1
|
Chalifoux N, Ko T, Slovis J, Spelde A, Kilbaugh T, Mavroudis CD. Cerebral Autoregulation: A Target for Improving Neurological Outcomes in Extracorporeal Life Support. Neurocrit Care 2024:10.1007/s12028-024-02002-5. [PMID: 38811513 DOI: 10.1007/s12028-024-02002-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 04/18/2024] [Indexed: 05/31/2024]
Abstract
Despite improvements in survival after illnesses requiring extracorporeal life support, cerebral injury continues to hinder successful outcomes. Cerebral autoregulation (CA) is an innate protective mechanism that maintains constant cerebral blood flow in the face of varying systemic blood pressure. However, it is impaired in certain disease states and, potentially, following initiation of extracorporeal circulatory support. In this review, we first discuss patient-related factors pertaining to venovenous and venoarterial extracorporeal membrane oxygenation (ECMO) and their potential role in CA impairment. Next, we examine factors intrinsic to ECMO that may affect CA, such as cannulation, changes in pulsatility, the inflammatory and adaptive immune response, intracranial hemorrhage, and ischemic stroke, in addition to ECMO management factors, such as oxygenation, ventilation, flow rates, and blood pressure management. We highlight potential mechanisms that lead to disruption of CA in both pediatric and adult populations, the challenges of measuring CA in these patients, and potential associations with neurological outcome. Altogether, we discuss individualized CA monitoring as a potential target for improving neurological outcomes in extracorporeal life support.
Collapse
Affiliation(s)
- Nolan Chalifoux
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
- Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Tiffany Ko
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Julia Slovis
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Audrey Spelde
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Todd Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Constantine D Mavroudis
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| |
Collapse
|
2
|
Thiara S, Sekhon MS. Blood pressure augmentation after cardiac arrest: Time to move beyond manipulating vital signs. Resuscitation 2023; 190:109913. [PMID: 37516157 DOI: 10.1016/j.resuscitation.2023.109913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/12/2023] [Indexed: 07/31/2023]
Affiliation(s)
- Sharanjit Thiara
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada; Collaborative Entity for REsearching Brain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada; Collaborative Entity for REsearching Brain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada; International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada; Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada.
| |
Collapse
|
3
|
Schoenthal T, Hoiland R, Griesdale DE, Sekhon MS. Cerebral hemodynamics after cardiac arrest: implications for clinical management. Minerva Anestesiol 2023; 89:824-833. [PMID: 37676177 DOI: 10.23736/s0375-9393.23.17268-3] [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] [Indexed: 09/08/2023]
Abstract
Following resuscitation from cardiac arrest, hypoxic ischemic brain injury (HIBI) ensues, which is the primary determinant of adverse outcome. The pathophysiology of HIBI can be compartmentalized into primary and secondary injury, resulting from cerebral ischemia during cardiac arrest and reperfusion following successful resuscitation, respectively. During the secondary injury phase, increased attention has been directed towards the optimization of cerebral oxygen delivery to prevent additive injury to the brain. During this phase, cerebral hemodynamics are characterized by early hyperemia following resuscitation and then a protracted phase of cerebral hypoperfusion termed "no-reflow" during which additional hypoxic-ischemic injury can occur. As such, identification of therapeutic strategies to optimize cerebral delivery of oxygen is at the forefront of HIBI research. Unfortunately, randomized control trials investigating the manipulation of arterial carbon dioxide tension and mean arterial pressure augmentation as methods to potentially improve cerebral oxygen delivery have shown no impact on clinical outcomes. Emerging literature suggests differential patient-specific phenotypes may exist in patients with HIBI. The potential to personalize therapeutic strategies in the critical care setting based upon patient-specific pathophysiology presents an attractive strategy to improve HIBI outcomes. Herein, we review the cerebral hemodynamic pathophysiology of HIBI, discuss patient phenotypes as it pertains to personalizing care, as well as suggest future directions.
Collapse
Affiliation(s)
- Tison Schoenthal
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Ryan Hoiland
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Department of Cellular and Physiological Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Center for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, Faculty of Health and Social Development, University of British Columbia Okanagan, Kelowna, BC, Canada
- International Collaboration on Repair Discoveries, Vancouver, BC, Canada
| | - Donald E Griesdale
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Center for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada -
- International Collaboration on Repair Discoveries, Vancouver, BC, Canada
- Djavad Mowafaghian Center for Brain Health, University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
4
|
Hoiland RL, Robba C, Menon DK, Citerio G, Sandroni C, Sekhon MS. Clinical targeting of the cerebral oxygen cascade to improve brain oxygenation in patients with hypoxic-ischaemic brain injury after cardiac arrest. Intensive Care Med 2023; 49:1062-1078. [PMID: 37507572 PMCID: PMC10499700 DOI: 10.1007/s00134-023-07165-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 07/07/2023] [Indexed: 07/30/2023]
Abstract
The cerebral oxygen cascade includes three key stages: (a) convective oxygen delivery representing the bulk flow of oxygen to the cerebral vascular bed; (b) diffusion of oxygen from the blood into brain tissue; and (c) cellular utilisation of oxygen for aerobic metabolism. All three stages may become dysfunctional after resuscitation from cardiac arrest and contribute to hypoxic-ischaemic brain injury (HIBI). Improving convective cerebral oxygen delivery by optimising cerebral blood flow has been widely investigated as a strategy to mitigate HIBI. However, clinical trials aimed at optimising convective oxygen delivery have yielded neutral results. Advances in the understanding of HIBI pathophysiology suggest that impairments in the stages of the oxygen cascade pertaining to oxygen diffusion and cellular utilisation of oxygen should also be considered in identifying therapeutic strategies for the clinical management of HIBI patients. Culprit mechanisms for these impairments may include a widening of the diffusion barrier due to peri-vascular oedema and mitochondrial dysfunction. An integrated approach encompassing both intra-parenchymal and non-invasive neuromonitoring techniques may aid in detecting pathophysiologic changes in the oxygen cascade and enable patient-specific management aimed at reducing the severity of HIBI.
Collapse
Affiliation(s)
- Ryan L Hoiland
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada.
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, Faculty of Health and Social Development, University of British Columbia Okanagan, Kelowna, BC, Canada.
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada.
- Collaborative Entity for REsearching Brain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada.
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - David K Menon
- Department of Medicine, University Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli", IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching Brain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
5
|
Miller EC, Katsidoniotaki MI, Haghighi N, Dos Santos KRM, Booker WA, Petersen N, Wapner R, Bello NA, Kougioumtzoglou IA, Marshall RS. Dynamic cerebral autoregulation in postpartum individuals with and without preeclampsia. Pregnancy Hypertens 2023; 33:39-45. [PMID: 37524001 PMCID: PMC10528950 DOI: 10.1016/j.preghy.2023.07.176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 06/30/2023] [Accepted: 07/25/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Changes in dynamic cerebral autoregulation (DCA) may contribute to postpartum maternal cerebrovascular complications after preeclampsia. We hypothesized that DCA is impaired in the first week postpartum after diagnosis of preeclampsia with severe features (PSF), compared with normotensive postpartum individuals and healthy non-pregnant female volunteers. METHODS We measured DCA within seven days after delivery in individuals with and without PSF, using transcranial Doppler and continuous arterial blood pressure monitoring with finger plethysmography. Historical data from 28 healthy female non-pregnant volunteers, collected using the same methods, were used for comparison. We used generalized harmonic wavelets to estimate autoregulation parameters (phase shift and gain) in very low frequency and low frequency bands, with lower phase shift and higher gain indicating impaired DCA function. We compared DCA parameters between the three groups using the Kruskal Wallis test. RESULTS A total of 69 postpartum participants contributed data, of whom 49 had preeclampsia with severe features. Median phase shifts in both postpartum groups were higher compared with historical controls across all frequency ranges (p = 0.001), indicating faster autoregulatory response. Gain was higher in both postpartum groups than in historical controls across all frequency ranges (p = 0.04), indicating impaired dampening effect. CONCLUSION We found that postpartum individuals, regardless of preeclampsia diagnosis, had higher phase shifts and higher gain than healthy non-pregnant/postpartum female volunteers. Our results suggest hyperdynamic DCA with impaired dampening effect in the first week postpartum, regardless of preeclampsia diagnosis.
Collapse
Affiliation(s)
- Eliza C Miller
- Department of Neurology, Columbia University, New York, NY, United States.
| | - Maria I Katsidoniotaki
- Department of Civil Engineering and Engineering Mechanics, Columbia University, New York, NY, United States
| | - Noora Haghighi
- Department of Neurology, Columbia University, New York, NY, United States
| | - Ketson R M Dos Santos
- Earthquake Engineering and Structural Dynamics Laboratory, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Whitney A Booker
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, United States
| | - Nils Petersen
- Department of Neurology, Division of Stroke and Neurocritical Care, Yale University School of Medicine, New Haven, CT, United States
| | - Ronald Wapner
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, United States
| | - Natalie A Bello
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Ioannis A Kougioumtzoglou
- Department of Civil Engineering and Engineering Mechanics, Columbia University, New York, NY, United States
| | | |
Collapse
|
6
|
Annoni F, Su F, Peluso L, Lisi I, Caruso E, Pischiutta F, Gouvea Bogossian E, Garcia B, Njimi H, Vincent JL, Gaspard N, Ferlini L, Creteur J, Zanier ER, Taccone FS. Hypertonic sodium lactate infusion reduces vasopressor requirements and biomarkers of brain and cardiac injury after experimental cardiac arrest. Crit Care 2023; 27:161. [PMID: 37087454 PMCID: PMC10122448 DOI: 10.1186/s13054-023-04454-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 04/19/2023] [Indexed: 04/24/2023] Open
Abstract
INTRODUCTION Prognosis after resuscitation from cardiac arrest (CA) remains poor, with high morbidity and mortality as a result of extensive cardiac and brain injury and lack of effective treatments. Hypertonic sodium lactate (HSL) may be beneficial after CA by buffering severe metabolic acidosis, increasing brain perfusion and cardiac performance, reducing cerebral swelling, and serving as an alternative energetic cellular substrate. The aim of this study was to test the effects of HSL infusion on brain and cardiac injury in an experimental model of CA. METHODS After a 10-min electrically induced CA followed by 5 min of cardiopulmonary resuscitation maneuvers, adult swine (n = 35) were randomly assigned to receive either balanced crystalloid (controls, n = 11) or HSL infusion started during cardiopulmonary resuscitation (CPR, Intra-arrest, n = 12) or after return of spontaneous circulation (Post-ROSC, n = 11) for the subsequent 12 h. In all animals, extensive multimodal neurological and cardiovascular monitoring was implemented. All animals were treated with targeted temperature management at 34 °C. RESULTS Thirty-four of the 35 (97.1%) animals achieved ROSC; one animal in the Intra-arrest group died before completing the observation period. Arterial pH, lactate and sodium concentrations, and plasma osmolarity were higher in HSL-treated animals than in controls (p < 0.001), whereas potassium concentrations were lower (p = 0.004). Intra-arrest and Post-ROSC HSL infusion improved hemodynamic status compared to controls, as shown by reduced vasopressor requirements to maintain a mean arterial pressure target > 65 mmHg (p = 0.005 for interaction; p = 0.01 for groups). Moreover, plasma troponin I and glial fibrillary acid protein (GFAP) concentrations were lower in HSL-treated groups at several time-points than in controls. CONCLUSIONS In this experimental CA model, HSL infusion was associated with reduced vasopressor requirements and decreased plasma concentrations of measured biomarkers of cardiac and cerebral injury.
Collapse
Affiliation(s)
- Filippo Annoni
- Department of Intensive Care, Erasme Hospital, Lennik Road 808, 1070, Brussels, Belgium.
- Experimental Laboratory of Intensive Care, Free University of Brussels, Brussels, Belgium.
| | - Fuhong Su
- Department of Intensive Care, Erasme Hospital, Lennik Road 808, 1070, Brussels, Belgium
- Experimental Laboratory of Intensive Care, Free University of Brussels, Brussels, Belgium
| | - Lorenzo Peluso
- Department of Intensive Care, Erasme Hospital, Lennik Road 808, 1070, Brussels, Belgium
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Anesthesiology and Intensive Care, Humanitas Gavazzeni, Via M Gavazzeni 21, 24125, Bergamo, Italy
| | - Ilaria Lisi
- Laboratory of Traumatic Brain Injury and Neuroprotection, Department of Acute Brain Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156, Milan, Italy
| | - Enrico Caruso
- Laboratory of Traumatic Brain Injury and Neuroprotection, Department of Acute Brain Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156, Milan, Italy
| | - Francesca Pischiutta
- Laboratory of Traumatic Brain Injury and Neuroprotection, Department of Acute Brain Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156, Milan, Italy
| | | | - Bruno Garcia
- Department of Intensive Care, Erasme Hospital, Lennik Road 808, 1070, Brussels, Belgium
- Experimental Laboratory of Intensive Care, Free University of Brussels, Brussels, Belgium
| | - Hassane Njimi
- Department of Intensive Care, Erasme Hospital, Lennik Road 808, 1070, Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Lennik Road 808, 1070, Brussels, Belgium
| | - Nicolas Gaspard
- Department of Neurology, Erasme Hospital, Lennik Road 808, 1070, Brussels, Belgium
- Neurology Department, School of Medicine, Yale University, New Haven, CT, USA
| | - Lorenzo Ferlini
- Department of Neurology, Erasme Hospital, Lennik Road 808, 1070, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Lennik Road 808, 1070, Brussels, Belgium
| | - Elisa R Zanier
- Laboratory of Traumatic Brain Injury and Neuroprotection, Department of Acute Brain Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156, Milan, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Lennik Road 808, 1070, Brussels, Belgium
- Experimental Laboratory of Intensive Care, Free University of Brussels, Brussels, Belgium
| |
Collapse
|
7
|
Shi X, Zhang L, Zeng X, Li Y, Hu W, Xi S. NEUROLOGIC IMPAIRMENT IN PATIENTS WITH EXTRACORPOREAL CARDIOPULMONARY RESUSCITATION SUPPORT: CLINICAL FEATURES AND LONG-TERM OUTCOMES. Shock 2023; 59:41-48. [PMID: 36703277 DOI: 10.1097/shk.0000000000002041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
ABSTRACT Introduction: The present study aimed to explore the clinical features and long-term outcomes associated with neurologic impairment in patients with cardiac arrest (CA) who received extracorporeal cardiopulmonary resuscitation (ECPR). Methods: A total of 37 adult CA patients who underwent venoarterial extracorporeal membrane oxygenation and were admitted to our department between January 2015 and February 2022 were divided according to neurologic impairment. Baseline and CPR- and ECMO-related characteristics were compared between the two groups. Long-term neurologic outcomes were collected via telephone follow-ups. Results: Twenty-four (64.9%) ECPR-supported patients developed neurologic impairments. The two groups differed significantly in median age (P = 0.026), proportion of intra-aortic balloon pump (IABP) support (P = 0.011), proportion of continuous renal replacement therapy (P = 0.025), and median serum creatinine (Cr) level (P = 0.012) pre-ECMO. The 28-day mortality (P = 0.001), hospital mortality (P = 0.003), median duration from CA to restoration of spontaneous circulation (P = 0.029), proportion of patients with nonpulsatile perfusion (NP) >12 hours (P = 0.040), and median ECMO duration (P = 0.047) were higher in the neurologic impairment group. In contrast, the group without neurologic impairment exhibited a longer median intensive care unit length of stay (P = 0.047), longer median hospital LOS (P = 0.031), and more successful ECMO weaning (P = 0.049). Moreover, NP >12 hours combined with IABP support (odds ratio [OR], 14.769; 95% confidence interval [CI], 1.417~153.889; P = 0.024) and serum Cr level (OR, 1.028; 95% CI, 1.001~1.056; P = 0.043) were independent risk factors for neurologic impairment. Furthermore, neurologic impairment was associated with significantly worse 90-day survival (hazards ratio, 4.218; 95% CI, 1.745~10.2; P = 0.0014). Conclusions: The incidence of neurologic impairment was higher in patients who received ECPR and was closely related to 28-day mortality and discharge survival. NP >12 hours combined with IABP support and serum Cr levels were independent risk factors for neurologic impairments in ECPR-supported patients. Neurologic impairment significantly adversely affected the long-term outcomes of ECPR-supported patients after discharge.
Collapse
Affiliation(s)
- Xiaobei Shi
- Department of Radiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Lili Zhang
- Intensive Care Unit, Beijing First Hospital of Integrated Chinese and Western Medicine, Beijing, China
| | - Xiaokang Zeng
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yiwei Li
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Wei Hu
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Shaosong Xi
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| |
Collapse
|
8
|
Hwang M, Sridharan A, Freeman CW, Viaene AN, Kilbaugh TJ. Contrast-Enhanced Ultrasound of Brain Perfusion in Cardiopulmonary Resuscitation. Ultrasound Q 2022; 38:257-261. [PMID: 35221316 PMCID: PMC9402813 DOI: 10.1097/ruq.0000000000000596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT To evaluate the feasibility and potential utility of contrast-enhanced ultrasound for real-time imaging of whole-brain perfusion during cardiopulmonary resuscitation (CPR), cardiac arrest was induced in 8- to 7-week-old 10-kg piglets ( Sus scrofa domesticus ). Contrast-enhanced ultrasound was performed through a parietal cranial window in the coronal plane visualizing the thalami during hemodynamic-directed CPR. Whole-brain mean and maximum pixel intensities in each slice during resuscitation were calculated. Piglets were monitored for 24 hours postarrest. Seven piglets achieved return of spontaneous circulation and 6 survived to 24 hours. Of the 6 surviving piglets, 2 piglets demonstrated greater intra-CPR brain enhancement at maximum 73.2% and 42.1% and mean 36.7% and 31.9% enhancement above background, respectively, compared with maximum 5.8%, 22.9%, 6.0%, and 26.6% and mean 5.1%, 8.9%, 2.9%, and 6.6% above background, respectively, in the other 4. Intra-CPR average mean arterial pressures were similar between all 6 surviving piglets. One piglet achieved return of spontaneous circulation but expired 10 minutes later with enhancement maximum 45.2% and mean 18.9% enhancement above background. The final piglet did not achieve return of spontaneous circulation and exhibited minimal enhancement at maximum 2.8% and mean 0.9% enhancement above background. Contrast-enhanced ultrasound can detect brain perfusion during CPR, identifying a spectrum of cerebral blood flow responses in the brain despite similar systemic hemodynamics. This novel application can form the basis for future large animal model studies and eventually human clinical studies to further explore the neurologic implications of cerebral blood flow responses during resuscitation and stimulate novel strategies for optimizing brain perfusion restoration.
Collapse
Affiliation(s)
- Misun Hwang
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Anush Sridharan
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Colbey W. Freeman
- Department of Radiology, University of Pennsylvania Health System, Philadelphia, PA
| | - Angela N. Viaene
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Health System, Philadelphia, PA
- Department of Pathology and Laboratory Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Todd J. Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
| |
Collapse
|
9
|
Kirschen MP, Majmudar T, Diaz-Arrastia R, Berg R, Abella BS, Topjian A, Balu R. Deviations from PRx-derived optimal blood pressure are associated with mortality after cardiac arrest. Resuscitation 2022; 175:81-87. [PMID: 35276311 PMCID: PMC9135307 DOI: 10.1016/j.resuscitation.2022.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/28/2022] [Accepted: 03/02/2022] [Indexed: 01/18/2023]
Abstract
AIM Pressure reactivity index (PRx) provides a surrogate measurement of cerebrovascular autoregulation (CAR). We determined whether deviations from PRx-derived optimal mean arterial pressure (MAPopt) were associated with in-hospital mortality after adult cardiac arrest. METHODS Retrospective analysis of post-cardiac arrest patients who had continuously recorded intracranial pressure (ICP) and MAP. PRx was calculated as a moving, linear correlation between ICP and MAP. Impaired CAR was defined as PRx ≥ 0.3. MAPopt was calculated using a multi-window weighted algorithm. The burdens of MAP < 5 mmHg below MAPopt (MAPopt-5) and > 5 mmHg above MAPopt (MAPopt + 5) were calculated by integrating the area between MAP and MAPopt-5 or MAPopt + 5 curves, respectively. Univariate logistic regression tested the association between burden of MAP < MAPopt-5 and outcome. RESULTS Twenty-two patients were analyzed. Thirteen (59%) patients died before hospital discharge. Time (median [IQR]) between ROSC and monitoring initiation was 16 [14, 21] hours and duration of monitoring was 35 [22, 48] hours; neither differed between survivors and non-survivors. Median MAPopt was 89 [85, 97] mmHg and did not differ between survivors and non-survivors (89 [83, 94] vs. 91 [85, 105] mmHg, p = 0.64). Burden of MAP < MAPopt-5 was greater for non-survivors compared to survivors (OR 3.6 [95% CI 1.2-15.6]). Range of intact CAR (upper-lower limit) was narrower for non-survivors when compared to survivors (5 [0, 22] vs. 24 [7, 36] mmHg, p = 0.03). CONCLUSION A greater burden of MAP below PRx-derived MAPopt-5 was associated with mortality after cardiac arrest. Non-survivors had a narrower range of intact CAR than survivors.
Collapse
Affiliation(s)
- Matthew P Kirschen
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, United States.
| | | | | | - Robert Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, United States
| | - Benjamin S Abella
- Department of Emergency Medicine, University of Pennsylvania, United States; Center for Resuscitation Science, University of Pennsylvania, United States
| | - Alexis Topjian
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, United States
| | - Ramani Balu
- Department of Emergency Medicine, University of Pennsylvania, United States; Center for Resuscitation Science, University of Pennsylvania, United States
| |
Collapse
|
10
|
Annoni F, Peluso L, Hirai LA, Babini G, Khaldi A, Herpain A, Pitisci L, Ferlini L, Garcia B, Taccone FS, Creteur J, Su F. A comprehensive neuromonitoring approach in a large animal model of cardiac arrest. Animal Model Exp Med 2022; 5:56-60. [PMID: 35229991 PMCID: PMC8879632 DOI: 10.1002/ame2.12200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 12/01/2021] [Accepted: 12/23/2021] [Indexed: 11/27/2022] Open
Abstract
Background Anoxic brain injuries represent the main determinant of poor outcome after cardiac arrest (CA). Large animal models have been described to investigate new treatments during CA and post‐resuscitation phase, but a detailed model that includes extensive neuromonitoring is lacking. Method Before an electrically‐induced 10‐minute CA and resuscitation, 46 adult pigs underwent neurosurgery for placement of a multifunctional probe (intracranial pressure or ICP, tissue oxygen tension or PbtO2 and cerebral temperature) and a bolt‐based technique for the placement and securing of a regional blood flow probe and two sEEG electrodes; two modified cerebral microdialysis (CMD) probes were also inserted in the frontal lobes and accidental misplacement was prevented using a perforated head support. Result 42 animals underwent the CA procedure and 41 achieved the return of spontaneous circulation (ROSC). In 4 cases (8.6%) an adverse event took place during preparation, but only in two cases (4.3%) this was related to the neurosurgery. In 6 animals (13.3%) the minor complications that occurred resolved after probe repositioning. Conclusion Herein we provide a detailed comprehensive neuromonitoring approach in a large animal model of CA that might help future research.
Collapse
Affiliation(s)
- Filippo Annoni
- Intensive Care Experimental Laboratory, Intensive Care Unit Erasme Hospital Brussel Belgium
| | - Lorenzo Peluso
- Intensive Care Experimental Laboratory, Intensive Care Unit Erasme Hospital Brussel Belgium
| | | | - Giovanni Babini
- Department of Pathophysiology and Transplants University of Milan Milan Italy
- Department of Anesthesiology Intensive Care and Emergency Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
| | - Amina Khaldi
- Intensive Care Experimental Laboratory, Intensive Care Unit Erasme Hospital Brussel Belgium
| | - Antoine Herpain
- Intensive Care Experimental Laboratory, Intensive Care Unit Erasme Hospital Brussel Belgium
| | - Lorenzo Pitisci
- Intensive Care Experimental Laboratory, Intensive Care Unit Erasme Hospital Brussel Belgium
| | - Lorenzo Ferlini
- Intensive Care Experimental Laboratory, Intensive Care Unit Erasme Hospital Brussel Belgium
| | - Bruno Garcia
- Intensive Care Experimental Laboratory, Intensive Care Unit Erasme Hospital Brussel Belgium
| | - Fabio Silvio Taccone
- Intensive Care Experimental Laboratory, Intensive Care Unit Erasme Hospital Brussel Belgium
| | - Jacques Creteur
- Intensive Care Experimental Laboratory, Intensive Care Unit Erasme Hospital Brussel Belgium
| | - Fuhong Su
- Intensive Care Experimental Laboratory, Intensive Care Unit Erasme Hospital Brussel Belgium
| |
Collapse
|
11
|
Grand J, Hassager C, Schmidt H, Møller JE, Mølstrøm S, Nyholm B, Kjaergaard J. Hemodynamic evaluation by serial right heart catheterizations after cardiac arrest; protocol of a sub-study from the Blood Pressure and Oxygenation Targets after Out-of-Hospital Cardiac Arrest-trial (BOX). Resusc Plus 2021; 8:100188. [PMID: 34950913 PMCID: PMC8671111 DOI: 10.1016/j.resplu.2021.100188] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/20/2021] [Accepted: 11/22/2021] [Indexed: 01/20/2023] Open
Abstract
Background Neurological injury and mortality remain high in comatose patients resuscitated from out-of-hospital cardiac arrest (OHCA). Hypotension and hypoxia during post-resuscitation care have been associated with poor outcome, but the optimal oxygenation- and blood pressure-targets are unknown. The impact of different doses of norepinephrine on advanced hemodynamic after OHCA and the impact of different oxygenation-targets on pulmonary circulation and resistance (PVR), are unknown. The aims of this substudy of the "Blood pressure and oxygenations targets after out-of-hospital cardiac arrest (BOX)"-trial are to investigate the effect of two different MAP- and oxygenation-targets on advanced systemic and pulmonary hemodynamics measured by pulmonary artery catheters (PAC). Methods The BOX-trial is an investigator-initiated, randomized, controlled study comparing targeted MAP of 63 mmHg vs 77 mmHg (double-blinded intervention) and 9-10 kPa versus PaO2 of 13-14 kPa oxygenation-targets (open-label). Per protocol, all patients will be monitored systematically with PACs. The primary endpoint of the hemodynamic-substudy is cardiac output for the MAP-intervention, and PVR for the oxygenation-intervention. For both endpoints, the difference within 48 h between groups are assessed. Secondary endpoints are pulmonary capillary wedge pressure and pulmonary arterial pressure and association between advanced hemodynamic variables and mortality and biomarkers of inflammation and brain injury. Discussion In the BOX-trial, patients will be randomly allocated to two levels of MAP and oxygenation, which are central parts of post-resuscitation care and where evidence is sparse. The advanced-hemodynamic substudy will give valuable knowledge of the hemodynamic consequences of changing blood pressure and oxygen-levels of the critical cardiac patient. It will be one of the largest clinical, prospective trials of advanced hemodynamics measured by serial PACs in consecutive comatose patients, resuscitated after OHCA. The randomized and placebo-controlled trialdesign of the MAP-intervention minimizes risk of selection bias and confounders. Furthermore, hemodynamic characteristics and associations with outcome will be investigated. Trial registration ClinicalTrials.gov (ClinicalTrials.gov Identifier: NCT03141099). Registered March 30, 2017.
Collapse
Affiliation(s)
- Johannes Grand
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Henrik Schmidt
- Department of Anesthesiology and Intensive Care, Odense University Hospital, 5000 Odense C, Denmark
| | - Jacob E Møller
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark.,Department of Cardiology, Odense University Hospital, 5000 C Odense, Denmark
| | - Simon Mølstrøm
- Department of Cardiology, Odense University Hospital, 5000 C Odense, Denmark
| | - Benjamin Nyholm
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
| |
Collapse
|
12
|
Kang C, Jeong W, Park JS, You Y, Min JH, Cho YC, Ahn HJ, In YN, Lee IH. Different Stratification of Physiological Factors Affecting Cerebral Perfusion Pressure in Hypoxic-Ischemic Brain Injury after Cardiac Arrest According to Visible or Non-Visible Primary Brain Injury: A Retrospective Observational Study. J Clin Med 2021; 10:jcm10225385. [PMID: 34830665 PMCID: PMC8625895 DOI: 10.3390/jcm10225385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 11/04/2021] [Accepted: 11/16/2021] [Indexed: 12/05/2022] Open
Abstract
We aimed to explore the stratification of physiological factors affecting cerebral perfusion pressure, including arterial oxygen tension, arterial carbon dioxide tension, mean arterial pressure, intracranial pressure (ICP), and blood-brain barrier (BBB) status, with respect to primary or secondary brain injury (PBI or SBI) after out-of-hospital cardiac arrest (OHCA). Among the retrospectively enrolled 97 comatose OHCA survivors undergoing post-cardiac arrest (PCA) care, 46 (47.4%) with already established PBI (high signal intensity (HSI) on diffusion-weighted imaging (DWI) had higher ICP (p = 0.02) and poorer BBB status (p < 0.01) than the non-HSI group. On subgroup analysis within the non-HSI group to exclude the confounding effect of already established PBI, 40 (78.4%) patients with good neurological outcomes had lower ICP at 24 h (11.0 vs. 16.0 mmHg, p < 0.01) and more stable BBB status (p = 0.17 in pairwise comparison) compared to those with poor neurological outcomes, despite the non-significant differences in other physiological factors. OHCA survivors with HSI on DWI showed significantly higher ICP and poorer BBB status at baseline before PCA care than those without HSI. Despite the negative DWI findings before PCA care, OHCA survivors have a cerebral penumbra at risk for potentially leading the poor neurological outcome from unsuppressed SBI, which may be associated with increased ICP and BBB permeability.
Collapse
Affiliation(s)
- Changshin Kang
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (C.K.); (W.J.); (Y.Y.); (Y.C.C.); (H.J.A.)
| | - Wonjoon Jeong
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (C.K.); (W.J.); (Y.Y.); (Y.C.C.); (H.J.A.)
| | - Jung Soo Park
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (C.K.); (W.J.); (Y.Y.); (Y.C.C.); (H.J.A.)
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon 35015, Korea; (J.H.M.); (Y.N.I.)
- Correspondence: ; Tel.: +82-42-280-6001
| | - Yeonho You
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (C.K.); (W.J.); (Y.Y.); (Y.C.C.); (H.J.A.)
| | - Jin Hong Min
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon 35015, Korea; (J.H.M.); (Y.N.I.)
- Department of Emergency Medicine, Chungnam National University Sejong Hospital, 20 Bodeum 7-ro, Sejong 30099, Korea
| | - Yong Chul Cho
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (C.K.); (W.J.); (Y.Y.); (Y.C.C.); (H.J.A.)
| | - Hong Joon Ahn
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (C.K.); (W.J.); (Y.Y.); (Y.C.C.); (H.J.A.)
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon 35015, Korea; (J.H.M.); (Y.N.I.)
| | - Yong Nam In
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon 35015, Korea; (J.H.M.); (Y.N.I.)
- Department of Emergency Medicine, Chungnam National University Sejong Hospital, 20 Bodeum 7-ro, Sejong 30099, Korea
| | - In Ho Lee
- Department of Radiology, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon 35015, Korea;
| |
Collapse
|
13
|
Sekhon MS, Hoiland RL, Griesdale DE. The importance of the oxygen cascade after cardiac arrest. Resuscitation 2021; 168:231-233. [PMID: 34592401 DOI: 10.1016/j.resuscitation.2021.09.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 09/15/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
| | - Ryan L Hoiland
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada; Centre for Heart, Lung, & Vascular Health, School of Health and Exercise Sciences, University of British Columbia - Okanagan, Kelowna, BC, Canada
| | - Donald E Griesdale
- Centre for Heart, Lung, & Vascular Health, School of Health and Exercise Sciences, University of British Columbia - Okanagan, Kelowna, BC, Canada
| |
Collapse
|
14
|
Skrifvars MB. Hunting high and low for the right blood pressure after cardiac arrest. Resuscitation 2021; 167:385-386. [PMID: 34363857 DOI: 10.1016/j.resuscitation.2021.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 07/22/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| |
Collapse
|
15
|
Kwon WY, Jung YS, Suh GJ, Kim T, Kwak H, Kim T, Kim JY, Lee MS, Kim KS, Shin J, Lee HJ, You KM. Regional cerebral oxygen saturation in cardiac arrest survivors undergoing targeted temperature management 36℃ versus 33℃: A randomized clinical trial. Resuscitation 2021; 167:362-371. [PMID: 34331985 DOI: 10.1016/j.resuscitation.2021.07.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/16/2021] [Accepted: 07/21/2021] [Indexed: 11/18/2022]
Abstract
AIM of study To investigate whether regional cerebral oxygen saturation (rSO2) differs in out-of-hospital cardiac arrest (OHCA) survivors undergoing targeted temperature management (TTM) 36℃ versus 33℃. METHODS A randomized clinical trial was conducted at intensive care units in two referral hospitals. Fifty-seven comatose OHCA survivors were randomized into either a 36℃ or 33℃ group. Patients were cooled and maintained at an oesophageal temperature of either 36℃ or 33℃ for 24 hours, rewarmed at a rate of 0.25℃/hour, and maintained at < 37.5℃ until 72 hours. During 72 hours of TTM, rSO2 was continuously monitored on the left forehead using near-infrared spectroscopy (INVOSTM 5100C). The rSO2 level at 72 hours was compared between the two groups. Next, serial rSO2 levels for 72 hours were compared using mixed effects regression. The association between rSO2 levels and 6-month neurological outcomes was also evaluated. RESULTS There were no significant differences in the rSO2 level at 72 hours between the 36℃ and 33℃ groups (p = 0.372). Furthermore, serial rSO2 levels for 72 hours of TTM were not different between the two groups (p = 0.733). However, low rSO2 levels, particularly at 24 hours of TTM, were significantly associated with poor 6-month neurological outcomes (odds ratio = 0.899, 95% confidence interval: 0.831 - 0.974). The area under the receiver operating characteristic curve of the rSO2 level at 24 hours for poor neurological outcomes was 0.800. CONCLUSIONS Regardless of target temperatures, low rSO2 levels during TTM were significantly associated with poor 6-month neurological outcomes in OHCA survivors.
Collapse
Affiliation(s)
- Woon Yong Kwon
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul 03080, Republic of Korea; Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Yoon Sun Jung
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Gil Joon Suh
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul 03080, Republic of Korea; Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea.
| | - Taekyun Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Hyeongkyu Kwak
- Department of Emergency Medicine, Uijeongbu Eulji University Hospital/Eulji University School of Medicine, Uijeongbu-si, Gyeonggi-do, Republic of Korea
| | - Taekwon Kim
- Department of Emergency Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Jeong Yeon Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Min Sung Lee
- Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Kyung Su Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Jonghwan Shin
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul 03080, Republic of Korea; Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul 07061, Republic of Korea
| | - Hui Jai Lee
- Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul 07061, Republic of Korea
| | - Kyung Min You
- Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul 07061, Republic of Korea
| |
Collapse
|
16
|
Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. Postreanimationsbehandlung. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00892-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|
17
|
Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care. Intensive Care Med 2021; 47:369-421. [PMID: 33765189 PMCID: PMC7993077 DOI: 10.1007/s00134-021-06368-4] [Citation(s) in RCA: 386] [Impact Index Per Article: 128.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/08/2021] [Indexed: 12/13/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation and organ donation.
Collapse
Affiliation(s)
- Jerry P. Nolan
- University of Warwick, Warwick Medical School, Coventry, CV4 7AL UK
- Royal United Hospital, Bath, BA1 3NG UK
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
- Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W. Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC), Université Catholique de Louvain, Brussels, Belgium
- Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Division of Health Sciences, Warwick Medical School, University of Warwick, Room A108, Coventry, CV4 7AL UK
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Véronique R. M. Moulaert
- Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Markus B. Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB UK
| |
Collapse
|
18
|
Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Mariero Olasveengen T, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care. Resuscitation 2021; 161:220-269. [PMID: 33773827 DOI: 10.1016/j.resuscitation.2021.02.012] [Citation(s) in RCA: 315] [Impact Index Per Article: 105.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation, and organ donation.
Collapse
Affiliation(s)
- Jerry P Nolan
- University of Warwick, Warwick Medical School, Coventry CV4 7AL, UK; Royal United Hospital, Bath, BA1 3NG, UK.
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy; Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W Böttiger
- University Hospital of Cologne, Kerpener Straße 62, D-50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC) Université Catholique de Louvain, Brussels, Belgium; Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Room A108, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Gisela Lilja
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden
| | - Véronique R M Moulaert
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB, UK
| |
Collapse
|
19
|
Goal-Directed Care Using Invasive Neuromonitoring Versus Standard of Care After Cardiac Arrest: A Matched Cohort Study. Crit Care Med 2021; 49:1333-1346. [PMID: 33711002 DOI: 10.1097/ccm.0000000000004945] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Following return of spontaneous circulation after cardiac arrest, hypoxic ischemic brain injury is the primary cause of mortality and disability. Goal-directed care using invasive multimodal neuromonitoring has emerged as a possible resuscitation strategy. We evaluated whether goal-directed care was associated with improved neurologic outcome in hypoxic ischemic brain injury patients after cardiac arrest. DESIGN Retrospective, single-center, matched observational cohort study. SETTING Quaternary academic medical center. PATIENTS Adult patients admitted to the ICU following return of spontaneous circulation postcardiac arrest with clinical evidence of hypoxic ischemic brain injury defined as greater than or equal to 10 minutes of cardiac arrest with an unconfounded postresuscitation Glasgow Coma Scale of less than or equal to 8. INTERVENTIONS We compared patients who underwent goal-directed care using invasive neuromonitoring with those treated with standard of care (using both total and matched groups). MEASUREMENTS AND MAIN RESULTS Goal-directed care patients were matched 1:1 to standard of care patients using propensity scores and exact matching. The primary outcome was a 6-month favorable neurologic outcome (Cerebral Performance Category of 1 or 2). We included 65 patients, of whom 21 received goal-directed care and 44 patients received standard of care. The median age was 50 (interquartile range, 35-61), 48 (74%) were male, and seven (11%) had shockable rhythms. Favorable neurologic outcome at 6 months was significantly greater in the goal-directed care group (n = 9/21 [43%]) compared with the matched (n = 2/21 [10%], p = 0.016) and total (n = 8/44 [18%], p = 0.034) standard of care groups. Goal-directed care group patients had higher mean arterial pressure (p < 0.001 vs total; p = 0.0060 vs matched) and lower temperature (p = 0.007 vs total; p = 0.041 vs matched). CONCLUSIONS In this preliminary study of patients with hypoxic ischemic brain injury postcardiac arrest, goal-directed care guided by invasive neuromonitoring was associated with a 6-month favorable neurologic outcome (Cerebral Performance Category 1 or 2) versus standard of care. Significant work is required to confirm this finding in a prospectively designed study.
Collapse
|
20
|
Arterial carbon dioxide tension has a non-linear association with survival after out-of-hospital cardiac arrest: A multicentre observational study. Resuscitation 2021; 162:82-90. [PMID: 33571603 DOI: 10.1016/j.resuscitation.2021.01.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/16/2021] [Accepted: 01/22/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE International guidelines recommend targeting normocapnia in mechanically ventilated out-of-hospital cardiac arrest (OHCA) survivors, but the optimal arterial carbon dioxide (PaCO2) target remains controversial. We hypothesised that the relationship between PaCO2 and survival is non-linear, and targeting an intermediate level of PaCO2 compared to a low or high PaCO2 in the first 24-h of ICU admission is associated with an improved survival to hospital discharge (STHD) and at 12-months. METHODS We conducted a retrospective multi-centre cohort study of adults with non-traumatic OHCA requiring admission to one of four tertiary hospital intensive care units for mechanical ventilation. A four-knot restricted cubic spline function was used to allow non-linearity between the mean PaCO2 within the first 24 h of ICU admission after OHCA and survival, and optimal PaCO2 cut-points were identified from the spline curve to generate corresponding odds ratios. RESULTS We analysed 3769 PaCO2 results within the first 24-h of ICU admission, from 493 patients. PaCO2 and survival had an inverted U-shape association; normocapnia was associated with significantly improved STHD compared to either hypocapnia (<35 mmHg) (adjusted odds ratio [aOR] 0.45, 95% confidence interval [CI] 0.24-0.83) or hypercapnia (>45 mmHg) (aOR 0.45, 95% CI 0.24-0.84). Of the twelve predictors assessed, PaCO2 was the third most important predictor, and explained >11% of the variability in survival. The survival benefits of normocapnia extended to 12-months. CONCLUSIONS Normocapnia within the first 24-h of intensive care admission after OHCA was associated with an improved survival compared to patients with hypocapnia or hypercapnia.
Collapse
|
21
|
Abstract
Cardiac arrest is a catastrophic event with high morbidity and mortality. Despite advances over time in cardiac arrest management and postresuscitation care, the neurologic consequences of cardiac arrest are frequently devastating to patients and their families. Targeted temperature management is an intervention aimed at limiting postanoxic injury and improving neurologic outcomes following cardiac arrest. Recovery of neurologic function governs long-term outcome after cardiac arrest and prognosticating on the potential for recovery is a heavy burden for physicians. An early and accurate estimate of the potential for recovery can establish realistic expectations and avoid futile care in those destined for a poor outcome. This chapter reviews the epidemiology, pathophysiology, therapeutic interventions, prognostication, and neurologic sequelae of cardiac arrest.
Collapse
Affiliation(s)
- Rick Gill
- Department of Neurology, Loyola University Chicago, Chicago, Stritch School of Medicine, Maywood, IL, United States
| | - Michael Teitcher
- Department of Neurology, Loyola University Chicago, Chicago, Stritch School of Medicine, Maywood, IL, United States
| | - Sean Ruland
- Department of Neurology, Loyola University Chicago, Chicago, Stritch School of Medicine, Maywood, IL, United States.
| |
Collapse
|
22
|
Soar J, Berg KM, Andersen LW, Böttiger BW, Cacciola S, Callaway CW, Couper K, Cronberg T, D'Arrigo S, Deakin CD, Donnino MW, Drennan IR, Granfeldt A, Hoedemaekers CWE, Holmberg MJ, Hsu CH, Kamps M, Musiol S, Nation KJ, Neumar RW, Nicholson T, O'Neil BJ, Otto Q, de Paiva EF, Parr MJA, Reynolds JC, Sandroni C, Scholefield BR, Skrifvars MB, Wang TL, Wetsch WA, Yeung J, Morley PT, Morrison LJ, Welsford M, Hazinski MF, Nolan JP. Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2020; 156:A80-A119. [PMID: 33099419 PMCID: PMC7576326 DOI: 10.1016/j.resuscitation.2020.09.012] [Citation(s) in RCA: 126] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations for advanced life support includes updates on multiple advanced life support topics addressed with 3 different types of reviews. Topics were prioritized on the basis of both recent interest within the resuscitation community and the amount of new evidence available since any previous review. Systematic reviews addressed higher-priority topics, and included double-sequential defibrillation, intravenous versus intraosseous route for drug administration during cardiac arrest, point-of-care echocardiography for intra-arrest prognostication, cardiac arrest caused by pulmonary embolism, postresuscitation oxygenation and ventilation, prophylactic antibiotics after resuscitation, postresuscitation seizure prophylaxis and treatment, and neuroprognostication. New or updated treatment recommendations on these topics are presented. Scoping reviews were conducted for anticipatory charging and monitoring of physiological parameters during cardiopulmonary resuscitation. Topics for which systematic reviews and new Consensuses on Science With Treatment Recommendations were completed since 2015 are also summarized here. All remaining topics reviewed were addressed with evidence updates to identify any new evidence and to help determine which topics should be the highest priority for systematic reviews in the next 1 to 2 years.
Collapse
|
23
|
Berg KM, Soar J, Andersen LW, Böttiger BW, Cacciola S, Callaway CW, Couper K, Cronberg T, D’Arrigo S, Deakin CD, Donnino MW, Drennan IR, Granfeldt A, Hoedemaekers CW, Holmberg MJ, Hsu CH, Kamps M, Musiol S, Nation KJ, Neumar RW, Nicholson T, O’Neil BJ, Otto Q, de Paiva EF, Parr MJ, Reynolds JC, Sandroni C, Scholefield BR, Skrifvars MB, Wang TL, Wetsch WA, Yeung J, Morley PT, Morrison LJ, Welsford M, Hazinski MF, Nolan JP, Issa M, Kleinman ME, Ristagno G, Arafeh J, Benoit JL, Chase M, Fischberg BL, Flores GE, Link MS, Ornato JP, Perman SM, Sasson C, Zelop CM. Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2020; 142:S92-S139. [DOI: 10.1161/cir.0000000000000893] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
This
2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations
for advanced life support includes updates on multiple advanced life support topics addressed with 3 different types of reviews. Topics were prioritized on the basis of both recent interest within the resuscitation community and the amount of new evidence available since any previous review. Systematic reviews addressed higher-priority topics, and included double-sequential defibrillation, intravenous versus intraosseous route for drug administration during cardiac arrest, point-of-care echocardiography for intra-arrest prognostication, cardiac arrest caused by pulmonary embolism, postresuscitation oxygenation and ventilation, prophylactic antibiotics after resuscitation, postresuscitation seizure prophylaxis and treatment, and neuroprognostication. New or updated treatment recommendations on these topics are presented. Scoping reviews were conducted for anticipatory charging and monitoring of physiological parameters during cardiopulmonary resuscitation. Topics for which systematic reviews and new Consensuses on Science With Treatment Recommendations were completed since 2015 are also summarized here. All remaining topics reviewed were addressed with evidence updates to identify any new evidence and to help determine which topics should be the highest priority for systematic reviews in the next 1 to 2 years.
Collapse
|
24
|
Pan C, Zheng X, Wang L, Chen Q, Lin Q. Pretreatment with human urine-derived stem cells protects neurological function in rats following cardiopulmonary resuscitation after cardiac arrest. Exp Ther Med 2020; 20:112. [PMID: 32989390 PMCID: PMC7517276 DOI: 10.3892/etm.2020.9240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 07/10/2020] [Indexed: 12/21/2022] Open
Abstract
Cardiopulmonary resuscitation (CPR) after cardiac arrest (CA) often leads to neurological deficits in the absence of effective treatment. The aim of the present basic research study was to investigate the effects of human urine-derived stem cells (hUSCs) on the recovery of neurological function in rats after CA/CPR. hUSCs were isolated in vitro and identified using flow cytometry. A rat model of CA was established, and CPR was performed. Animals were scored for neurofunctional deficits following hUSC transplantation. The expression levels of brain-derived neurotrophic factor (BDNF) and vascular endothelial growth factor (VEGF) in the hippocampus and temporal cortex were detected via immunofluorescence. Moreover, brain water content and serum S100 calcium binding protein B (S100B) levels were measured 7 days following hUSC transplantation. The results demonstrated that hUSCs had upregulated expression levels of CD29, CD90, CD44, CD105, CD73, CD224 and CD146, and expressed low levels of CD34 and human leukocyte antigen-DR isotype. In addition, hUSCs were able to differentiate into neuronal cells in vitro. The SPSS 19.0 statistical package was used for statistical analysis, and it was found that the neurological function of the rats after CA/CPR was significantly improved following hUSC transplantation. Furthermore, hUSCs aggregated in the hippocampus and temporal cortex, and secreted large amounts of BDNF and VEGF. hUSC transplantation also effectively inhibited brain edema and serum S100B levels after CPR. Therefore, the results suggested that hUSC transplantation significantly improved the neurological function of rats after CA/CPR, possibly by promoting the expression levels of BDNF and VEGF, as well as inhibiting brain edema.
Collapse
Affiliation(s)
- Chun Pan
- Emergency Department, Suzhou Emergency Center, Suzhou, Jiangsu 215008, P.R. China
| | - Xu Zheng
- Department of Anesthesiology, The Affiliated Suzhou Science and Technology Town Hospital of Nanjing Medical University, Suzhou, Jiangsu 215008, P.R. China
| | - Liang Wang
- Emergency Department, Suzhou Emergency Center, Suzhou, Jiangsu 215008, P.R. China
| | - Qian Chen
- Laboratory Center, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, Jiangsu 215008, P.R. China
| | - Qi Lin
- Dispatch Department, Suzhou Emergency Center, Suzhou, Jiangsu 215000, P.R. China
| |
Collapse
|
25
|
Rud J, May TL, Riker RR, Seder DB. Early cerebral edema after cardiac arrest and its ramifications. Resuscitation 2020; 154:112-114. [PMID: 32619533 DOI: 10.1016/j.resuscitation.2020.06.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 06/24/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Jonathan Rud
- Maine Medical Center Department of Internal Medicine, Portland, ME, USA
| | - Teresa L May
- Maine Medical Center Department of Critical Care Services, Portland, ME, USA; Tufts University School of Medicine, Boston, MA, USA
| | - Richard R Riker
- Maine Medical Center Department of Critical Care Services, Portland, ME, USA; Tufts University School of Medicine, Boston, MA, USA
| | - David B Seder
- Maine Medical Center Department of Critical Care Services, Portland, ME, USA; Tufts University School of Medicine, Boston, MA, USA.
| |
Collapse
|
26
|
Rikhraj KJK, Wood MD, Hoiland RL, Thiara S, Griesdale DEG, Sekhon MS. Determining Optimal Mean Arterial Pressure After Cardiac Arrest: A Systematic Review. Neurocrit Care 2020; 34:621-634. [PMID: 32572823 DOI: 10.1007/s12028-020-01027-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The use of cerebral autoregulation monitoring to identify patient-specific optimal mean arterial pressure (MAPOPT) has emerged as a technique to augment cerebral oxygen delivery in post-cardiac arrest patients. Our systematic review aims to determine (a) the average MAPOPT in these patients, (b) the feasibility of identifying MAPOPT, (c) the brain tissue oxygenation levels when MAP is within proximity to the MAPOPT and (d) the relationship between neurological outcome and MAPOPT-targeted resuscitation strategies. We carried out this review in accordance with the PRISMA guidelines. We included all studies that used cerebral autoregulation to determine MAPOPT in adult patients (> 16 years old) who achieved return of spontaneous circulation (ROSC) following cardiac arrest. All studies had to include our primary outcome of MAPOPT. We excluded studies where the patients had any history of traumatic brain injury, ischemic stroke or intracranial hemorrhage. We identified six studies with 181 patients. There was wide variability in cerebral autoregulation monitoring methods, length of monitoring, calculation and reporting of MAPOPT. Amongst all studies, the median or mean MAPOPT was consistently above 65 mmHg (range 70-114 mmHg). Definitions of feasibility varied among studies and were difficult to summarize. Only one study noted that brain tissue oxygenation increased as patients' MAP approached MAPOPT. There was no consistent association between targeting MAPOPT and improved neurological outcome. There is considerable heterogeneity in MAPOPT due to differences in monitoring methods of autoregulation. Further research is needed to assess the clinical utility of MAPOPT-guided strategies on decreasing secondary injury and improving neurological outcomes after ROSC.
Collapse
Affiliation(s)
- Kiran J K Rikhraj
- Department of Emergency Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Room 2438, Jim Pattison Pavilion, 2nd Floor, 899 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada.
| | - Michael D Wood
- Department of Anaesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, 899 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Ryan L Hoiland
- Department of Anaesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, 899 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada.,Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, University of British Columbia Okanagan, 3333 University Way, Kelowna, BC, V1V1V7, Canada
| | - Sharanjit Thiara
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, 899 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Donald E G Griesdale
- Department of Anaesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, 899 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada.,Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, 899 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada.,Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, 899 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, 899 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada
| |
Collapse
|
27
|
Elmer J, Coppler PJ, May TL, Hirsch K, Faro J, Solanki P, Brown M, Puyana JS, Rittenberger JC, Callaway CW. Unsupervised learning of early post-arrest brain injury phenotypes. Resuscitation 2020; 153:154-160. [PMID: 32531403 DOI: 10.1016/j.resuscitation.2020.05.051] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/24/2020] [Accepted: 05/31/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Trials may be neutral when they do not appropriately target the experimental intervention. We speculated multimodality assessment of early hypoxic-ischemic brain injury would identify phenotypes likely to benefit from therapeutic interventions. METHODS We performed a retrospective study including comatose patients resuscitated from out-of-hospital cardiac arrest (OHCA) by one of 126 emergency medical services or in-hospital arrest at one of 26 hospitals from 2011 to 2019. All patients were ultimately transported to a single tertiary center for care including standardized initial neurological examination, brain imaging and electroencephalography; targeted temperature management (TTM); hemodynamic optimization targeting mean arterial pressure (MAP) >80 mmHg; and, coronary angiography for clinical suspicion for acute coronary syndrome. We used unsupervised learning to identify brain injury phenotypes defined by admission neurodiagnostics. We tested for interactions between phenotype and TTM, hemodynamic management and cardiac catheterization in models predicting recovery. RESULTS We included 1086 patients with mean (SD) age 58 (17) years of whom 955 (88%) were resuscitated from OHCA. Survival to hospital discharge was 27%, and 248 (23%) were discharged with Cerebral Performance Category (CPC) 1-3. We identified 5 clusters defining distinct brain injury phenotypes, each comprising 14% to 30% of the cohort with discharge CPC 1-3 in 59% to <1%. We found significant interactions between cluster and TTM strategy (P = 0.01), MAP (P < 0.001) and coronary angiography (P = 0.04) in models predicting outcomes. CONCLUSIONS We identified patterns of early hypoxic-ischemic injury based on multiple diagnostic modalities that predict responsiveness to several therapeutic interventions recently tested in neutral clinical trials.
Collapse
Affiliation(s)
- Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA; Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, USA.
| | - Patrick J Coppler
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Teresa L May
- Department of Critical Care Medicine, Maine Medical Center, Portland, USA
| | - Karen Hirsch
- Department of Neurology, Stanford University School of Medicine, Stanford, USA
| | - John Faro
- University of Cincinnati College of Medicine, Cincinnati, USA
| | - Pawan Solanki
- Department of Anesthesiology, University of Buffalo, Buffalo, USA
| | - McKenzie Brown
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Jacob S Puyana
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Jon C Rittenberger
- Guthrie- Robert Packer Hospital Emergency Medicine Residency, Sayre, PA, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA
| |
Collapse
|
28
|
Holmberg MJ, Nicholson T, Nolan JP, Schexnayder S, Reynolds J, Nation K, Welsford M, Morley P, Soar J, Berg KM. Oxygenation and ventilation targets after cardiac arrest: A systematic review and meta-analysis. Resuscitation 2020; 152:107-115. [PMID: 32389599 DOI: 10.1016/j.resuscitation.2020.04.031] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 04/26/2020] [Indexed: 01/21/2023]
Abstract
AIM To perform a systematic review and meta-analysis of the literature on oxygenation and ventilation targets after successful resuscitation from cardiac arrest in order to inform an update of international guidelines. METHODS The review was performed according to PRISMA and registered on PROSPERO (ID: X). Medline, EMBASE, and the Cochrane Library were searched on August 22, 2019. The population included both adult and pediatric patients with cardiac arrest. Two investigators reviewed abstracts, extracted data, and assessed the risk of bias. Meta-analyses were performed for studies without excessive bias. Certainty of evidence was evaluated using GRADE. RESULTS We included 7 trials and 36 observational studies comparing oxygenation or ventilation targets. Most of the trials and observational studies included adults with out-of-hospital cardiac arrest. There were 6 observational studies in children. Bias for trials ranged from low to high risk, with group imbalances and blinding being primary concerns. Bias for observational studies was rated as serious or critical risk with confounding and exposure classification being primary sources of bias. Meta-analyses including two trials comparing low vs high oxygen therapy and two trials comparing hypercapnia vs no hypercapnia were inconclusive. Point estimates of individual studies generally favored normoxemia and normocapnia over hyper- or hypoxemia and hyper- or hypocapnia. CONCLUSIONS We identified a large number of studies related to oxygenation and ventilation targets in cardiac arrest. The majority of studies did not reach statistical significance and were limited by excessive risk of bias. Point estimates of individual studies generally favored normoxemia and normocapnia.
Collapse
Affiliation(s)
- Mathias J Holmberg
- Beth Israel Deaconess Medical Center, Boston, MA, USA; Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | | | - Jerry P Nolan
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom; Royal United Hospital, Bath, United Kingdom
| | - Steve Schexnayder
- University of Arkansas, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Joshua Reynolds
- Michigan State University College of Human Medicine, East Lansing, MI, USA
| | - Kevin Nation
- New Zealand Resuscitation Council, Wellington, New Zealand
| | | | - Peter Morley
- Royal Melbourne Hospital Clinical School, The University of Melbourne Parkville, Victoria, Australia
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
| | - Katherine M Berg
- Beth Israel Deaconess Medical Center, Boston, MA, USA; Waikato District Hospital, Hamilton, New Zealand.
| | | |
Collapse
|
29
|
Hosseini M, Wilson RH, Crouzet C, Amirhekmat A, Wei KS, Akbari Y. Resuscitating the Globally Ischemic Brain: TTM and Beyond. Neurotherapeutics 2020; 17:539-562. [PMID: 32367476 PMCID: PMC7283450 DOI: 10.1007/s13311-020-00856-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Cardiac arrest (CA) afflicts ~ 550,000 people each year in the USA. A small fraction of CA sufferers survive with a majority of these survivors emerging in a comatose state. Many CA survivors suffer devastating global brain injury with some remaining indefinitely in a comatose state. The pathogenesis of global brain injury secondary to CA is complex. Mechanisms of CA-induced brain injury include ischemia, hypoxia, cytotoxicity, inflammation, and ultimately, irreversible neuronal damage. Due to this complexity, it is critical for clinicians to have access as early as possible to quantitative metrics for diagnosing injury severity, accurately predicting outcome, and informing patient care. Current recommendations involve using multiple modalities including clinical exam, electrophysiology, brain imaging, and molecular biomarkers. This multi-faceted approach is designed to improve prognostication to avoid "self-fulfilling" prophecy and early withdrawal of life-sustaining treatments. Incorporation of emerging dynamic monitoring tools such as diffuse optical technologies may provide improved diagnosis and early prognostication to better inform treatment. Currently, targeted temperature management (TTM) is the leading treatment, with the number of patients needed to treat being ~ 6 in order to improve outcome for one patient. Future avenues of treatment, which may potentially be combined with TTM, include pharmacotherapy, perfusion/oxygenation targets, and pre/postconditioning. In this review, we provide a bench to bedside approach to delineate the pathophysiology, prognostication methods, current targeted therapies, and future directions of research surrounding hypoxic-ischemic brain injury (HIBI) secondary to CA.
Collapse
Affiliation(s)
- Melika Hosseini
- Department of Neurology, School of Medicine, University of California, Irvine, USA
| | - Robert H Wilson
- Department of Neurology, School of Medicine, University of California, Irvine, USA
- Beckman Laser Institute, University of California, Irvine, USA
| | - Christian Crouzet
- Department of Neurology, School of Medicine, University of California, Irvine, USA
- Beckman Laser Institute, University of California, Irvine, USA
| | - Arya Amirhekmat
- Department of Neurology, School of Medicine, University of California, Irvine, USA
| | - Kevin S Wei
- Department of Neurology, School of Medicine, University of California, Irvine, USA
| | - Yama Akbari
- Department of Neurology, School of Medicine, University of California, Irvine, USA.
- Beckman Laser Institute, University of California, Irvine, USA.
| |
Collapse
|
30
|
Hoiland RL, Sekhon MS, Cardim D, Wood MD, Gooderham P, Foster D, Griesdale DE. Lack of agreement between optimal mean arterial pressure determination using pressure reactivity index versus cerebral oximetry index in hypoxic ischemic brain injury after cardiac arrest. Resuscitation 2020; 152:184-191. [PMID: 32229218 DOI: 10.1016/j.resuscitation.2020.03.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 03/13/2020] [Accepted: 03/21/2020] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Invasive monitoring of cerebral autoregulation using the pressure reactivity index (PRx) allows for the determination of optimal mean arterial pressure (MAPOPT) in hypoxic ischemic brain injury (HIBI) patients following cardiac arrest. However, the utility of non-invasive surrogates to determine MAPOPT has not been addressed. We aimed to determine the agreement between PRx-derived MAPOPT versus MAPOPT determined by the near-infrared spectroscopy (NIRS) based cerebral oximetry index (COx). METHODS Ten HIBI patients were enrolled. PRx-derived MAPOPT, lower (LLA) and upper limits of autoregulation (ULA) were compared against COx-derived MAPOPT, LLA and ULA. Multimodal neuromonitoring included mean arterial pressure, intracranial pressure, brain tissue oxygenation, jugular venous oxygen saturation, and NIRS-derived regional cerebral oxygen saturation. RESULTS Repeated measures Bland-Altman plots demonstrated limited agreement between MAPOPT derived from COx and PRx (mean bias: 1.4 mmHg; upper limit of agreement: 25.9 mmHg; lower limit of agreement: -23.0 mmHg). Similarly, there was limited agreement between the absolute values of PRx and COx. Mean bias was 0.26 and the upper and lower limits of agreement were 1.05 and -0.53, respectively. Systematic bias was apparent, whereby at low PRx values COx overestimated PRx and at high PRx values, COx underestimated PRx. COx was limited in its ability to determine impaired autoregulation defined by PRx (receiver operator characteristic area under the curve was 0.488). CONCLUSION Collectively, we demonstrate that COx-based determination of MAPOPT lacks agreement with MAPOPT derived from PRx. Further research must be done to evaluate the physiologic and clinical efficacy of PRx derived MAPOPT in HIBI.
Collapse
Affiliation(s)
- Ryan L Hoiland
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada; Centre for Heart, Lung, & Vascular Health, School of Health and Exercise Sciences, University of British Columbia-Okanagan, Kelowna, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Danilo Cardim
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Michael D Wood
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Peter Gooderham
- Division of Neurosurgery, Department of Surgery, Vancouver General Hospital, West 12th Avenue, University of British Columbia, Vancouver, BC V5Z 1M9, Canada
| | - Denise Foster
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Donald E Griesdale
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada; Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada; Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.
| |
Collapse
|
31
|
Brain Hypoxia Secondary to Diffusion Limitation in Hypoxic Ischemic Brain Injury Postcardiac Arrest. Crit Care Med 2020; 48:378-384. [DOI: 10.1097/ccm.0000000000004138] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
|
32
|
Reardon PM, Hickey M, English SW, Hibbert B, Simard T, Hendin A, Yadav K. Optimizing the Early Resuscitation After Out-of-Hospital Cardiac Arrest. J Intensive Care Med 2019; 35:1556-1563. [PMID: 31512559 DOI: 10.1177/0885066619873318] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Resuscitation after out-of-hospital cardiac arrest can be one of the most challenging scenarios in acute-care medicine. The devastating effects of postcardiac arrest syndrome carry a substantial morbidity and mortality that persist long after return of spontaneous circulation. Management of these patients requires the clinician to simultaneously address multiple emergent priorities including the resuscitation of the patient and the efficient diagnosis and management of the underlying etiology. This review provides a concise evidence-based overview of the core concepts involved in the early postcardiac arrest resuscitation. It will highlight the components of an effective management strategy including addressing hemodynamic, oxygenation, and ventilation goals as well as carefully considering cardiac catheterization and targeted temperature management. An organized approach is paramount to providing effective care to patients in this vulnerable time period.
Collapse
Affiliation(s)
- Peter M Reardon
- Division of Critical Care, Department of Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada.,Department of Emergency Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada
| | - Michael Hickey
- Division of Critical Care, Department of Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada.,Department of Emergency Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada
| | - Shane W English
- Division of Critical Care, Department of Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, 6363University of Ottawa, Ottawa Ontario Canada
| | - Benjamin Hibbert
- Division of Cardiology, 27339University of Ottawa Heart Institute, Ottawa, Ontario, Canada.,Department of Cellular and Molecular Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada
| | - Trevor Simard
- Division of Cardiology, 27339University of Ottawa Heart Institute, Ottawa, Ontario, Canada.,Department of Cellular and Molecular Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada
| | - Ariel Hendin
- Division of Critical Care, Department of Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada.,Department of Emergency Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
33
|
The Burden of Brain Hypoxia and Optimal Mean Arterial Pressure in Patients With Hypoxic Ischemic Brain Injury After Cardiac Arrest*. Crit Care Med 2019; 47:960-969. [DOI: 10.1097/ccm.0000000000003745] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
34
|
Abstract
Cardiac arrest remains a significant cause of death and disability throughout the world. However, as our understanding of cardiac arrest and resuscitation physiology has developed, new technologies are fundamentally altering our potential to improve survival and neurologic sequela. Some advances are relatively simple, requiring only alterations in current basic life support measures or integration with pre-hospital organization, whereas others, such as extra-corporeal membrane oxygenation, require significant time and resource investments. When combined with consistent rescuer and patient-physiologic monitoring, these innovations allow an unprecedented capacity to personalize cardiac arrest resuscitation to patient-specific pathophysiology. However, as more extensive options are established, it can be difficult for providers to incorporate novel resuscitation techniques into a cardiac arrest protocol which can fit a wide variety of cases with varying complexity. This article will explore recent advances in our understanding of cardiac arrest physiology and resuscitation sciences, with particular focus on the metabolic phase after significant ischemia has been induced. To this end, we establish a practical consideration for providers seeking to integrate novel advances in cardiac arrest resuscitation into daily practice.
Collapse
Affiliation(s)
- Cyrus E Kuschner
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra Boulevard, Hempstead, NY, 11549, USA
| | - Lance B Becker
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra Boulevard, Hempstead, NY, 11549, USA
| |
Collapse
|
35
|
Ameloot K, De Deyne C, Eertmans W, Ferdinande B, Dupont M, Palmers PJ, Petit T, Nuyens P, Maeremans J, Vundelinckx J, Vanhaverbeke M, Belmans A, Peeters R, Demaerel P, Lemmens R, Dens J, Janssens S. Early goal-directed haemodynamic optimization of cerebral oxygenation in comatose survivors after cardiac arrest: the Neuroprotect post-cardiac arrest trial. Eur Heart J 2019; 40:1804-1814. [DOI: 10.1093/eurheartj/ehz120] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 12/02/2018] [Accepted: 03/06/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- Koen Ameloot
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, Genk, Belgium
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
- Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
| | - Cathy De Deyne
- Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
- Department of Anesthesiology and Critical Care Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Ward Eertmans
- Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
- Department of Anesthesiology and Critical Care Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Bert Ferdinande
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, Genk, Belgium
| | - Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, Genk, Belgium
| | - Pieter-Jan Palmers
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, Genk, Belgium
| | - Tibaut Petit
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, Genk, Belgium
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Philippe Nuyens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, Genk, Belgium
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Joren Maeremans
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, Genk, Belgium
- Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
| | - Joris Vundelinckx
- Department of Anesthesiology and Critical Care Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium
| | | | - Ann Belmans
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Ronald Peeters
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Philippe Demaerel
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Robin Lemmens
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
- VIB, Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium
- Department of Neurosciences, Experimental Neurology, and Leuven Brain Institute (LBI), KU Leuven, University of Leuven, Leuven, Belgium
| | - Jo Dens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, Genk, Belgium
- Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
| | - Stefan Janssens
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
36
|
Sandroni C, Parnia S, Nolan JP. Cerebral oximetry in cardiac arrest: a potential role but with limitations. Intensive Care Med 2019; 45:904-906. [PMID: 30840118 DOI: 10.1007/s00134-019-05572-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 02/15/2019] [Indexed: 11/24/2022]
Affiliation(s)
- Claudio Sandroni
- Istituto Anestesiologia e Rianimazione, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Largo Francesco Vito, 1, 00168, Rome, Italy
| | - Sam Parnia
- Division of Pulmonary, Critical Care and Sleep Medicine, New York University Langone Medical Center, 462 First Avenue, OBV, 6th Floor, CD621, New York, NY, 10016, USA
| | - Jerry P Nolan
- Department of Anaesthesia, Royal United Hospital, Bath, UK. .,Warwick Medical School, University of Warwick, Coventry, CV4 7A, UK.
| |
Collapse
|
37
|
Ben-Hamouda N, Oddo M. Monitorage cérébral après arrêt cardiaque : techniques et utilité clinique potentielle. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
L’arrêt cardiaque cause une hypoxie-ischémie globale, suivi de reperfusion, qui est susceptible d’engendrer des effets délétères sur la perfusion et l’oxygénation cérébrales, ainsi que le métabolisme cellulaire. Dans ce contexte, et en l’absence de thérapies spcéfiques de l’ischémie-reperfusion globale, le traitement est essentiellement de soutien, visant à optimiser la perfusion et l’oxygénation cérébrale, dans le but de prévenir ou atténuer les dégâts secondaires sur la fonction cérébrale. Dans ce contexte, le monitorage cérébral multimodal, notamment les techniques non-invasives, ont une utilité potentielle à la phase agiuë de l’arrêt cardiaque. Le but prinicpal de cette revue est de décrire les techniques actuellement dipsonibles, en nous focalisant surtout sur les outils noninvasifs (doppler transcranien, spectrospcope de proche infrarouge, électroencéphalographie, pupillométrie automatisée proche infrarouge), leur utilité clinique potentielle ainsi que leurs limitations, dans la prise en charge aiguë (optimisation de la perfusion et de l’oxygénation cérébrales) ainsi que pour la détermination du pronostic précoce après arrêt cardiaque.
Collapse
|
38
|
The impact of diastolic blood pressure values on the neurological outcome of cardiac arrest patients. Resuscitation 2018; 130:167-173. [PMID: 30031784 DOI: 10.1016/j.resuscitation.2018.07.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 07/12/2018] [Accepted: 07/18/2018] [Indexed: 12/22/2022]
Abstract
AIM Which haemodynamic variable is the best predictor of neurological outcome remains unclear. We investigated the association of several haemodynamic variables with neurological outcome in CA patients. METHODS Retrospective analysis of adult comatose survivors of CA admitted to the intensive care unit (ICU) of a University Hospital. Exclusion criteria were early death due to withdrawal of care, missing haemodynamic data and use of intra-aortic balloon pump or extracorporeal membrane oxygenation. We retrieved CA characteristics; lactate concentration and cardiovascular sequential organ failure assessment (cSOFA) score on admission; systolic (SAP), diastolic (DAP), mean arterial pressure (MAP), and the use of vasopressors and inotropic agents during the first 6 h of ICU stay. Unfavourable neurological outcome (UO) was defined as a 3-month cerebral performance category score of 3-5. RESULTS Among the 170 patients (median age 63 years, 67% male, 60% out-of-hospital CA), 106 (63%) had UO. Admission lactate was higher in patients with UO than in those with favourable neurological outcome (4.0[2.4-7.3] vs. 2.5[1.4-6.0] mEq/L; p = 0.003) as was the cSOFA (3 [1-4] vs. 2[0-3]; p = 0.007). The lowest DAP during the first 6 h after ICU admission was significantly lower in patients with unfavourable neurological outcome, notably in patients with high cSOFA scores. In multivariable analysis, high adrenaline doses and the lowest value of DAP during the first 6 h after ICU admission was significantly associated with unfavourable neurological outcome. CONCLUSIONS In CA patients admitted to the ICU, low DAP during the first 6 h is an independent predictor of unfavourable neurological outcome at 3 months.
Collapse
|
39
|
Russo JJ, Di Santo P, Simard T, James TE, Hibbert B, Couture E, Marbach J, Osborne C, Ramirez FD, Wells GA, Labinaz M, Le May MR. Optimal mean arterial pressure in comatose survivors of out-of-hospital cardiac arrest: An analysis of area below blood pressure thresholds. Resuscitation 2018; 128:175-180. [DOI: 10.1016/j.resuscitation.2018.04.028] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 03/31/2018] [Accepted: 04/20/2018] [Indexed: 12/15/2022]
|