Application of cardiac surgery techniques to improve the results of cardiopulmonary resuscitation after cardiac arrest: Controlled automated reperfusion of the whole body.
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ABSTRACT:
SUBMITTER: Beyersdorf F
PROVIDER: S-EPMC9390159 | biostudies-literature | 2021 Dec
REPOSITORIES: biostudies-literature
Publications
Application of cardiac surgery techniques to improve the results of cardiopulmonary resuscitation after cardiac arrest: Controlled automated reperfusion of the whole body.
Beyersdorf Friedhelm F Trummer Georg G Benk Christoph C Pooth Jan-Steffen JS
JTCVS open 20211020
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Project description:Cardiopulmonary resuscitation (CPR) is associated with a high mortality rate. Furthermore, the few survivors often have severe, persistent cerebral dysfunction. A potential cause for this unsatisfactory outcome after CPR is the combination of cardiac arrest (ischemia) and the inability to restore adequate hemodynamics during conventional CPR (reperfusion), resulting in ischemia/reperfusion injury of the whole body. Therefore we developed a concept counteracting this ischemia/reperfusion injury during the process of CPR.We present data from a patient, in whom the concept of a novel controlled automated reperfusion of the whole body (CARL) was applied after 120 min of CPR under normothermic conditions. The patient survived without cerebral deficits and showed full recovery of all organs after prolonged cardiac arrest (CA) except for the spinal cord, where a defect at the level of the 11th thoracic vertebra caused partial loss of motoric function of the legs.This is the first reported clinical application of CARL after CA. The implementation of CARL resulted in unexpected survival and recovery after prolonged normothermic CA and CPR. In synopsis with the preclinical experience in pigs this case shows, that the new concept of CARL treating ischemia/reperfusion during the CPR may be an important element within the future treatment of CA.Trial was retrospectively registered in the "German Clinical Trials Register" ( www.germanctr.de ) under No.: DRKS00005773 on July 28th, 2015.
| S-EPMC5504811 | biostudies-other
Project description:The modern treatment of cardiac arrest is an increasingly complex medical procedure with a rapidly changing array of therapeutic approaches designed to restore life to victims of sudden death. The 2 primary goals of providing artificial circulation and defibrillation to halt ventricular fibrillation remain of paramount importance for saving lives. They have undergone significant improvements in technology and dissemination into the community subsequent to their establishment 60 years ago. The evolution of artificial circulation includes efforts to optimize manual cardiopulmonary resuscitation, external mechanical cardiopulmonary resuscitation devices designed to augment circulation, and may soon advance further into the rapid deployment of specially designed internal emergency cardiopulmonary bypass devices. The development of defibrillation technologies has progressed from bulky internal defibrillators paddles applied directly to the heart, to manually controlled external defibrillators, to automatic external defibrillators that can now be obtained over-the-counter for widespread use in the community or home. But the modern treatment of cardiac arrest now involves more than merely providing circulation and defibrillation. As suggested by a 3-phase model of treatment, newer approaches targeting patients who have had a more prolonged cardiac arrest include treatment of the metabolic phase of cardiac arrest with therapeutic hypothermia, agents to treat or prevent reperfusion injury, new strategies specifically focused on pulseless electric activity, which is the presenting rhythm in at least one third of cardiac arrests, and aggressive post resuscitation care. There are discoveries at the cellular and molecular level about ischemia and reperfusion pathobiology that may be translated into future new therapies. On the near horizon is the combination of advanced cardiopulmonary bypass plus a cocktail of multiple agents targeted at restoration of normal metabolism and prevention of reperfusion injury, as this holds the promise of restoring life to many patients for whom our current therapies fail.
| S-EPMC5920653 | biostudies-literature
Project description:To investigate the effects of the combination of extracorporeal cardiopulmonary resuscitation and thrombolytic therapy on the recovery of vital organ function after prolonged cardiac arrest.Laboratory investigation.University laboratory.Pigs.Animals underwent 30-minute untreated ventricular fibrillation cardiac arrest followed by extracorporeal cardiopulmonary resuscitation for 6 hours. Animals were allocated into two experimental groups: t-extracorporeal cardiopulmonary resuscitation (t-ECPR) group, which received streptokinase 1 million units, and control extracorporeal cardiopulmonary resuscitation (c-ECPR), which did not receive streptokinase. In both groups, the resuscitation protocol included the following physiologic targets: mean arterial pressure greater than 70 mm Hg, cerebral perfusion pressure greater than 50 mm Hg, PaO2 150 ± 50 torr (20 ± 7 kPa), PaCO2 40 ± 5 torr (5 ± 1 kPa), and core temperature 33°C ± 1°C. Defibrillation was attempted after 30 minutes of extracorporeal cardiopulmonary resuscitation.A cardiac resuscitability score was assessed on the basis of success of defibrillation, return of spontaneous heart beat, weanability from extracorporeal cardiopulmonary resuscitation, and left ventricular systolic function after weaning. The addition of thrombolytic to extracorporeal cardiopulmonary resuscitation significantly improved cardiac resuscitability (3.7 ± 1.6 in t-ECPR vs 1.0 ± 1.5 in c-ECPR). Arterial lactate clearance was higher in t-ECPR than in c-ECPR (40% ± 15% vs 18% ± 21%). At the end of the experiment, the intracranial pressure was significantly higher in c-ECPR than in t-ECPR. Recovery of brain electrical activity, as assessed by quantitative analysis of electroencephalogram signal, and ischemic neuronal injury on histopathologic examination did not differ between groups. Animals in t-ECPR group did not have increased bleeding complications, including intracerebral hemorrhages.In a porcine model of prolonged cardiac arrest, t-ECPR improved cardiac resuscitability and reduced brain edema, without increasing bleeding complications. However, early electroencephalogram recovery and ischemic neuronal injury were not improved.
| S-EPMC4948940 | biostudies-literature
Project description:AimTo assess the use of extracorporeal cardiopulmonary resuscitation (ECPR), compared with manual or mechanical cardiopulmonary resuscitation (CPR), for out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) in adults and children.MethodsThe PRISMA guidelines were followed. We searched Medline, Embase, and Evidence-Based Medicine Reviews for randomized clinical trials and observational studies published before May 22, 2018. The population included adult and pediatric patients with OHCA and IHCA of any origin. Two investigators reviewed studies for relevance, extracted data, and assessed risk of bias using the ROBINS-I tool. Outcomes included short-term and long-term survival and favorable neurological outcome.ResultsWe included 25 observational studies, of which 15 studies were in adult OHCA, 7 studies were in adult IHCA, and 3 studies were in pediatric IHCA. There were no studies in pediatric OHCA. No randomized trials were included. Results from individual studies were largely inconsistent, although several studies in adult and pediatric IHCA were in favor of ECPR. The risk of bias for individual studies was overall assessed to be critical, with confounding being the primary source of bias. The overall quality of evidence was assessed to be very low. Heterogeneity across studies precluded any meaningful meta-analyses.ConclusionsThere is inconclusive evidence to either support or refute the use of ECPR for OHCA and IHCA in adults and children. The quality of evidence across studies is very low.
| S-EPMC6441971 | biostudies-literature
Project description:BackgroundVeno-arterial extracorporeal membrane oxygenation has increasingly emerged as a feasible treatment to mitigate the progressive multiorgan dysfunction that occurs during cardiac arrest, in support of further resuscitation efforts.ObjectivesBecause the recent systematic review commissioned in 2018 by the International Liaison Committee on Resuscitation Advanced Life Support task did not include studies without a control group, our objective was to conduct a review incorporating these studies to increase available evidence supporting the use of extracorporeal cardiopulmonary resuscitation (ECPR) for cardiac arrest patients, while waiting for high-quality evidence from randomized controlled trials (RCTs).MethodsMEDLINE, Embase, and Science Citation Index (Web of Science) were searched for eligible studies from database inception to July 20, 2020. The population of interest was adult patients who had suffered cardiac arrest in any setting. We included all cohort studies with 1 exposure/1 group and descriptive studies (ie, case series studies). We excluded RCTs, non-RCTs, and observational analytic studies with a control group. Outcomes included short-term survival and favorable neurological outcome. Short-term outcomes (ie, hospital discharge, 30 days, and 1 month) were combined into a single category.ResultsOur searches of databases and other sources yielded a total of 4302 citations. Sixty-two eligible studies were included (including a combined total of 3638 participants). Six studies were of in-hospital cardiac arrest, 34 studies were of out-of-hospital cardiac arrest, and 22 studies included both in-hospital and out-of-hospital cardiac arrest. Seven hundred and sixty-eight patients of 3352 (23%) had short-term survival; whereas, 602 of 3366 (18%) survived with favorable neurological outcome, defined as a cerebral performance category score of 1 or 2.ConclusionsCurrent clinical evidence is mostly drawn from observational studies, with their potential for confounding selection bias. Although studies without controls cannot supplant case-control or cohort studies, several ECPR studies without a control group show successful resuscitation with impressive results that may provide valuable information to inform a comparison.
| S-EPMC7813516 | biostudies-literature
Project description:ImportanceFrailty is associated with mortality following surgery and cardiopulmonary resuscitation (CPR) for in-hospital cardiac arrest. Despite the growing focus on frailty as a basis for preoperative risk stratification and concern that CPR in patients with frailty may border on futility, the association between frailty and outcomes following perioperative CPR is unknown.ObjectiveTo determine the association between frailty and outcomes following perioperative CPR.Design, setting, and participantsThis longitudinal cohort study of patients used the American College of Surgeons National Surgical Quality Improvement Program, including more than 700 participating hospitals in the US, from January 1, 2015, through December 31, 2020. Follow-up duration was 30 days. Patients 50 years or older undergoing noncardiac surgery who received CPR on postoperative day 0 were included; patients were excluded if data required to determine frailty, establish outcome, or perform multivariable analyses were missing. Data were analyzed from September 1, 2022, through January 30, 2023.ExposuresFrailty defined as Risk Analysis Index (RAI) of 40 or greater vs less than 40.Outcomes and measuresThirty-day mortality and nonhome discharge.ResultsAmong the 3149 patients included in the analysis, the median age was 71 (IQR, 63-79) years, 1709 (55.9%) were men, and 2117 (69.2%) were White. Mean (SD) RAI was 37.73 (6.18), and 792 patients (25.9%) had an RAI of 40 or greater, of whom 534 (67.4%) died within 30 days of surgery. Multivariable logistic regression adjusting for race, American Society of Anesthesiologists physical status, sepsis, and emergency surgery demonstrated a positive association between frailty and mortality (adjusted odds ratio [AOR], 1.35 [95% CI, 1.11-1.65]; P = .003). Spline regression analysis demonstrated steadily increasing probability of mortality and nonhome discharge with increasing RAI above 37 and 36, respectively. Association between frailty and mortality following CPR varied by procedure urgency (AOR for nonemergent procedures, 1.55 [95% CI, 1.23-1.97]; AOR for emergent procedures, 0.97 [95% CI, 0.68-1.37]; P = .03 for interaction). An RAI of 40 or greater was associated with increased odds of nonhome discharge compared with an RAI of less than 40 (AOR, 1.85 [95% CI, 1.31-2.62]; P < .001).Conclusions and relevanceThe findings of this cohort study suggest that although roughly 1 in 3 patients with an RAI of 40 or greater survived at least 30 days following perioperative CPR, higher frailty burden was associated with increased mortality and greater risk of nonhome discharge among survivors. Identifying patients who are undergoing surgery and have frailty may inform primary prevention strategies, guide shared decision-making regarding perioperative CPR, and promote goal-concordant surgical care.
| S-EPMC10318473 | biostudies-literature
Project description:BackgroundExtracorporeal cardiopulmonary resuscitation (ECPR) is an emerging concept in cardiac arrest and cardiopulmonary resuscitation. Recent research has documented a significant improvement in favorable outcomes, notable survival to discharge, and neurologically intact survival.ObjectivesThe present study undertakes a scoping review to summarize the available evidence by assessing the use of ECPR, compared with no ECPR or the standard of care, for adult patients who sustain cardiac arrest in any setting, in studies which record survival and neurologic outcomes.MethodsThis review followed the PRISMA extension for scoping reviews (PRISMA-ScR) guidelines. Four online databases were used to identify papers published from database inception to July 12, 2020. We selected 23 observational studies from Asia, Europe, and North America that used survival to discharge or neurologically intact survival as a primary or secondary endpoint variable in patients with cardiac arrest refractory to standard treatment.ResultsTwenty-three observational studies were included in the review. Eleven studies were of out-of-hospital cardiac arrest, 7 studies were of in-hospital cardiac arrest, and 5 studies included mixed populations. Ten studies reported long-term favorable neurological outcomes (ie, Cerebral Performance Category score of 1 - 2 at 3 months [n = 3], 6 months [n = 3], and 1 year [n = 4]), of which only 4 had statistical significance at 5% significance levels. Current knowledge is mostly drawn from single-center observations, with most of the evidence coming from case series and cohort studies, hence is prone to publication bias. No randomized control trials were included.ConclusionsThis scoping review highlights the need for high-quality studies to increase the level of evidence and reduce knowledge gaps to change the paradigm of care for patients with shock-refractory cardiac arrest.
| S-EPMC7880165 | biostudies-literature
Project description:Background: Cerebral ischemia/reperfusion injury is a common secondary effect of cardiac arrest which is largely responsible for postresuscitative mortality. Therefore development of therapies which restore and protect the brain function after cardiac arrest is essential. Methylene blue (MB) has been experimentally proven neuroprotective in a porcine model of global ischemia-reperfusion in experimental cardiac arrest. However, no comprehensive analyses have been conducted at gene expression level. Methods: Pigs underwent either untreated cardiac arrest (CA) or CA with subsequent cardiopulmonary resuscitation (CPR) accompanied with an infusion of saline or an infusion of saline with MB. Genome-wide transcriptional profiling using the Affymetrix porcine microarray was performed to 1) gain understanding of delayed neuronal death initiation in porcine brain during ischemia and after 30, 60 and 180 min following reperfusion, and 2) identify the mechanisms behind the neuroprotective effect of MB after ischemic injury (at 30, 60 and 180 min). Results: Our results show that restoration of spontaneous circulation (ROSC) induces major transcriptional changes related to stress response, inflammation, apoptosis and even cytoprotection. In contrast, the untreated ischemic and anoxic insult affected only few genes mainly involved in intra-/extracellular ionic balance. Furthermore, our data show that the neuroprotective role of MB is diverse and fulfilled by regulation of the expression of soluble guanylate cyclase and biological processes accountable for inhibition of apoptosis, modulation of stress response, neurogenesis and neuroprotection. Conclusions: Our results support that MB could be a valuable intervention and should be investigated as a therapeutic agent against neural damage associated with I/R injury induced by cardiac arrest. One group of pigs underwent cardiac arrest (CA) without subsequent cardiopulmonary resuscitation (CPR) and the brain of the animals was removed after 5, 20 or 30 min post CA for genome-wide expression study. Two groups of pigs underwent first CA for 12 min with a subsequent 8 min-long CPR and received either an infusion of saline or an infusion of saline with MB from one minute after the start of CPR until 50 min after return of spontaneous circulation (ROSC). In both latter groups the brains were removed for microarray analysis at the following time points: 30, 60, 180 min.
2010-06-16 | E-GEOD-22165 | biostudies-arrayexpress
Project description:Background: Cerebral ischemia/reperfusion injury is a common secondary effect of cardiac arrest which is largely responsible for postresuscitative mortality. Therefore development of therapies which restore and protect the brain function after cardiac arrest is essential. Methylene blue (MB) has been experimentally proven neuroprotective in a porcine model of global ischemia-reperfusion in experimental cardiac arrest. However, no comprehensive analyses have been conducted at gene expression level. Methods: Pigs underwent either untreated cardiac arrest (CA) or CA with subsequent cardiopulmonary resuscitation (CPR) accompanied with an infusion of saline or an infusion of saline with MB. Genome-wide transcriptional profiling using the Affymetrix porcine microarray was performed to 1) gain understanding of delayed neuronal death initiation in porcine brain during ischemia and after 30, 60 and 180 min following reperfusion, and 2) identify the mechanisms behind the neuroprotective effect of MB after ischemic injury (at 30, 60 and 180 min). Results: Our results show that restoration of spontaneous circulation (ROSC) induces major transcriptional changes related to stress response, inflammation, apoptosis and even cytoprotection. In contrast, the untreated ischemic and anoxic insult affected only few genes mainly involved in intra-/extracellular ionic balance. Furthermore, our data show that the neuroprotective role of MB is diverse and fulfilled by regulation of the expression of soluble guanylate cyclase and biological processes accountable for inhibition of apoptosis, modulation of stress response, neurogenesis and neuroprotection. Conclusions: Our results support that MB could be a valuable intervention and should be investigated as a therapeutic agent against neural damage associated with I/R injury induced by cardiac arrest.
2010-06-05 | GSE22165 | GEO
Project description: Not available
| S-EPMC9276392 | biostudies-literature