Kidney Protection by Hypothermic Total Liquid Ventilation after Cardiac Arrest in Rabbits

Abstract Background: Total liquid ventilation (TLV) with perfluorocarbons has been shown to induce rapid protective cooling in animal models of myocardial ischemia and cardiac arrest, with improved neurological and cardiovascular outcomes after resuscitation. In this study, the authors hypothesized that hypothermic TLV can also limit kidney injury after cardiac arrest. Methods: Anesthetized rabbits were submitted to 15 min of untreated ventricular fibrillation. After resuscitation, three groups of eight rabbits each were studied such as (1) life support plus hypothermia (32°–33°C) induced by cold TLV (TLV group), (2) life support without hypothermia (control group), and (3) Sham group (no cardiac arrest). Life support was continued for 6 h before euthanasia and kidney removal. Results: Time to target esophageal temperature was less than 5 min in the TLV group. Hypothermia was accompanied by preserved renal function in the TLV group as compared with control group regarding numerous markers including creatinine blood levels (12 ± 1 vs. 16 ± 2 mg/l, respectively; mean ± SEM), urinary N-acetyl-β-(d)-glucosaminidase (1.70 ± 0.11 vs. 3.07 ± 0.10 U/mol of creatinine), γ-glutamyltransferase (8.36 ± 0.29 vs. 12.96 ± 0.44 U/mol of creatinine), or β2-microglobulin (0.44 ± 0.01 vs. 1.12 ± 0.04 U/mol of creatinine). Kidney lesions evaluated by electron microscopy and conventional histology were also attenuated in TLV versus control groups. The renal-protective effect of TLV was not related to differences in delayed inflammatory or immune renal responses because transcriptions of, for example, interferon-γ, tumor necrosis factor-α, interleukin-1β, monocyte chemoattractant protein-1, toll-like receptor-2, toll-like receptor-4, and vascular endothelial growth factor were similarly altered in TLV and control versus Sham. Conclusion: Ultrafast cooling with TLV is renal protective after cardiac arrest and resuscitation, which could increase kidney availability for organ donation.

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Abstract 19: Ultra-Fast Cooling Induced by Total Liquid Ventilation Provides Neuroprotection Through a Delay in the Acute Systemic Inflammatory Response After Cardiac Arrest in Rabbits

Circulation ◽

10.1161/circ.140.suppl_2.19 ◽

2019 ◽

Vol 140 (Suppl_2) ◽

Author(s):

Emilie Boissady ◽

Matthias Kohlhauer ◽

Fanny Lidouren ◽

Bijan Ghaleh ◽

Renaud Tissier

Keyword(s):

Cardiac Arrest ◽

Inflammatory Response ◽

Neuronal Degeneration ◽

Neurological Dysfunction ◽

Control Group ◽

Blood Levels ◽

Control Groups ◽

Liquid Ventilation ◽

Ultra Fast Cooling ◽

Fast Cooling

Introduction: Ultra-fast cooling with total liquid ventilation (TLV) is potently protective in animal models of cardiac arrest. Hypothesis: Here, we hypothesized that this protection involves a mitigation of the acute phase of the inflammatory syndrome after cardiac arrest. Methods: Rabbits were anesthetized and submitted to 10 min of ventricular fibrillation. After resuscitation, animals underwent normothermic follow-up (Control, n=6) or ultra-fast cooling by TLV started after resuscitation (TLV, n=6). TLV was used for induction of cooling during 20 min and hypothermia was further maintained during 3 h using external techniques before rewarming. A third group was submitted to a Sham procedure (n=5). Survival and neurological dysfunction were assessed during 3 days. Results: TLV improved the clinical neurological recovery as compared to Control group after cardiac arrest. It was corroborated by histological examination showing an attenuation of neuronal degeneration in parasagittal cortex and hippocampus in TLV vs Control groups. After resuscitation, TLV delayed the elevation of interleukin-6 blood levels as compared to Control after cardiac arrest (e.g., 298±63 vs 991±471 pg/ml at 180 min after cardiac arrest in TLV vs Control, respectively). Blood cytometry analyses showed a massive recruitment of neutrophils and leukocytes (including T4, T8 and B-lymphocytes) in both groups. The early lymphocytosis was attenuated in TLV vs Control groups, despite not achieving statistical significance. Blood levels of high-mobility group box 1 increased rapidly and similarly in both groups after cardiac arrest. This suggests that TLV does not mitigate the early release of danger-associated molecular patterns after resuscitation, which is closely related to the immediate cell death after resuscitation. Altogether, these results show an attenuation of the early inflammatory response during hypothermia, suggesting a role of early but not delayed inflammation in the mechanism of ultra-fast cooling after cardiac arrest. Conclusion: Beneficial effect of hypothermic TLV could be explained by a delay in immune peripheral cells activation and cytokine release, rather than sustained inhibition of inflammation after cardiac arrest.

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Abstract 01: The Importance of Time to Cooling in Out-Of-Hospital Cardiac Arrest Patients to Influence Neurologically Intact Survival: A Sub-Analysis of the Princess Trial

Circulation ◽

10.1161/circ.140.suppl_2.01 ◽

2019 ◽

Vol 140 (Suppl_2) ◽

Author(s):

Akil Awad ◽

Fabio Silvio Taccone ◽

Martin Jonsson ◽

Sune Forsberg ◽

Jacob Hollenberg ◽

...

Keyword(s):

Cardiac Arrest ◽

Propensity Score ◽

Life Support ◽

Cerebral Performance Category ◽

Neurologic Outcome ◽

Secondary Outcome ◽

Control Group ◽

Shockable Rhythm ◽

Good Neurologic Outcome ◽

Hospital Cardiac Arrest

Background: Early initiation of hypothermia has shown to be important to reduce brain injuries in experimental cardiac arrest models. The aim of this study was to investigate the association between time to initiate cooling and neurological intact survival in patients with out-of-hospital cardiac arrest (OHCA). Methods: A secondary analysis of prospectively collected data from the PRINCESS trial (NCT01400373) including 677 OHCA patients randomized to transnasal evaporative intra-arrest cooling or standard advanced life support and cooling started subsequent to hospital arrival. Time to randomization was used a proxy measurement for time to initiate cooling. An early treatment group was defined as patients randomized by the EMS <20 minutes from the time of the cardiac arrest. Propensity scores were used to find matching patients in the control group. Patients with initial shockable rhythms were analyzed as a predefined subgroup. The primary outcome was good neurologic outcome, Cerebral Performance Category (CPC) 1-2 at 90 days. Secondary outcome was complete recovery (CPC 1). Results: In total 406 patients were randomized <20 minutes from the cardiac arrest and were propensity score matched (1:1). In the propensity score matched analysis the proportion of patients with CPC 1-2 was 21.7% in the intervention and 17.2% in the control group, odds ratio (OR) 1.33, 95% confidence interval (CI) 0.80-2.21, p=0.273. In patients with initial shockable rhythm (79 intervention, 79 control) the difference in CPC 1-2 was 48.1% versus 32.0%, OR 2.05, 95%CI 1.00-4.21, p=0.0498. The proportion of patients with complete neurologic recovery, CPC 1, was 19.7% in the intervention and 13.3% in the control group, OR 1.60, 95% CI 0.92-2.79, p=0.097. In patients with initial shockable rhythm the proportion with CPC 1 was 45.6% versus 24.6%, OR 2.81, 95% CI 1.23-6.42, p=0.014. Conclusions: In this ancillary study of OHCA patients receiving intra-arrest cooling, there were differences in survival with good neurologic outcome and in complete neurological recovery in favor of early intra-arrest cooling patient group compared to standard care. These differences were statistically significant in the subgroup of patients with initial shockable rhythms.

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Urinary N-Acetyl-Beta-D-Glucosaminidase Activity in Rat Experimental Ischemic and Toxic Models of Acute Kidney Injury

Bulletin of University of Agricultural Sciences and Veterinary Medicine Cluj-Napoca Veterinary Medicine ◽

10.15835/buasvmcn-vm:12618 ◽

2017 ◽

Vol 74 (1) ◽

pp. 105

Author(s):

Razvan Andrei CODEA ◽

Mircea MIRCEAN ◽

Sidonia Alina BOGDAN ◽

Andras Laszlo NAGY ◽

Alexandra BIRIS ◽

...

Keyword(s):

Acute Kidney Injury ◽

Experimental Model ◽

Wistar Rats ◽

Ischemia Reperfusion Injury ◽

Ischemia Reperfusion ◽

Kidney Injury ◽

Control Group ◽

Tubular Injury ◽

Group 2 ◽

Group 1

The identification of a suitable prevention method which facilitates limiting the deleterious effects of acute kidney injuries is highly required. In order to identify a proper treatment for acute kidney injuries, a suitable experimental model that replicates the structural, metabolic and inflammatory lesions that occur in the natural acute injured kidney is highly necessary. Intense urinary NAG activity can be found in a variety of renal disease such as toxic nephropathies, ischemic renal injury following cardiac surgery or renal transplantation but also in glomerular disease especially in diabetic nephropathy. Rises in urinary NAG enzyme activity strongly suggests tubular cell damage and support NAG enzyme as a biomarker of renal tubular injury. The aim of this paper is to obtain a stable in vivo acute kidney injury experimental model, in Wistar, rats and to evaluate the urinary activity of N-acetyl-Î²-D-glucosaminidase (NAG) enzyme, blood levels of urea and creatinine and microstructural renal alterations induced by ischemia/reperfusion injury respectively gentamicin nephrotoxicity. For this purpose we have used a rat experimental model. Adult male Wistar rats weighing 250-300 g were randomly divided into 3 groups with 8 rats in each group. Group 1 served as a model for the renal ischemia/reperfusion injury experiment, group 2 served for toxic kidney injury experimental model and group 3 served as control group. All individuals in both groups 1 and 2 presented marked elevations in blood urea and creatinine at the moment of euthanasia (day 3 for group 1 and day 9 for group 2) compared to the control group where biochemical values remained within normal limits. Urine analysis of both group 1 and 2 showed marked urinary NAG index activity which suggests acute tubular injury, suggestion confirmed by histological evaluation of the renal parenchyma sampled from this subjects

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Protective Effect of Morocco Carob Honey Against Lead-Induced Anemia and Hepato-Renal Toxicity

Cellular Physiology and Biochemistry ◽

10.1159/000445610 ◽

2016 ◽

Vol 39 (1) ◽

pp. 115-122 ◽

Cited By ~ 5

Author(s):

Aicha Fassi Fihri ◽

Noori S. Al-Waili ◽

Redouan El-Haskoury ◽

Meryem Bakour ◽

Afaf Amarti ◽

...

Keyword(s):

Protective Effect ◽

Renal Toxicity ◽

Biological Activities ◽

Kidney Injury ◽

Lead Toxicity ◽

Control Group ◽

Daily Group ◽

Group 4 ◽

Group 3 ◽

Group 2

Background/Aims: Natural honey has many biological activities including protective effect against toxic materials. The aim of this study was to evaluate the protective effect of carob honey against lead-induced hepato-renal toxicity and lead-induced anemia in rabbits. Methods: Twenty four male rabbits were allocated into four groups six rabbits each; group 1: control group, received distilled water (0.1 ml / kg.b.wt /daily); group 2: received oral lead acetate (2 g/kg.b.wt/daily); group 3: treated with oral honey (1g /kg.b.wt/daily) and oral lead (2 g/kg.b.wt/daily), and group 4: received oral honey (1 g/kg.b.wt/daily). Honey and lead were given daily during 24 days of experimentation. Laboratory tests and histopathological evaluations of kidneys were done. Results: Oral administration of lead induced hepatic and kidney injury and caused anemia during three weeks of the exposure. Treatment with honey prevented hepato-renal lead toxicity and ameliorated lead-induced anemia when honey was given to animals during lead exposure. Conclusion: It might be concluded that honey has a protective effect against lead-induced blood, hepatic and renal toxic effects.

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Effects and Retention of Self-Re-Learning Using Video Recording of Advanced Life Support (ALS) On Nursing Students’ Knowledge, Self-Efficacy, and Skills Performance

10.21203/rs.3.rs-68840/v1 ◽

2020 ◽

Author(s):

Kyeongmin Jang ◽

Sung Hwan Kim ◽

Ja Young Oh ◽

Ji Yeon Mun

Keyword(s):

Cardiac Arrest ◽

Nursing Students ◽

Self Efficacy ◽

Life Support ◽

Video Recording ◽

Advanced Life Support ◽

Control Group ◽

Control Group Design ◽

Hospital Deaths ◽

Experimental Group

Abstract Background In-hospital cardiac arrests account for 80% of hospital deaths, and the survival rate is not significantly different from that of pre-hospitalized cardiac arrest patients. The nurses would presumably be the first to see an in-hospital cardiac arrest patient. This study proposed to measure nursing students’ knowledge, self-efficacy, and skills performance of advanced life support (ALS) 6 months after the training by sending their videos taken during the final skills test after the ALS training.Methods This is an experimental study with a randomized control group design. The participants’ knowledge, self-efficacy, and skill performance of ALS were evaluated immediately after the training and participants were videotaped during the final skills test. Thereafter, we sent the video to the experimental group through the mobile phone messenger application once a month from the third month after training. Approximately six months after the training day, we conducted a follow-up test of the measured variables using the blinded method.Results Six months after the ALS training, knowledge scores decreased significantly in both groups (p<0.001). Self-efficacy decreased by about 3 from 50.55 to 47.18 in the experimental group (p = 0.089), while it decreased by 10 in the control group from 50.67 to 39 (p<0.001). The skills performance decreased from 27.5 to 26.68 in the experimental group, while it decreased significantly from 27.95 to 16.9 in the control group (p< 0.001).Conclusion Self-study with videos taken during an ALS skills test helps enhance the sustainable effects of training, such as knowledge, self-efficacy, and skills performance.

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Mitigation of cisplatin induced nephrotoxicity by casticin in male albino rats

Brazilian Journal of Biology ◽

10.1590/1519-6984.243438 ◽

2023 ◽

Vol 83 ◽

Author(s):

N. Ehsan ◽

M. U. Ijaz ◽

A. Ashraf ◽

S. Sarwar ◽

A. Samad ◽

...

Keyword(s):

Kidney Injury ◽

Thiobarbituric Acid ◽

Treated Group ◽

Free Radical Scavenger ◽

Control Group ◽

Albino Rats ◽

Radical Scavenger ◽

Neutrophil Gelatinase Associated Lipocalin ◽

Group 2 ◽

Kidney Injury Molecule 1

Abstract Cisplatin (CP) is a commonly used, powerful antineoplastic drug, having numerous side effects. Casticin (CAS) is considered as a free radical scavenger and a potent antioxidant. The present research was planned to assess the curative potential of CAS on CP persuaded renal injury in male albino rats. Twenty four male albino rats were distributed into four equal groups. Group-1 was considered as a control group. Animals of Group-2 were injected with 5mg/kg of CP intraperitoneally. Group-3 was co-treated with CAS (50mg/kg) orally and injection of CP (5mg/kg). Group-4 was treated with CAS (50mg/kg) orally throughout the experiment. CP administration substantially reduced the activities of catalase (CAT), superoxide dismutase (SOD), peroxidase (POD), glutathione S-transferase (GST), glutathione reductase (GSR), glutathione (GSH) content while increased thiobarbituric acid reactive substances (TBARS), and hydrogen peroxide (H2O2) levels. Urea, urinary creatinine, urobilinogen, urinary proteins, kidney injury molecule-1 (KIM-1), and neutrophil gelatinase-associated lipocalin (NGAL) levels were substantially increased. In contrast, albumin and creatinine clearance was significantly reduced in CP treated group. The results demonstrated that CP significantly increased the inflammation indicators including nuclear factor kappa-B (NF-κB), tumor necrosis factor-α (TNF-α), Interleukin-1β (IL-1β), Interleukin-6 (IL-6) levels and cyclooxygenase-2 (COX-2) activity and histopathological damages. However, the administration of CAS displayed a palliative effect against CP-generated renal toxicity and recovered all parameters by bringing them to a normal level. These results revealed that the CAS is an effective compound having the curative potential to counter the CP-induced renal damage.

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Stromal Cell-Derived Factor (SDF)-1-Pretreated Bone Marrow Mesenchymal Stem Cells (BMSCs) Ameliorates Acute Kidney Injury in Mice

Journal of Biomaterials and Tissue Engineering ◽

10.1166/jbt.2021.2701 ◽

2021 ◽

Vol 11 (7) ◽

pp. 1255-1262

Author(s):

Xiaohui Dong ◽

Xifeng Lv

Keyword(s):

Inflammatory Cell ◽

Kidney Injury ◽

Inflammatory Cell Infiltration ◽

Cell Infiltration ◽

Control Group ◽

Serum Cytokines ◽

Marrow Mesenchymal Stem Cells ◽

Stromal Cell Derived Factor ◽

Group 2 ◽

Experimental Group

To explore the effects of stromal cell-derived factor (SDF-1) pretreatment of bone marrow mesenchymal stem cells (BMSCs) on acute kidney injury (AKI) in mice. BMSCs were cultured and treated with SDF-1 to detect osteogenic and adipogenic ability. Cisplatin (20 mg/kg) was used to establish AKI model and then divided into blank group, control group 2 (BMSCs injection), and experimental group (intraperitoneal injection of BMSCs treated with SDF-1 (80 ng/ml)) followed by analysis of serum cytokines (Toll like receptor 4 (TLR4), tumor necrosis factor-α (TNF-α), and interleukine-6 (IL-6)) by enzyme linked immunosorbent assay (ELISA). In cultured BMSCs, positive rates of CD29, CD44, CD45, and CD11b were 98.2%, 97.6%, 2.5% and 2.1%, respectively. When the concentration of SDF-1 was within 80 ng/mL, the chemotaxis and proliferation ability was dose-dependent (p < 0.05). SDF-1 pretreatment did not affect BMSCs adipogenic and osteogenic abilities. The creatinine and serum cytokines (TLR4, TNF-α, and IL-6) level in experimental group showed statistical significance (p < 0.05). At 24 h, thrombosis and tubular dilatation in the mesangial region of control group 2 and experimental group under light microscope were similar without difference of inflammatory cell infiltration and fibrosis. At 72 h, the glomerular mesangium widened in control group 2 with focal segmental sclerosis, renal tubules dilated, and protein casts and inflammatory cell infiltration and fibrosis. Experimental group showed a small amount of cell proliferation in the glomerular mesangium with few inflammatory cell infiltration and fibrosis. SDF-1 can enhance the migration and proliferation activity of BMSCs, reduce extracellular matrix precipitation, improve renal fibrosis, and alleviate AKI.

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Abstract 283: Hands-off Time During Lay Rescuer Basic Life Support Remains High After a Standard Basic Life Support Course

Circulation ◽

10.1161/circ.130.suppl_2.283 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Michael Mueller ◽

Christian Rudolph ◽

Cynthia Poenicke ◽

Andre Eichelkraut ◽

Norbert Papkalla ◽

...

Keyword(s):

Cardiac Arrest ◽

Basic Life Support ◽

Life Support ◽

Control Group ◽

Chest Compressions ◽

Lay Persons ◽

Lay Rescuer ◽

Test Scenarios ◽

Off Time ◽

External Defibrillator

The current international guidelines for resuscitation recommend high quality chest compressions with minimal interruptions as important prerequisite for optimal survival after cardiac arrest. During the standard four hours BLS course of the European Resuscitation Council (ERC) the participants learn to provide chest compressions, ventilations and to use an automated external defibrillator. We know that lay rescuers are able to learn these skills. However, it is unclear whether lay rescuers manage to minimize interruptions of chest compressions. Objective: To evaluate the no-flow fraction (NFF) during lay rescuer BLS including chest compressions, ventilation and the use of an AED. Methods: 24 participants of a BLS/ AED course were assessed before (T1) and after (T2) the BLS training in a standardized scenario in pairs of 2 rescuers. We used a Resusci Anne Simulator manikin (Laerdal, Norway) and a Lifepak 1000 AED trainer device for the assessment. The scenario was an adult patient with cardiac arrest and persistent ventricular fibrillation (VF), duration of the scenario was 5 minutes. 28 lay persons served as control group and were assessed in pairs of 2 rescuers twice at the same day. Two-sided t-test was used to test differences between groups and between test scenarios (T1 vs. T2), p<.05 was considered significant. Results: The NFF decreased from 0.68 ± 0.1 (before the course) to 0.5 ± 0.07 (after the course), p=.000. In the control group the NFF was 0.63 ± 0.1 (scenario 1) and 0.59 ± 0.14 (second scenario), p=.244. Conclusion: A standard BLS course reduces the interruptions of chest compressions during lay rescuer CPR. However, 50% of the scenario no chest compressions are given. Interruptions are mainly due to ventilations or related to the use of the AED. Further research is necessary to improve the BLS algorithm regarding reduction of interruptions.

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Effect of Lipid Emulsion on the Improvement of Renal Damage in Colistin-induced Nephrotoxicity

Current Drug Safety ◽

10.2174/1574886315999201228194200 ◽

2020 ◽

Vol 15 ◽

Author(s):

Naci Senkal ◽

Ozum Atasoy ◽

Emine Bilge Caparali ◽

Mumin Alper Erdogan ◽

Oytun Erbas

Keyword(s):

Lipid Emulsion ◽

Renal Damage ◽

Cell Injury ◽

Kidney Injury ◽

Control Group ◽

Tubular Damage ◽

Sprague Dawley ◽

Tissue Samples ◽

Group 2 ◽

Group 1

Background:: Colistin utilization has gradually increased worldwide with the arising of multidrug-resistant (MDR) gram-negative bacilli despite its nephrotoxicity. Lipid emulsion (LE) is widely used for the toxic overdose treatment of various drugs. Objective:: The aim of the present study is to evaluate the effect of lipid emulsion on improvement of renal damage in colistin-induced nephrotoxicity with experimental Sprague Dawley rat model. Methods:: Twenty-four male Sprague Dawley rats were initially assigned at random into 2 groups. Sixteen rats were given a single dose of 20 mg/kg colistin, eight rats received no medication (control group). Sixteen rats that were administered colistin sub-divided into 2 groups. Group 1/LE rats (n = 8) were given 20 ml/kg solution of lipid emulsion, and group 2/S rats (n = 8) were given 20 ml/kg/day (i.p.) of 0.9% NaCl saline; both were administered for 10 days. Then tubular injury was evaluated histopathologically. Serum levels of blood urea nitrogen (BUN), Kidney Injury Molecule-1 (KIM-1), and creatinine were measured. Besides, malondialdehyde (MDA) levels were determined in tissue samples for the assessment of lipid peroxidation. Results:: The mean percent of tubular epithelial cell injury and tubular dilatation was found significantly higher in group 2/S than control and group 1/LE (p < 0.0001 and < 0.001; respectively). KIM-1 and MDA levels were also statistically higher in group 2/S than control and group 1/LE. (p < 0.0001 and < 0.0001; respectively). Additionally, serum BUN and creatinine levels of group 2/S were significantly greater than control and group 1/LE (p < 0.0001 and < 0.0001; respectively). Conclusion:: In this present study, we determined that colistin-induced proximal tubular damage was decreased as histopathologically and serologically by the effect of lipid emulsion. Thus, our findings may guide to the future studies on the clinical use of colistin., particularly in MDR positive intensive care infections.

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Sudden cardiac arrest pharmacotherapy with preﬁlled syringes improves adherence to Advanced Life Support protocol in understaffed resuscitation pre-hospital care teams

10.22514/sv.2020.16.0098 ◽

2020 ◽

Keyword(s):

Cardiac Arrest ◽

Simulation Study ◽

Life Support ◽

Sudden Cardiac Arrest ◽

Advanced Life Support ◽

Control Group ◽

Performance Quality ◽

Prefilled Syringes ◽

The Impact

Every procedural facilitation or a change in available equipment in treatment of out-of-hospital arrest (OHCA) by two-person teams may significantly enhance their performance quality. The aim of this study was to assess the impact of adrenaline in prefilled syringes on improving the adherence to Advanced Life Support protocol by understaffed teams. The research was based on a randomized cross-over high-fidelity simulation study. Two-person teams took part in two 10-minute simulation scenarios featuring sudden cardiac arrest in ventricular fibrillation (VF). The control group (group C) had at its disposal standard ampoules, whereas the experimental group (group E) prefilled syringes. The execution times of CPR start, defibrillation shocks, intravenous (IV) access, epinephrine and amiodarone doses were measured. Additionally, the chest compression fraction (CCF) was calculated. The designed two-minute loops were considerably prolonged in group C. Nineteen teams (31.1%) in group C but 49 (80.3%) in group E carried out the fifth defibrillation (P < 0.001). After two minutes of CPR nobody in group C switched to perform chest compressions. IV access was obtained significantly earlier in group E (114.7 ± 52.2 sec) than in group C (150.2 ± 68.6 sec)(P = 0.002). Two doses of adrenaline were administered in group E, whereas its second dose only by 12 teams in group C. The simulation study has proved that for understaffed teams a use of prefilled syringes not only did enhance the flow of ALS procedure, but it also improved the quality of cardiopulmonary resuscitation.

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