- 8, respectively) than did antioxidant pretreated hyperoxically resuscitated dogs (mean scores: 22 +/- 1, P = 0.0007 and 22 +/- 1, P = 0.004, respectively) and normoxically resuscitated dogs (mean scores: 28 +/- 4, P = 0.025 and 33 +/- 8, P = 0.041 respectively). These data suggest that oxidant injury has a major role in central nervous system dysfunction following successful resuscitation from 9 min of cardiac arrest. Also, resuscitation from cardiac arrest with hyperoxic FIO2's may contribute to and further exacerbate neurologic dysfunction.
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Affiliation(s)
- C F Zwemer
- Department of Physiology and Surgery, University of Michigan Medical School, Ann Arbor 48109-0622
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Eleff SM, Kim H, Shaffner DH, Traystman RJ, Koehler RC. Effect of cerebral blood flow generated during cardiopulmonary resuscitation in dogs on maintenance versus recovery of ATP and pH. Stroke 1993; 24:2066-73. [PMID: 8248989 DOI: 10.1161/01.str.24.12.2066] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND PURPOSE Cardiopulmonary resuscitation with external chest compression generates low perfusion pressures that may be inadequate for restoring cerebral metabolism and may worsen intracellular pH. We tested the hypothesis that cerebral reperfusion with a low perfusion pressure after arrest restores brain adenosine triphosphate (ATP) and pH to levels attained at the same perfusion pressure without preceding complete ischemia. METHODS Brain ATP and intracellular pH were measured by magnetic resonance spectroscopy, and cerebral blood flow was measured with microspheres in anesthetized dogs. External chest compressions were begun in group A (n = 6) immediately after the onset of arrest (ie, arrest time zero) and in group B (n = 10) after 6 minutes of arrest (ie, arrest time 6 minutes). In both groups, mean cerebral perfusion pressure was regulated at 30 mm Hg for 70 minutes by adjustment of inflation pressure of a pneumatic thoracic vest. RESULTS At 12 minutes of resuscitation, cerebral blood flow was 27 +/- 4 mL/min per 100 g in group A and 21 +/- 4 mL/min per 100 g in group B, but ATP in group B (58 +/- 10% of prearrest) was less than in group A (105 +/- 6%). With prolonged resuscitation, ATP deteriorated to near zero levels in dogs in group B, with blood flow less than 15 mL/min per 100 g. Dogs with greater blood flow never achieved complete metabolic recovery. In group B, intracellular pH was unchanged from the 6.3 value at the start of resuscitation, even in those dogs with extremely low blood flows. CONCLUSIONS Levels of cerebral perfusion pressure sufficient to maintain cerebral oxidative metabolism without complete ischemia during cardiopulmonary resuscitation are not sufficient to restore metabolism after complete ischemia during cardiopulmonary resuscitation. However, low "trickle" blood flow did not worsen intracellular acidosis.
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Affiliation(s)
- S M Eleff
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Md
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