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Shehatta AL, Kaddoura R, Orabi B, Mohamed Ibrahim MI, El-Menyar A, Alyafei SA, Alkhulaifi A, Ibrahim AS, Hassan IF, Omar AS. Extracorporeal Membrane Oxygenation Pathway for Management of Refractory Cardiac Arrest: a Retrospective Study From a National Center of Extracorporeal Cardiopulmonary Resuscitation. Crit Pathw Cardiol 2024; 23:149-158. [PMID: 38381697 DOI: 10.1097/hpc.0000000000000352] [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: 02/23/2024]
Abstract
BACKGROUND Cardiac arrest remains a critical condition with high mortality and catastrophic neurological impact. Extracorporeal cardiopulmonary resuscitation (ECPR) has been introduced as an adjunct in cardiopulmonary resuscitation modalities. However, survival with good neurological outcomes remains a major concern. This study aims to explore our early experience with ECPR and identify the factors associated with survival in patients presenting with refractory cardiac arrest. METHODS This is a retrospective cohort study analyzing 6-year data from a tertiary center, the country reference for ECPR. This study was conducted at a national center of ECPR. Participants of this study were adult patients who experienced witnessed refractory cardiopulmonary arrest and were supported by ECPR. ECPR was performed for eligible patients as per the local service protocols. RESULTS Data from 87 patients were analyzed; of this cohort, 62/87 patients presented with in-hospital cardiac arrest (IHCA) and 25/87 presented with out-of-hospital cardiac arrest (OHCA). Overall survival to decannulation and hospital discharge rates were 26.4% and 25.3%, respectively. Among survivors (n = 22), 19 presented with IHCA (30.6%), while only 3 survivors presented with OHCA (12%). A total of 15/87 (17%) patients were alive at 6-month follow-up. All survivors had good neurological function assessed as Cerebral Performance Category 1 or 2. Multivariate logistic regression to predict survival to hospital discharge showed that IHCA was the only independent predictor (odds ratio: 5.8, P = 0.042); however, this positive association disappeared after adjusting for the first left ventricular ejection fraction after resuscitation. CONCLUSIONS In this study, the use of ECPR for IHCA was associated with a higher survival to discharge compared to OHCA. This study demonstrated a comparable survival rate to other established centers, particularly for IHCA. Neurological outcomes were comparable in both IHCA and OHCA survivors. However, large multicenter studies are warranted for better understanding and improving the outcomes.
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Affiliation(s)
- Ahmed Labib Shehatta
- From the Department of Medicine, Medical Intensive Care Unit, Hamad General Hospital, Doha, Qatar
- Department of Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Rasha Kaddoura
- Department of Pharmacy, Heart Hospital, Hamad Medical Corporation, Qatar
| | - Bassant Orabi
- Department of Pharmacy, Heart Hospital, Hamad Medical Corporation, Qatar
| | | | - Ayman El-Menyar
- Department of Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
- Department of Clinical Research, Trauma and Vascular Surgery, Hamad Medical Corporation
| | | | - Abdulaziz Alkhulaifi
- Department of Cardiothoracic Surgery Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Abdulsalam Saif Ibrahim
- From the Department of Medicine, Medical Intensive Care Unit, Hamad General Hospital, Doha, Qatar
- Department of Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Ibrahim Fawzy Hassan
- From the Department of Medicine, Medical Intensive Care Unit, Hamad General Hospital, Doha, Qatar
- Department of Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Amr S Omar
- Department of Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
- Department of Cardiothoracic Surgery Heart Hospital, Hamad Medical Corporation, Doha, Qatar
- Department of Critical Care Medicine, Beni Suef University, Egypt
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El-Menyar A, Wahlen BM. Cardiac arrest, stony heart, and cardiopulmonary resuscitation: An updated revisit. World J Cardiol 2024; 16:126-136. [PMID: 38576519 PMCID: PMC10989225 DOI: 10.4330/wjc.v16.i3.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/17/2024] [Accepted: 02/26/2024] [Indexed: 03/21/2024] Open
Abstract
The post-resuscitation period is recognized as the main predictor of cardiopulmonary resuscitation (CPR) outcomes. The first description of post-resuscitation syndrome and stony heart was published over 50 years ago. Major manifestations may include but are not limited to, persistent precipitating pathology, systemic ischemia/reperfusion response, post-cardiac arrest brain injury, and finally, post-cardiac arrest myocardial dysfunction (PAMD) after successful resuscitation. Why do some patients initially survive successful resuscitation, and others do not? Also, why does the myocardium response vary after resuscitation? These questions have kept scientists busy for several decades since the first successful resuscitation was described. By modifying the conventional modalities of resuscitation together with new promising agents, rescuers will be able to salvage the jeopardized post-resuscitation myocardium and prevent its progression to a dismal, stony heart. Community awareness and staff education are crucial for shortening the resuscitation time and improving short- and long-term outcomes. Awareness of these components before and early after the restoration of circulation will enhance the resuscitation outcomes. This review extensively addresses the underlying pathophysiology, management, and outcomes of post-resuscitation syndrome. The pattern, management, and outcome of PAMD and post-cardiac arrest shock are different based on many factors, including in-hospital cardiac arrest vs out-of-hospital cardiac arrest (OHCA), witnessed vs unwitnessed cardiac arrest, the underlying cause of arrest, the duration, and protocol used for CPR. Although restoring spontaneous circulation is a vital sign, it should not be the end of the game or lone primary outcome; it calls for better understanding and aggressive multi-disciplinary interventions and care. The development of stony heart post-CPR and OHCA remain the main challenges in emergency and critical care medicine.
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Affiliation(s)
- Ayman El-Menyar
- Department of Trauma and Vascular Surgery, Clinical Research, Hamad Medical Corporation, Doha 3050, Qatar
- Department of Clinical Medicine, Weill Cornell Medical College, Doha 24144, Qatar.
| | - Bianca M Wahlen
- Department of Anesthesiology, Hamad Medical Corporation, Doha 3050, Qatar
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De Giorgio D, Olivari D, Fumagalli F, Novelli D, Cerrato M, Motta F, Ristagno G, Latini R, Staszewsky L. Post-cardiac arrest temporal evolution of left ventricular function in a rat model: speckle-tracking echocardiography and cardiac circulating biomarkers. EUROPEAN HEART JOURNAL. IMAGING METHODS AND PRACTICE 2024; 2:qyae006. [PMID: 39045191 PMCID: PMC11195708 DOI: 10.1093/ehjimp/qyae006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 01/30/2024] [Indexed: 07/25/2024]
Abstract
Aims There is little information from experimental studies regarding the evolution of post-resuscitation cardiac arrest [post-return of spontaneous circulation (post-ROSC)] myocardial dysfunction during mid-term follow-up. For this purpose, we assessed left ventricular (LV) function and circulating cardiac biomarkers at different time points in a rat model of cardiac arrest (CA). Methods and results Rats were divided into two groups: control and post-ROSC rats. Eight minutes of untreated ventricular fibrillation were followed by 8 min of cardiopulmonary resuscitation. Conventional and speckle-tracking echocardiographic (STE) parameters and cardiac circulating biomarkers concentrations were assessed, at 3, 4, 72, and 96 h post-ROSC. At 3 and 4 h post-ROSC, LV systolic function was severely impaired, and high-sensitivity cardiac troponin T and N-terminal pro-atrial natriuretic peptide (NT-proANP) plasma concentrations were significantly increased, compared with control rats (P < 0.0001 for all). At 72 and 96 h post-ROSC, LV ejection fraction (LVEF) normalized. At 96 h, the following variables were significantly different from control rats: early trans-mitral peak velocity, 56.8 ± 3.1 vs. 87.8 ± 3.8 cm/s, P < 0.0001; late trans-mitral peak velocity, 50.6 ± 4.7 vs. 73.7 ± 4.2 cm/s, P < 0.0001; mean s' wave velocity, 4.6 ± 0.3 vs. 5.9 ± 0.3 cm/s, P < 0.0001, global longitudinal strain (GLS) -7.5 ± 0.5 and vs. -11 ± 1.2%, P < 0.01; GLS rate (GLSR) -0.9 ± 0.4 and -2.3 ± 0.2 1/s, P < 0.01; and NT-proANP concentration, 2.5 (0.2; 6.0) vs. 0.4 (0.01; 1.0) nmol/L, P < 0.01. Conclusion s' velocity, GLS, and GLSR indicated that LV systolic function was still impaired 96 h post-ROSC. These findings agree with NT-proANP concentrations, which continue to be high. Normalization of LVEF supports the use of STE for its greater sensitivity for monitoring post-CA cardiac function. Further investigations are needed to provide evidence of the post-ROSC LV diastolic function pattern.
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Affiliation(s)
- Daria De Giorgio
- Department of Cardiovascular Medicine, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156 Milan, Italy
| | - Davide Olivari
- Department of Cardiovascular Medicine, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156 Milan, Italy
| | - Francesca Fumagalli
- Department of Cardiovascular Medicine, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156 Milan, Italy
| | - Deborah Novelli
- Department of Cardiovascular Medicine, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156 Milan, Italy
| | - Marianna Cerrato
- Department of Cardiovascular Medicine, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156 Milan, Italy
| | - Francesca Motta
- Department of Cardiovascular Medicine, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156 Milan, Italy
| | - Giuseppe Ristagno
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
| | - Roberto Latini
- Department of Cardiovascular Medicine, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156 Milan, Italy
| | - Lidia Staszewsky
- Department of Cardiovascular Medicine, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156 Milan, Italy
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Vis A, Lammers JC, de Vroege R, van Nieuwburg MM, Jansen MS, Visser JM, Meuris B, Gründeman PF, Kluin J. Strategies to Improve Survival from Surgery for Heart Valve Implantation in Sheep. Comp Med 2021; 71:235-239. [PMID: 34082857 DOI: 10.30802/aalas-cm-20-000118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Sheep are a commonly used and validated model for cardiovascular research and, more specifically, for heart valve research. Implanting a heart valve on the arrested heart in sheep is complex and is often complicated by difficulties in restarting the heart, causing significant on-table mortality. Therefore, optimal cardioprotective management during heart valve implantation in sheep is essential. However, little is known about successful cardioprotective management techniques in sheep. This article reports our experience in the cardioprotective management of 20 female sheep that underwent surgical aortic valve replacement with a stented tissue-engineered heart valve prosthesis. During this series of experiments, we modified our cardioprotection protocol to improve survival. We emphasize the importance of total body hypothermia and external cooling of the heart. Furthermore, we recommend repeated cardioplegia administration at 20 min intervals during surgery, with the final dosage of cardioplegia given immediately before the de-clamping of the aorta. To reduce the number of defibrillator shocks during a state of ventricular fibrillation (VF), we have learned to restart the heart by reclamping the aorta, administering cardioplegia until cardiac arrest, and de-clamping the aorta thereafter. Despite these encouraging results, more research is needed to finalize a protocol for this procedure.
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Affiliation(s)
- Annemijn Vis
- Department of Cardiothoracic Surgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Jan Cam Lammers
- Department of Extracorporeal Circulation, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Roel de Vroege
- Department of Extracorporeal Circulation, Haga Teaching Hospital, The Hague, The Netherlands
| | | | - Marlijn S Jansen
- Division Heart and Lungs, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joyce Mj Visser
- Division Heart and Lungs, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bart Meuris
- Department of Cardiac Surgery, KU Leuven, Leuven, Belgium
| | - Paul F Gründeman
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jolanda Kluin
- Department of Cardiothoracic Surgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands;,
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Gebremedhn EG, Gebregergs GB, Anderson BB. The knowledge level of final year undergraduate health science students and medical interns about cardiopulmonary resuscitation at a university teaching hospital of Northwest Ethiopia. World J Emerg Med 2014; 5:29-34. [PMID: 25215144 DOI: 10.5847/wjem.j.issn.1920-8642.2014.01.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 01/09/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cardiopulmonary resuscitation (CPR) is a life-saving technique which is used after cardiopulmonary arrest. Chance of survival after arrest will increase if it is coupled with sufficient knowledge. Final year undergraduate health science students and interns manage many trauma and critically ill patients in our hospital. Even though all students took CPR training in undergraduate course, we sometimes saw difficulties in the resuscitation of patients after cardiopulmonary arrest by undergraduate health professionals. This study was to assess the level of knowledge of undergraduate health science students and medical interns about cardiopulmonary resuscitation. METHODS Hospital based cross-sectional study was conducted from February 1 to March 30, 2013. All undergraduate health professionals were included. The mean score of knowledge was compared for sex, original residence and department of the participants by using Student's t test and ANOVA with Scheffe's test. P values <0.05 were considered statistically significant. RESULTS Four hundred sixty-one out of 506 students were included in this study with a response rate of 91.1%. The overall mean knowledge score of final year undergraduate health science students and interns was 11.1 (SD=0.2). The mean knowledge scores of nurses, interns, health officer, midwifery, anesthesia and psychiatry nursing students were 9.84 (SD=2.5), 13.34 (SD=2.8), 9.81 (SD=3.0), 8.77 (SD=2.6), 13.31 (SD=2.7) and 8.43 (SD=2.4) respectively. CONCLUSIONS The knowledge level of undergraduate health professionals about cardiopulmonary resuscitation was insufficient. Training about CPR for undergraduate health professionals should be emphasized.
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Affiliation(s)
- Endale G Gebremedhn
- Department of Anesthesia, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Gebremedhn B Gebregergs
- Department of Public Health, Bahir Dar College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Bernard B Anderson
- Department of Surgery, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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6
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Trummer G, Foerster K, Buckberg GD, Benk C, Mader I, Heilmann C, Liakopoulos O, Beyersdorf F. Superior neurologic recovery after 15 minutes of normothermic cardiac arrest using an extracorporeal life support system for optimized blood pressure and flow. Perfusion 2013; 29:130-8. [PMID: 23885022 DOI: 10.1177/0267659113497776] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Sudden cardiac arrest is one of the leading causes of death. Conventional CPR techniques after cardiac arrest provide circulation with reduced and varying blood flow and pressure. We hypothesize that using pressure- and flow-controlled reperfusion of the whole body improves neurological recovery and survival after 15 min of normothermic cardiac arrest. METHODS Pigs were randomized in two experimental groups and exposed to 15 min of ventricular fibrillation (VF). After this period, the animals in the control group received conventional CPR with open chest compression (n=6), while circulation in the treatment group (n=6) was established with an extracorporeal life support system (ECLS) to control blood pressure and flow. Follow-up included the assessment of neurological recovery and magnetic resonance imaging (MRI) for up to 7 days. RESULTS Five of the six animals in the control group died, one animal was resuscitated successfully. In the treatment group, 1/6 could not be separated from ECLS. Five out of the six pigs survived and were transferred to the animal facility. One animal was unable to walk and had to be sacrificed 30 hours after ECLS. The remaining 4 animals of the treatment group and the surviving pig from the control group showed complete neurological recovery. Brain MRI revealed no pathological changes. CONCLUSION We were able to demonstrate a significant improvement in survival after 15 minutes of normothermic cardiac arrest. These results support our hypothesis that using an ECLS for pressure- and flow-controlled circulation after circulatory arrest is superior to conventional CPR.
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Affiliation(s)
- G Trummer
- 1Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
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7
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Foerster K, D'Inka M, Beyersdorf F, Benk C, Nguyen-Thanh T, Mader I, Fritsch B, Ihling C, Mueller K, Heilmann C, Trummer G. Prolonged cardiac arrest and resuscitation by extracorporeal life support: favourable outcome without preceding anticoagulation in an experimental setting. Perfusion 2013; 28:520-8. [PMID: 23827862 DOI: 10.1177/0267659113495081] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
State-of-the-art cardiopulmonary resuscitation (CPR) restores circulation with inconsistent blood-flow and pressure. Extracorporeal life support (ECLS) following CPR opens the opportunity for "controlled reperfusion". In animal experiments investigating CPR with ECLS, systemic anticoagulation before induced cardiac arrest is normal, but a major point of dispute, since preliminary heparinization in patients undergoing unwitnessed cardiac arrest is impossible. In this study, we investigated options for ECLS after an experimental 15 minutes normothermic cardiac arrest, without preceding anticoagulation, in pigs. Neurological recovery was assessed by a scoring system, electroencephalography and brain magnetic resonance imaging. Additionally, brain histology was performed on day seven after cardiac arrest. We demonstrated that preliminary heparin administration was not necessary for survival or neurological recovery in this setting. Heparin flushing of the cannulae seemed sufficient to avoid thrombus formation. These findings may ease the way to using ECLS in patients with sudden cardiac arrest.
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Affiliation(s)
- K Foerster
- 1Heart Center Freiburg University, Freiburg, Germany
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8
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Early Enhanced External Counter Pulsation Improves Neurological Recovery After the Return of Spontaneous Circulation in a Mongrel Dog Cardiac Arrest Model*. Crit Care Med 2013; 41:e62-73. [DOI: 10.1097/ccm.0b013e318278b469] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Stub D, Byrne M, Pellegrino V, Kaye DM. Extracorporeal membrane oxygenation to support cardiopulmonary resuscitation in a sheep model of refractory ischaemic cardiac arrest. Heart Lung Circ 2013; 22:421-7. [PMID: 23375811 DOI: 10.1016/j.hlc.2012.11.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2012] [Accepted: 11/24/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Survival after out-of-hospital cardiac arrest remains limited. It is therefore imperative to develop new resuscitation techniques. We aimed to determine the potential role of extracorporeal membrane oxygenation assisted CPR (ECPR) in an animal model of refractory ischaemic cardiac arrest. METHODS Twelve sheep were assigned to either ECPR (n=6) or 'conventional' (n=6) resuscitation. All sheep had coronary occlusion, followed by induction of ventricular fibrillation (VF). CPR was than commenced for 10 min in both groups, followed by randomisation to ECPR or CPR for a further 10 min. At 23 min post induction of VF, advanced life support measures were commenced with direct cardioversion, adrenaline and amiodarone. Outcomes measures included rates of return of spontaneous circulation (ROSC), and analysis of VF wave form. RESULTS Baseline haemodynamics were similar between the two groups. CPR consistently produced coronary perfusion pressures (CPP) greater than 15 mmHg in both groups, with significantly increased CPP post commencement of ECMO in the ECPR group (17.84±2 mmHg vs 22.94±3 mmHg, p=0.04). Number of shocks, pH, lactate and oxygenation were also comparable. Significantly greater rates of ROSC were seen in the ECPR sheep, 3/6 (50%) vs 0/6 (0%) (p=0.032), which was also associated with significantly increased VF amplitude measures (0.51±0.08 mV vs 0.42±0.06 mV, p=0.04). CONCLUSIONS This study indicates that ECPR increases return of circulation and coronary perfusion pressure in a sheep model of ischaemic VF arrest. Our findings have supported the development of a pilot trial into the effectiveness and feasibility of ECPR in the clinical setting.
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Affiliation(s)
- Dion Stub
- Baker IDI Heart and Diabetes Institute, Melbourne, Australia.
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10
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Aufhauser DD, Rose T, Levine M, Barnett R, Ochroch EA, Aukburg S, Greenblatt E, Olthoff K, Shaked A, Abt P. Cardiac arrest associated with reperfusion of the liver during transplantation: incidence and proposal for a management algorithm. Clin Transplant 2012; 27:185-92. [DOI: 10.1111/ctr.12052] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2012] [Indexed: 11/30/2022]
Affiliation(s)
- David D. Aufhauser
- Department of Surgery; Hospital of the University of Pennsylvania; Philadelphia; PA; USA
| | - Tom Rose
- Department of Surgery; Hospital of the University of Pennsylvania; Philadelphia; PA; USA
| | - Matthew Levine
- Department of Surgery; Hospital of the University of Pennsylvania; Philadelphia; PA; USA
| | - Rebecca Barnett
- Department of Anesthesia; Hospital of the University of Pennsylvania; Philadelphia; PA; USA
| | - E. Andrew Ochroch
- Department of Anesthesia; Hospital of the University of Pennsylvania; Philadelphia; PA; USA
| | - Stanley Aukburg
- Department of Anesthesia; Hospital of the University of Pennsylvania; Philadelphia; PA; USA
| | - Eric Greenblatt
- Department of Anesthesia; Hospital of the University of Pennsylvania; Philadelphia; PA; USA
| | - Kim Olthoff
- Department of Surgery; Hospital of the University of Pennsylvania; Philadelphia; PA; USA
| | - Abraham Shaked
- Department of Surgery; Hospital of the University of Pennsylvania; Philadelphia; PA; USA
| | - Peter Abt
- Department of Surgery; Hospital of the University of Pennsylvania; Philadelphia; PA; USA
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12
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Ultrastructural evidence of mitochondrial abnormalities in postresuscitation myocardial dysfunction. Resuscitation 2012; 83:386-94. [DOI: 10.1016/j.resuscitation.2011.08.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Revised: 07/20/2011] [Accepted: 08/11/2011] [Indexed: 11/20/2022]
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Chalkias A, Xanthos T. Post-cardiac arrest syndrome: Mechanisms and evaluation of adrenal insufficiency. World J Crit Care Med 2012; 1:4-9. [PMID: 24701395 PMCID: PMC3956066 DOI: 10.5492/wjccm.v1.i1.4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Revised: 10/18/2011] [Accepted: 12/21/2011] [Indexed: 02/06/2023] Open
Abstract
Cardiac arrest is one of the leading causes of death and represents maximal stress in humans. After restoration of spontaneous circulation, post-cardiac arrest syndrome is the predominant disorder in survivors. Besides the post-arrest brain injury, the post-resuscitation myocardial stunning, and the systemic ischemia/reperfusion response, this syndrome is characterized by adrenal insufficiency, a disorder that often remains undiagnosed. The pathophysiology of adrenal insufficiency has not been elucidated. We performed a comprehensive search of three medical databases in order to describe the major pathophysiological disturbances which are responsible for the occurrence of the disorder. Based on the available evidence, this article will help physicians to better evaluate and understand the hidden yet deadly post-cardiac arrest adrenal insufficiency.
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Affiliation(s)
- Athanasios Chalkias
- Athanasios Chalkias, Theodoros Xanthos, Department of Anatomy, Medical School, University of Athens, 11527 Athens, Greece
| | - Theodoros Xanthos
- Athanasios Chalkias, Theodoros Xanthos, Department of Anatomy, Medical School, University of Athens, 11527 Athens, Greece
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Chalkias A, Xanthos T. Post-cardiac arrest brain injury: pathophysiology and treatment. J Neurol Sci 2012; 315:1-8. [PMID: 22251931 DOI: 10.1016/j.jns.2011.12.007] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Revised: 12/15/2011] [Accepted: 12/19/2011] [Indexed: 12/31/2022]
Abstract
Cardiac arrest is a leading cause of death that affects more than a million individuals worldwide every year. Despite the recent advancement in the field of cardiac arrest and resuscitation, the management and prognosis of post-cardiac arrest brain injury remain suboptimal. The pathophysiology of post-cardiac arrest brain injury involves a complex cascade of molecular events, most of which remain unknown. Considering that a potentially broad therapeutic window for neuroprotective drug therapy is offered in most successfully resuscitated patient after cardiac arrest, the need for further research is imperative. The aim of this article is to present the major pathophysiological disturbances leading to post-cardiac arrest brain injury, as well as to review the available pharmacological therapies.
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Affiliation(s)
- Athanasios Chalkias
- National and Kapodistrian University of Athens, Medical School, Department of Anatomy, Greece.
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15
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Abstract
Caring in the emergency department for the patient with return of spontaneous circulation after cardiac arrest is challenging. A coordinated and systematic approach to post-cardiac arrest care can improve the mortality and the chance of meaningful neurologic recovery. By achieving appropriate targets for oxygenation, ventilation, and hemodynamic parameters, along with initiating therapeutic hypothermia and arranging early percutaneous coronary intervention, the emergency physician can have the most significant impact on patients who have just been revived from death.
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Meybohm P, Gruenewald M, Albrecht M, Müller C, Zitta K, Foesel N, Maracke M, Tacke S, Schrezenmeir J, Scholz J, Bein B. Pharmacological postconditioning with sevoflurane after cardiopulmonary resuscitation reduces myocardial dysfunction. Crit Care 2011; 15:R241. [PMID: 22011328 PMCID: PMC3334792 DOI: 10.1186/cc10496] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Revised: 09/07/2011] [Accepted: 10/19/2011] [Indexed: 11/22/2022] Open
Abstract
Introduction In this study, we sought to examine whether pharmacological postconditioning with sevoflurane (SEVO) is neuro- and cardioprotective in a pig model of cardiopulmonary resuscitation. Methods Twenty-two pigs were subjected to cardiac arrest. After 8 minutes of ventricular fibrillation and 2 minutes of basic life support, advanced cardiac life support was started. After successful return of spontaneous circulation (N = 16), animals were randomized to either (1) propofol (CONTROL) anesthesia or (2) SEVO anesthesia for 4 hours. Neurological function was assessed 24 hours after return of spontaneous circulation. The effects on myocardial and cerebral damage, especially on inflammation, apoptosis and tissue remodeling, were studied using cellular and molecular approaches. Results Animals treated with SEVO had lower peak troponin T levels (median [IQR]) (CONTROL vs SEVO = 0.31 pg/mL [0.2 to 0.65] vs 0.14 pg/mL [0.09 to 0.25]; P < 0.05) and improved left ventricular systolic and diastolic function compared to the CONTROL group (P < 0.05). SEVO was associated with a reduction in myocardial IL-1β protein concentrations (0.16 pg/μg total protein [0.14 to 0.17] vs 0.12 pg/μg total protein [0.11 to 0.14]; P < 0.01), a reduction in apoptosis (increased procaspase-3 protein levels (0.94 arbitrary units [0.86 to 1.04] vs 1.18 arbitrary units [1.03 to 1.28]; P < 0.05), increased hypoxia-inducible factor (HIF)-1α protein expression (P < 0.05) and increased activity of matrix metalloproteinase 9 (P < 0.05). SEVO did not, however, affect neurological deficit score or cerebral cellular and molecular pathways. Conclusions SEVO reduced myocardial damage and dysfunction after cardiopulmonary resuscitation in the early postresuscitation period. The reduction was associated with a reduced rate of myocardial proinflammatory cytokine expression, apoptosis, increased HIF-1α expression and increased activity of matrix metalloproteinase 9. Early administration of SEVO may not, however, improve neurological recovery.
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Affiliation(s)
- Patrick Meybohm
- Department of Anaesthesiology and Intensive Care Medicine, Schleswig-Holstein University Hospital, Campus Kiel, Schwanenweg 21, D-24105 Kiel, Germany.
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Chalkias A, Xanthos T. Pathophysiology and pathogenesis of post-resuscitation myocardial stunning. Heart Fail Rev 2011; 17:117-28. [DOI: 10.1007/s10741-011-9255-1] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Ji XF, Li CS, Wang S, Yang L, Cong LH. Comparison of the efficacy of nifekalant and amiodarone in a porcine model of cardiac arrest. Resuscitation 2010; 81:1031-6. [PMID: 20627529 DOI: 10.1016/j.resuscitation.2010.04.023] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2010] [Revised: 03/18/2010] [Accepted: 04/01/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To compare the efficacy of nifekalant and amiodarone in the treatment of cardiac arrest in a porcine model. METHODS After 4min of untreated ventricular fibrillation, animals were randomly treated with nifekalant (2mgkg(-1)), amiodarone (5mgkg(-1)) or saline placebo (n=12 pigs per group). Precordial compression and ventilation were initiated after drug administration and defibrillation was attempted 2min later. Hemodynamics were continuously measured for 6h after successful resuscitation. RESULTS Compared with saline, nifekalant and amiodarone equally decreased the number of electric shocks, defibrillation energy, epinephrine dose, and duration of cardiopulmonary resuscitation required for successful resuscitation (P<0.01). The incidence of restoration of spontaneous circulation (ROSC) and the 24-h survival rate were higher in both antiarrhythmic drug groups (P<0.05) vs. the saline group. Furthermore, post-resuscitation myocardial dysfunction at 4-6h after successful resuscitation was improved in animals given antiarrhythmic drugs as compared with the saline group (P<0.05). There were no differences between nifekalant and amiodarone for any of these parameters. CONCLUSION The effect of nifekalant was similar to that of amiodarone for improving defibrillation efficacy and for the treatment of cardiac arrest. Administration of either nifekalant or amiodarone before defibrillation increased the ROSC and 24-h survival rates and improved post-resuscitation cardiac function in this porcine model.
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Affiliation(s)
- Xian-Fei Ji
- Department of Emergency, Beijing Chaoyang Hospital, Capital Medical University, 8# Baijiazhuang Road, Chaoyang District, Beijing 100020, China
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Liakopoulos OJ, Allen BS, Buckberg GD, Hristov N, Tan Z, Villablanca JP, Trummer G. Resuscitation After Prolonged Cardiac Arrest: Role of Cardiopulmonary Bypass and Systemic Hyperkalemia. Ann Thorac Surg 2010; 89:1972-9. [DOI: 10.1016/j.athoracsur.2010.02.052] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Revised: 02/10/2010] [Accepted: 02/12/2010] [Indexed: 10/19/2022]
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Successful resuscitation after prolonged periods of cardiac arrest: A new field in cardiac surgery. J Thorac Cardiovasc Surg 2010; 139:1325-32, 1332.e1-2. [DOI: 10.1016/j.jtcvs.2009.08.046] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2009] [Revised: 07/23/2009] [Accepted: 08/09/2009] [Indexed: 11/23/2022]
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Martín-Hernández H, López-Messa JB, Pérez-Vela JL, Molina-Latorre R, Cárdenas-Cruz A, Lesmes-Serrano A, Alvarez-Fernández JA, Fonseca-San Miguel F, Tamayo-Lomas LM, Herrero-Ansola YP. [Managing the post-cardiac arrest syndrome. Directing Committee of the National Cardiopulmonary Resuscitation Plan (PNRCP) of the Spanish Society for Intensive Medicine, Critical Care and Coronary Units (SEMICYUC)]. Med Intensiva 2009; 34:107-26. [PMID: 19931943 DOI: 10.1016/j.medin.2009.09.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2009] [Revised: 08/07/2009] [Accepted: 09/10/2009] [Indexed: 11/27/2022]
Abstract
Since the advent of cardiopulmonary resuscitation more than 40 years ago, we have achieved a return to spontaneous circulation in a growing proportion of patients with cardiac arrest. Nevertheless, most of these patients die in the first few days after admission to the intensive care unit (ICU), and this situation has not improved over the years. Mortality in these patients is mainly associated to brain damage. Perhaps recognizing that cardiopulmonary resuscitation does not end with the return of spontaneous circulation but rather with the return of normal brain function and total stabilization of the patient would help improve the therapeutic management of these patients in the ICU. In this sense, the term cardiocerebral resuscitation proposed by some authors might be more appropriate. The International Liaison Committee on Resuscitation recently published a consensus document on the "Post-Cardiac Arrest Syndrome" and diverse authors have proposed that post-arrest care be integrated as the fifth link in the survival chain, after early warning, early cardiopulmonary resuscitation by witnesses, early defibrillation, and early advanced life support. The therapeutic management of patients that recover spontaneous circulation after cardiopulmonary resuscitation maneuvers based on life support measures and a series of improvised actions based on "clinical judgment" might not be the best way to treat patients with post-cardiac arrest syndrome. Recent studies indicate that using goal-guided protocols to manage these patients including therapeutic measures of proven efficacy, such as inducing mild therapeutic hypothermia and early revascularization, when indicated, can improve the prognosis considerably in these patients. Given that there is no current protocol based on universally accepted evidence, the Steering Committee of the National Cardiopulmonary Resuscitation Plan of the Spanish Society of Intensive Medicine and Cardiac Units has elaborated this document after a thorough review of the literature and an online discussion involving all the members of the committee and a consensus meeting with the aim of providing a platform for the development of local protocols in different ICSs in our country to fit their own means and characteristics.
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Affiliation(s)
- H Martín-Hernández
- Servicio de Medicina Intensiva, Hospital Galdakao-Usansolo, Vizcaya, España
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El-Menyar AA, Davidson BL. Clinical implications of cytokines in the critical-care unit. Expert Rev Cardiovasc Ther 2009; 7:835-45. [PMID: 19589119 DOI: 10.1586/erc.09.46] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
To understand the role of different cytokines in the pathophysiology and management of different acute cardiovascular disorders in critically ill patients, we reviewed most of the pertinent articles published on Medline, Scopus and EBSCO host research databases from 1985 to January 2009. We used the indexing terms 'cytokines', 'cardiovascular', 'sepsis', 'critical care', 'myocardial dysfunction', 'shock', 'thromboembolism', 'inflammatory' and 'arrhythmias'. Myocardial dysfunction, dysrhythmic and thromboembolic disorders all appear associated with important fluctuations in cytokines. When and how to sample cytokine levels and the ways in which cytokines contribute to patient deterioration or improvement require further clinical studies. The measurement and interplay of several different cytokines may ultimately be of substantial clinical importance in the diagnosis, treatment and prognosis of patients with different acute cardiovascular disorders managed by critical-care physicians in intensive-care units. Although the role of cytokines in cardiovascular disorders is debatable, the clinical implication of cytokines in the critical-care unit is a new horizon that warrants more attention.
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Affiliation(s)
- Ayman A El-Menyar
- Weill Cornell Medical College and Hamad General Hospital, Department of Cardiology and Cardiovascular Surgery, HMC, Doha, State of Qatar.
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CARDIOPROTECTIVE EFFECT OF THERAPEUTIC HYPOTHERMIA FOR POSTRESUSCITATION MYOCARDIAL DYSFUNCTION. Shock 2009; 32:210-6. [DOI: 10.1097/shk.0b013e318196ee99] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Utstein style study of cardiopulmonary bypass after cardiac arrest. Am J Emerg Med 2008; 26:649-54. [PMID: 18606315 DOI: 10.1016/j.ajem.2007.09.019] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2007] [Revised: 09/27/2007] [Accepted: 09/29/2007] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The aim of this study is to describe the effect emergency cardiopulmonary bypass (CPB) for resuscitation on the survival rate of patients. METHODS The study population was composed of persons 16 years or older who had out-of-hospital cardiac arrest and were transferred to the Sapporo Medical University Hospital from the scene between January 1, 2000, and September 30, 2004. Children younger than 16 years and persons who were dead were excluded. Data were collected according to the Utstein style. Survival rates and cerebral performance category were analyzed using chi(2) analysis for the patients with presumed cardiac etiology. Cardiopulmonary bypass was applied to patients who showed no response with standard advanced cardiac life support. The interval from collapse and other noncardiac etiologies were considered criteria for exclusion. RESULTS Of the 919 patient medical records reviewed, CPB was performed in 92 patients. Of the 919 patients, 398 were of presumed cardiac etiology (n = 66 for CPB), 48 patients survived, and 24 patients (n = 7 for CPB) had a good cerebral outcome (cerebral performance category score 1). With CPB, the rate of survival at 3 months increased significantly (22.7% vs 9.9%, P < .05), but the rate of good cerebral outcome (10.6% vs 5.1%, P = .087) showed a positive trend. CONCLUSION The use of CPB for arrest patients was associated with reduced mortality. It did not increase good neurologic outcome significantly. Still, 7 cases with intact central nervous system would have been lost without CPB.
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El-Menyar AA. Cytokines and myocardial dysfunction: state of the art. J Card Fail 2008; 14:61-74. [PMID: 18226775 DOI: 10.1016/j.cardfail.2007.09.006] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2007] [Revised: 09/07/2007] [Accepted: 09/10/2007] [Indexed: 12/13/2022]
Abstract
BACKGROUND Myocardial dysfunction has been associated with inflammation and cytokine modulation. OBJECTIVES The study objective was to understand the role of cytokines in the pathophysiology and management of myocardial dysfunction. METHODS Heart failure has been revisited with revision of the pertinent published articles in the Medline, Scopus, Cochrane Database of Systematic Reviews, and EBSCO Host research. RESULTS For the proinflammatory cytokines, illumination of this important point requires further diagnostic and therapeutic investigations. Data on chronic heart failure are not so reassuring; therefore, patients with advanced heart failure should not be treated with anticytokines at this time. CONCLUSION Further studies are warranted to pave the way for introducing cytokine and immunomodulation therapy at the optimal and appropriate time.
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Adams JA, Wu D, Bassuk J, Arias J, Lozano H, Kurlansky P, Lamas GA. Nitric oxide synthase isoform inhibition before whole body ischemia reperfusion in pigs: Vital or protective? Resuscitation 2007; 74:516-25. [PMID: 17466432 DOI: 10.1016/j.resuscitation.2007.02.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2007] [Revised: 02/06/2007] [Accepted: 02/08/2007] [Indexed: 11/19/2022]
Abstract
BACKGROUND Nitric oxide (NO) is a critical regulator of vascular tone, and signal transduction. NO is produced via three unique synthases (NOS); endothelial (eNOS), and neuronal (nNOS) are both constitutively expressed and inducible (iNOS) produced primarily after stimulation. NO has been implicated during and after ischemia reperfusion injury as both a detrimental and cardioprotective mediator. Since cardiopulmonary resuscitation (CPR) in ventricular fibrillation (VF) is a model of whole body ischemia reperfusion injury, it provides an opportunity to assess the effects of NO from the three NOS isoforms. OBJECTIVE To determine the differential role of nitric oxide synthase isoforms inhibition in ventricular fibrillation CPR and investigate whether inhibition of the NOS isoforms afford any cardioprotection in this model. METHODS Thirty-two pigs, weight range 25-35 kg, were assigned to four groups of eight animals each. The animals were randomized to receive (1) N(G)-nitro-L-arginine methyl ester (LNAME), a non-selective endothelial nitric oxide synthase inhibitor, (2) 1-(2-trifluoromethylphenyl) imidazole (TRIM), a selective neuronal NOS inhibitor, (3) aminoguanidine (AMINOG), a selective inducible NOS inhibitor or (4) saline control (Control) in equal volumes, 30 min before induction of ventricular fibrillation (VF). After 3 min VF with no intervention, the animals received standard chest compressions using an automated chest compression device (Thumper) for 15 min. After 18 min of VF, single doses of vasopressin and bicarbonate were given and defibrillation attempted. Hemodynamics, regional blood flows, and echocardiography and were performed, before and after drug infusion, during CPR, and after return of spontaneous circulation (ROSC). RESULTS ROSC for 3 h occurred in 5/8 (63%), 1/8 (13%), 0/8 (0%), and 6/8 (75%) in Control, LNAME, TRIM, and AMINOG treated animals, respectively. After infusion of LNAME, there was a significant increase from baseline in blood pressure [127+/-6 mmHg versus 169+/-3 mmHg, p<0.002] and coronary perfusion pressure [119+/-6 mmHg versus 149+/-6 mmHg, p<0.003]. During CPR, there were no differences among groups in hemodynamics or regional blood flow. In surviving animals, AMINOG had significantly better myocardial function (left ventricular ejection fraction, fractional shortening, and wall motion score index) than control or LNAME treated animals, and attenuated the post-resuscitation hyperemic response in heart and brain. CONCLUSIONS Intact basal nNOS activity is vital for survival from whole body ischemia reperfusion injury. iNOS inhibition prior to ischemia reperfusion, protects myocardial function after ROSC and decreases myocardial and brain hyperemic response after ROSC.
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Affiliation(s)
- Jose A Adams
- Division of Neonatology, Mount Sinai Medical Center, Miami Beach, FL 33140, United States.
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Rech TH, Vieira SRR, Nagel F, Brauner JS, Scalco R. Serum neuron-specific enolase as early predictor of outcome after in-hospital cardiac arrest: a cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2007; 10:R133. [PMID: 16978415 PMCID: PMC1751053 DOI: 10.1186/cc5046] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2006] [Revised: 08/18/2006] [Accepted: 09/15/2006] [Indexed: 11/10/2022]
Abstract
Introduction Outcome after cardiac arrest is mostly determined by the degree of hypoxic brain damage. Patients recovering from cardiopulmonary resuscitation are at great risk of subsequent death or severe neurological damage, including persistent vegetative state. The early definition of prognosis for these patients has ethical and economic implications. The main purpose of this study was to investigate the prognostic value of serum neuron-specific enolase (NSE) in predicting outcomes in patients early after in-hospital cardiac arrest. Methods Forty-five patients resuscitated from in-hospital cardiac arrest were prospectively studied from June 2003 to January 2005. Blood samples were collected, at any time between 12 and 36 hours after the arrest, for NSE measurement. Outcome was evaluated 6 months later with the Glasgow outcome scale (GOS). Patients were divided into two groups: group 1 (unfavorable outcome) included GOS 1 and 2 patients; group 2 (favorable outcome) included GOS 3, 4 and 5 patients. The Mann–Whitney U test, Student's t test and Fisher's exact test were used to compare the groups. Results The Glasgow coma scale scores were 6.1 ± 3 in group 1 and 12.1 ± 3 in group 2 (means ± SD; p < 0.001). The mean time to NSE sampling was 20.2 ± 8.3 hours in group 1 and 28.4 ± 8.7 hours in group 2 (p = 0.013). Two patients were excluded from the analysis because of sample hemolysis. At 6 months, favorable outcome was observed in nine patients (19.6%). Thirty patients (69.8%) died and four (9.3%) remained in a persistent vegetative state. The 34 patients (81.4%) in group 1 had significantly higher NSE levels (median 44.24 ng/ml, range 8.1 to 370) than those in group 2 (25.26 ng/ml, range 9.28 to 55.41; p = 0.034). Conclusion Early determination of serum NSE levels is a valuable ancillary method for assessing outcome after in-hospital cardiac arrest.
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Affiliation(s)
- Tatiana H Rech
- Serviço de Medicina Intensiva, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350. Largo Eduardo Z. Faraco, Porto Alegre, RS, 90035-903, Brazil
| | - Silvia Regina Rios Vieira
- Serviço de Medicina Intensiva, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350. Largo Eduardo Z. Faraco, Porto Alegre, RS, 90035-903, Brazil
| | - Fabiano Nagel
- Serviço de Medicina Intensiva, Complexo Hospitalar Santa Casa de Misericórdia de Porto Alegre, Rua Prof. Anes Dias, 295. Porto Alegre, RS, 90020-090, Brazil
| | - Janete Salles Brauner
- Serviço de Medicina Intensiva, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350. Largo Eduardo Z. Faraco, Porto Alegre, RS, 90035-903, Brazil
| | - Rosana Scalco
- Serviço de Patologia Clínica, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350. Largo Eduardo Z. Faraco, Porto Alegre, RS, 90035-903, Brazil
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Abstract
The endothelium is a viable target for injury, repair and cellular modulation. Because of its vast extension and active metabolic status of producing mediators for vasomotor tone, coagulation, and inflammation, it is a key target for therapy during ischemia/reperfusion injury. Cardiopulmonary resuscitation is a model of whole-body ischemia/reperfusion injury. It has become apparent that the endothelium participates in a host of responses elicited by ischemia/reperfusion. This review examines the role of the endothelium during and after ischemia/reperfusion and the participation by its mediators and evidence for endothelial involvement during and after cardiopulmonary resuscitation. The strategic location of the endothelium makes it an excellent signal transduction mechanism for a host of disease processes. In addition to biochemical stimuli, mechanical stimulation of the endothelium elicits production of several mediators, including endothelium-derived nitric oxide, prostaglandins, and antithrombotics and anticoagulants. Whole-body, periodic acceleration is a novel method of stimulating the endothelium via pulsatile shear stress. Periodic acceleration has been shown to be an effective experimental method of cardiopulmonary resuscitation, with evidence of postresuscitation cardioprotective effects. This review indicates that understanding endothelial modulation during and after ischemia/reperfusion will significantly improve therapeutic choices.
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Affiliation(s)
- Jose A Adams
- Department of Neonatology, Mount Sinai Medical Center, Miami Beach, Florida, USA
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