Hypothermia for brain protection and resuscitation

An intractable hematoma after cranioplasty cured by scalp cryohemostasis treatment

We report an intractable post cranioplasty hematoma which required multiple operations. The titanium cranioplasty was for a cranial defect from surgery for an intracranial hemorrhage. Despite removal of the cranioplasty the haematoma repeatedly recurred. So we applied the cryohemostasis by the ice packs 4 times a day for 30 minutes. With this simple cooling method haemostasis was achieved.

Hypothermia exerts early neuroprotective effects involving protein conjugation of SUMO‑2/3 in a rat model of middle cerebral artery occlusion

How hypothermia serves an early protective role against cerebral ischemia remains to be determined. The small ubiquitin-related modifier protein (SUMO) functions as a post-translational modification system and SUMO-2/3 subtypes are often activated in early stress. The present study investigated changes in the protein level of SUMO using western blotting and immunocytochemistry when neurons were exposed to oxygen-glucose deprivation (OGD) in vitro, as well as in a rat model of middle cerebral artery occlusion (MCAO) in vivo. The results demonstrated that a large number of proteins were conjugated to SUMO-2/3 in OGD-injured neurons (within 10 min, peaking at 12 h), and was markedly enhanced under conditions of hypothermia (33°C). Concordantly, lactate dehydrogenase (LDH) release and the apoptosis rate, as determined by LDH and TUNEL assays, respectively, were lower in hypothermia-treated neurons. Similar results were obtained in a rat model of MCAO. Neurological deficit scores were lower in the hypothermia group than in the sham group in the early stage of cerebral ischemia (P<0.05). However, no significant differences in neurological deficit scores were detected between the hypothermia group and the sham group in the late stage of ischemia (21 days; P>0.05). This study implicates a role for SUMO-2/3 in early hypothermia-induced neuroprotection against stroke. The development of small molecule therapeutics based on SUMO-2/3 may benefit patients with cerebral ischemia.

Hypoxic ischaemic hypothermia promotes neuronal differentiation and inhibits glial differentiation from newly generated cells in the SGZ of the neonatal rat brain

Hypothermia is a potential therapy for cerebral hypoxic ischaemic injury in adults and neonates. The mechanism of the neuroprotective effects of hypothermia after hypoxia-ischaemia (HI) in the developing rat brain remains unclear. In this research, 7-day-old rats underwent left carotid artery ligation followed by the administration of 8% oxygen for 2 h. These rats were divided into hypothermic (rectal temperature, 32-33 °C for 24 h) and normothermic (36-37 °C for 24 h) groups immediately after HI. All rats were given 50 mg/kg/day 5-bromodeoxyuridine (BrdU) intraperitoneally at 4-6 days and sacrificed at 1 or 2 weeks after HI. We found a significant decrease in infarct volume and the neuron loss were also detected in the subgranular zone (SGZ) in the hypothermic group at 7 and 14 days after HI compared with the normothermic group. BrdU immunopositive cells were reduced greatly in the hypothermic group compared with the normothermic group. Hypothermia did not change the number of nestin-labelled cells in the ipsilateral SGZ at 1 and 2 weeks after HI. The differentiation of newly generated cells was assessed by double immunolabelling of BrdU with glial fibrillary acidic protein (GFAP), O4 or Neuronal Nuclei (NeuN). The ratio of BrdU(+)-GFAP(+) or BrdU(+)-O4(+) to total BrdU(+) staining decreased dramatically, but the ratio of BrdU(+)-NeuN(+) to total BrdU(+) staining increased significantly in the hypothermic group compared to the normothermic group at 2 and 6 weeks after HI. These results suggest that the reduction in neuron loss observed after mild hypothermia may be associated with enhanced neuronal differentiation and decreased glial differentiation in the SGZ after HI. These observations are noteworthy for clinical hypothermia therapy following cerebral HI injury during the perinatal period.

Murine models in critical care research

INTRODUCTION

Access to genetically engineered mice has opened many new opportunities to address questions relevant to the pathophysiology and treatment of patients in critical conditions. However, the results of studies in mice cannot disregard the unique ability of small rodents to adjust their temperature and high metabolic rate and the corresponding respiratory and circulatory requirements in response to hypoxia.

POINT OF VIEW

Studies performed in mice on questions related to metabolic, circulatory, and respiratory regulation should always be considered in light of the ability of mice to rapidly drop their nonshivering thermogenesis-related metabolism. As an example, it has been recently argued that a moderate level of inhaled hydrogen sulfide may have a potential benefit in patients in coma or shock or during an anoxic or ischemic insult, as this toxic gas dramatically reduces the metabolic rate in resting mice. However, acute hypometabolism has long been described in small mammals in response to hypoxia and is not specific to hydrogen sulfide. More importantly, mice have a specific metabolic rate that is 15-20 times higher than the specific metabolic level of a resting human. This difference can be accounted for by the large amount of heat produced by mice through nonshivering thermogenesis, related to the activity of uncoupling proteins. This mechanism, which is essential for maintaining homeothermia in small mammals, is virtually absent in larger animals, including in adult humans. Accordingly, no direct metabolic effect of hydrogen sulfide is observed in large mammals. We present the view that similar reasoning should be applied when the circulatory or respiratory response to hypoxic exposure is considered. This leads us to question whether a similar strategy could occur in mice in critical conditions other than hypoxia, such as in hypovolemic, septic, or cardiogenic shock.

CONCLUSION

Mouse models developed to understand the mechanisms of protection against hypoxia or ischemia or to propose new therapeutic approaches applicable in critical care patients should be understood in light of the specificity of the metabolic, respiratory, and circulatory responses of mice to a hypoxic insult, since many of these adaptations have no clear equivalent in humans.

Metabolomics of oxidative stress in recent studies of endogenous and exogenously administered intermediate metabolites

Aerobic metabolism occurs in a background of oxygen radicals and reactive oxygen species (ROS) that originate from the incomplete reduction of molecular oxygen in electron transfer reactions. The essential role of aerobic metabolism, the generation and consumption of ATP and other high energy phosphates, sustains a balance of approximately 3000 essential human metabolites that serve not only as nutrients, but also as antioxidants, neurotransmitters, osmolytes, and participants in ligand-based and other cellular signaling. In hypoxia, ischemia, and oxidative stress, where pathological circumstances cause oxygen radicals to form at a rate greater than is possible for their consumption, changes in the composition of metabolite ensembles, or metabolomes, can be associated with physiological changes. Metabolomics and metabonomics are a scientific disciplines that focuse on quantifying dynamic metabolome responses, using multivariate analytical approaches derived from methods within genomics, a discipline that consolidated innovative analysis techniques for situations where the number of biomarkers (metabolites in our case) greatly exceeds the number of subjects. This review focuses on the behavior of cytosolic, mitochondrial, and redox metabolites in ameliorating or exacerbating oxidative stress. After reviewing work regarding a small number of metabolites—pyruvate, ethyl pyruvate, and fructose-1,6-bisphosphate—whose exogenous administration was found to ameliorate oxidative stress, a subsequent section reviews basic multivariate statistical methods common in metabolomics research, and their application in human and preclinical studies emphasizing oxidative stress. Particular attention is paid to new NMR spectroscopy methods in metabolomics and metabonomics. Because complex relationships connect oxidative stress to so many physiological processes, studies from different disciplines were reviewed. All, however, shared the common goal of ultimately developing “omics”-based, diagnostic tests to help influence therapies.

Anesthesia and analgesia protocol during therapeutic hypothermia after cardiac arrest: a systematic review

BACKGROUND

Present practice guidelines recommend sedative-analgesic and neuromuscular blocking administration during therapeutic hypothermia in comatose patients after cardiac arrest. However, none suggests the best administration protocol. In this study, we evaluated intensivists' preferences regarding administration.

METHODS

A systematic literature review was conducted to identify clinical studies published between 1997 and July 2009. Selected articles had to meet the following criteria: use of hypothermia to improve neurologic outcome after cardiac arrest, and specific mention of the sedative protocol used. We checked drugs and dose used, the reason for their administration, and the specific type of neurologic and neuromuscular monitoring used.

RESULTS

We identified 44 studies reporting protocols used in 68 intensive care units (ICUs) from various countries. Midazolam, the sedative used most often, was used in 39 ICUs at doses between 5 mg/h and 0.3 mg/kg/h. Propofol was used in 13 ICUs at doses up to 6 mg/kg/h. Eighteen ICUs (26%) did not report using any analgesic. Fentanyl was the analgesic used the most, in 33 ICUs, at doses between 0.5 and 10 microg/kg/h, followed by morphine in 4 ICUs. Neuromuscular blocking drugs were routinely used to prevent shivering in 54 ICUs and to treat shivering in 8; in 1 ICU, their use was discouraged. Pancuronium was used the most, in 24 ICUs, followed by cisatracurium in 14. Four ICUs used neuromuscular blocking drug administration guided by train-of-four monitoring and 3 ICUs used continuous monitoring of cerebral activity.

CONCLUSIONS

There is great variability in the protocols used for anesthesia and analgesia during therapeutic hypothermia. Very often, the drug and the dose used do not seem the most appropriate. Only 3 ICUs routinely used electroencephalographic monitoring during paralysis. It is necessary to reach a consensus on how to treat this critical care population.

Induced hypothermia for trauma: current research and practice

Induction of hypothermia with the goal of providing therapeutic benefit has been accepted for use in the clinical setting of adult cardiac arrest and neonatal hypoxic-ischemic encephalopathy (HIE). However, its potential as a treatment in trauma is not as well defined. This review discusses potential benefits and complications of induced hypothermia (IH) with emphasis on the current state of knowledge and practice in various types of trauma. There is excellent preclinical research showing that in cases of penetrating trauma with cardiac arrest, inducing hypothermia to 10 degrees C using cardiopulmonary bypass (CPB) could possibly save those otherwise likely to die without causing neurologic sequelae. A human trial of this intervention is about to get underway. Preclinical studies suggest that inducing hypothermia may be useful to delay cardiac arrest in penetrating trauma victims who are hypotensive. There is potential for IH to be used in cases of blunt trauma, but it has not been well studied. In the case of traumatic brain injury (TBI), clinical trials have shown conflicting results, despite almost uniform efficacy seen in preclinical experiments. Major studies are analyzed and ways to standardize its use and optimize future clinical trials are discussed. More preclinical and clinical research is needed to better define whether there could be a role for IH in the case of spinal cord injuries.

Rapidly induced selective cerebral hypothermia using a cold carotid arterial flush during cardiac arrest in a dog model

PURPOSE

The present study was undertaken to determine whether flushing the carotid artery with normal saline at 4 degrees C (hypothermic carotid arterial flush, HCAF) during cardiac arrest can achieve selective cerebral hypothermia rapidly during cardiac arrest and improve cerebral outcome.

METHODS

Ventricular fibrillation (VF) was induced in fourteen dogs and circulatory arrest was maintained for 9 min. Dogs were then resuscitated by cardiopulmonary resuscitation. The dogs were divided into two groups; a control group (n=7), which underwent precisely the same procedure as the experimental group but not HCAF, and an experimental group (HCAF group; n=7), which received HCAF from 8 min after the onset of VF.

RESULTS

Two dogs in the control group and in the HCAF group died within 72 h after the recovery of spontaneous circulation (ROSC) due to extracerebral complications. The remaining 10 dogs survived to final evaluation at 72 h post-ROSC. In the HCAF group, tympanic temperature decreased from 37.7 degrees C (37.5-37.8) to 34 degrees C in 1 min (1-1.5) from the start of HCAF and was maintained below 34 degrees C until 6.5 min (3-12) after the start of HCAF, whereas oesophageal and rectal temperatures were maintained above 35 degrees C. Neurological deficit scores (0-100%) at 72 h post-ROSC were 42.4% (27.0-80.6) in the control group and 18.4% (14.0-36.0) in the HCAF group (p<0.05).

CONCLUSION

HCAF induced selective cerebral hypothermia rapidly during cardiac arrest and improved neurological deficit scores after 9 min of no blood flow in the described canine cardiac arrest model.

Cerebrovascular reactivity during hypothermia and rewarming

BACKGROUND

Experimental evidence from a murine model of traumatic brain injury (TBI) suggests that hypothermia followed by fast rewarming may damage cerebral microcirculation. The effects of hypothermia and subsequent rewarming on cerebral vasoreactivity in human TBI are unknown.

METHODS

This is a retrospective analysis of data acquired during a prospective, observational neuromonitoring and imaging data collection project. Brain temperature, intracranial pressure (ICP), and cerebrovascular pressure reactivity index (PRx) were continuously monitored.

RESULTS

Twenty-four TBI patients with refractory intracranial hypertension were cooled from 36.0 (0.9) to 34.2 (0.5) degrees C [mean (sd), P < 0.0001] in 3.9 (3.7) h. Induction of hypothermia [average duration 40 (45) h] significantly reduced ICP from 23.1 (3.6) to 18.3 (4.8) mm Hg (P < 0.05). Hypothermia did not impair cerebral vasoreactivity as average PRx changed non-significantly from 0.00 (0.21) to -0.01 (0.21). Slow rewarming up to 37.0 degrees C [rate of rewarming, 0.2 (0.2) degrees C h(-1)] did not increase ICP [18.6 (6.2) mm Hg] or PRx [0.06 (0.18)]. However, in 17 (70.1%) out of 24 patients, rewarming exceeded the brain temperature threshold of 37 degrees C. In these patients, the average brain temperature was allowed to increase to 37.8 (0.3) degrees C (P < 0.0001), ICP remained stable at 18.3 (8.0) mm Hg (P = 0.74), but average PRx increased to 0.32 (0.24) (P < 0.0001), indicating significant derangement in cerebrovascular reactivity. After rewarming, PRx correlated independently with brain temperature (R = 0.53; P < 0.05) and brain tissue O2 (R = 0.66; P < 0.01).

CONCLUSIONS

After moderate hypothermia, rewarming exceeding the 37 degrees C threshold is associated with a significant increase in average PRx, indicating temperature-dependent hyperaemic derangement of cerebrovascular reactivity.