Abstract 16154: Head and Shoulder Elevation Improves Cerebral Perfusion Pressure During Active Compression-decompression CPR and Conventional CPR in a Porcine Cardiac Arrest Model

Background: Chest compressions during conventional cardiopulmonary resuscitation (C-CPR) increase arterial and venous pressures simultaneously, delivering bidirectional high pressure compression waves to the brain. It is possible that this may be detrimental neurologically and could be partially overcome by elevating the head during CPR. Previous animal study work using a tilt table has shown that a 30° head up position for the entire body during CPR significantly increases cerebral blood flow and cerebral perfusion pressure (CerPP) over a period of 5 minutes. We hypothesize that elevating the head and shoulders only will increase CerPP over a prolonged period of time with two different CPR techniques. Methods: Female farm pigs were sedated, intubated, anesthetized, and placed on a table designed to elevate the head and shoulders to 30°. After 8 min of untreated ventricular fibrillation and 2 min of automated C-CPR in the supine position, pigs were randomized to head up (HUP) or supine (SUP) CPR for 20 more min. In Group A, pigs were treated after 2 min of C-CPR with automated active compression decompression (ACD) CPR at 100 cycles/min plus an impedance threshold device (ITD), randomized to HUP (n=8) or SUP (n=8). In Group B, pigs were randomized after 2 min of C-CPR to treatment with HUP (n=7) or SUP (n=7) automated C-CPR. After 22 total min of CPR, defibrillation was performed. The primary outcome of the study was the comparison of CerPP at 22 min between HUP and SUP positions within each group. Results: After 22 min of CPR, CerPP (mmHg) was 39±7 with HUP versus 14±4 with SUP CPR (p=0.013) in Group A and 3.4±2.2 with HUP versus -6.3±2.6 with SUP CPR (p = 0.014) in Group B. There was no significant difference within groups for coronary perfusion pressure (CPP) after 22 min, but CPP trended higher with HUP in Group A (32.0 ± 4.9) versus SUP (18.8 ± 4.7)(p=0.072). The CPPs in Group B were 5.8 ± 1.1 with HUP versus 3.3±1.8 with SUP CPR, p=0.26). In Group A, 6/8 pigs were resuscitated in both positions where no pigs could be resuscitated in Group B. Conclusions: The HUP position using two different CPR techniques significantly improved CerPP over a prolonged period of time. This simple maneuver has the potential to improve neurological outcomes after cardiac arrest.

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Abstract 194: Effects of PEG-20k on Coronary Perfusion Pressure and Post-Resuscitation Myocardial and Cerebral Function in a Rat Model of Cardiac Arrest

Circulation ◽

10.1161/circ.140.suppl_2.194 ◽

2019 ◽

Vol 140 (Suppl_2) ◽

Author(s):

Weiwei Ge ◽

Christine Moore ◽

Guanghui Zheng ◽

Xianfei Ji ◽

Fenglian He ◽

...

Keyword(s):

Cardiac Arrest ◽

Rat Model ◽

Perfusion Pressure ◽

Coronary Perfusion Pressure ◽

Coronary Perfusion ◽

Cerebral Function ◽

Sprague Dawley ◽

Total Blood ◽

Term Survival ◽

Significant Difference

Introduction: Epinephrine is the primary drug given during cardiopulmonary resuscitation (CPR), when given early, to reverse cardiac arrest (CA) by stimulation of α-adrenergic receptors in vascular smooth muscle. This increases coronary perfusion pressure (CPP) and increases rate of return of spontaneous circulation (ROSC). However, the use of epinephrine is not associated with a significant difference in long-term survival or favorable neurologic outcome when given late after arrest onset. In the present study, we compared the effects of aortic injection of polyethylene glycol-20k (PEG-20k) vs. epinephrine during CPR on CPP and postresuscitation myocardial and cerebral function in a rat model of CA. Hypothesis: Aortic injection of PEG-20k during CPR will increase CPP to the same extent as epinephrine without adversely affecting post-resuscitation myocardial and cerebral function. Methods: Twenty four male Sprague-Dawley rats weighing between 450-550 g were randomized into four groups: 1) PEG-20k 2) epinephrine 3) saline placebo 4) saline-intra-aorta (IA). Eight minutes of CPR was initiated after 6 minutes of untreated ventricular fibrillation. PEG-20k IA (10% est. total blood volume [1.8ml]), saline IA, saline IV or epinephrine IV (20ug/kg) was given after 4 minutes of CPR by continuous infusion over 3 minutes. CPP was recorded continuously and resuscitation was attempted with 4 Joule defibrillation. Myocardial function was measured at baseline, 2, 4, and 6 hours after ROSC by echocardiography and neurologic deficit scores (NDS) were recorded at 24, 48, and 72 hours after ROSC. Results: In both saline groups, CPP did not change. However, aortic injection of PEG-20k increased CPP significantly to the same extent as epinephrine (Fig 1). Post-resuscitation ejection fraction was significantly greater in PEG-20k compared to epinephrine (64 + 1 vs 45 + 3, p<0.05) and NDS was significantly improved in PEG-20k compared to epinephrine (100 + 50 vs 450 + 50, p<0.05).

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Abstract P26: Intra-CPR Hypothermia with and Without Volume Loading in an Ischemic Model of Cardiac Arrest

Circulation ◽

10.1161/circ.118.suppl_18.s_1450-c ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Demetris Yannopoulos ◽

Menekhem Zviman ◽

Aravindan Kolandaivelu ◽

Ravi Ranjan ◽

Yoav Dori ◽

...

Keyword(s):

Cardiac Arrest ◽

Infarct Size ◽

Perfusion Pressure ◽

Coronary Perfusion Pressure ◽

Size Group ◽

Coronary Perfusion ◽

Surface Cooling ◽

Volume Loading ◽

Infarction Size ◽

Group B

Background: Coronary occlusive ischemic events are responsible for 50 –70% of cardiac arrests in adults. We investigated the effects of intra-CPR mild hypothermia (HTM) (target 32–33°C) with and without volume loading on return to spontaneous circulation (ROSC) and infarction size in a severe, mid-LAD occlusion model of cardiac arrest. Methods: 46 (27±2.3kg) pigs had their mid LAD balloon occluded and were divided in 5 groups. After 15 minutes, ventricular fibrillation (VF) was electrically induced and 5 minutes of untreated VF were followed by 5 minutes of pneumatic vest CPR with a set compression pressure (250mmHg). If ROSC was obtained, animals were followed for another 95 minutes for a total LAD occlusion time of 120 min. Subsequently the balloon was deflated and 90 min of reperfusion were followed by myocardial staining to define area at risk (AAR) and myocardial infarct size. Group A had no additional intervention. Group B received immediately post ROSC surface cooling with cooling blankets and ice. Group C received intra-CPR 680±23ml of 28°C 0.9% NS via a central femoral venous catheter. Group D received during CPR 673±26 of 4°C NS followed by post ROSC surface cooling as in group B. Group E received intra-CPR and post ROSC volume-sparing HTM with an Endovascular Therapeutic Hypothermia System (ETHS) placed into the right atrium and set at a target of 32°C. Results: During CPR, coronary perfusion pressure was significantly decreased in groups C and D compared to groups A, B and E but groups D and E had significantly reduced infarct size. Group E had significantly improved EF compared to all other groups. Table . Conclusions: Intra-CPR HTM significantly reduces myocardial infarction size. Volume loading during CPR is detrimental for ROSC due to reduction of coronary perfusion pressure. ETHS intra-CPR application improves ROSC and post-resuscitation LV function and minimizes infarction in this ischemia-reperfusion cardiac arrest model. Results

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Cardiac arrest complicating cardiogenic shock: from pathophysiological insights to Impella-assisted cardiopulmonary resuscitation in a pheochromocytoma-induced Takotsubo cardiomyopathy—a case report

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytab092 ◽

2021 ◽

Vol 5 (3) ◽

Author(s):

Filippo Zilio ◽

Simone Muraglia ◽

Roberto Bonmassari

Keyword(s):

Cardiac Arrest ◽

Cardiopulmonary Resuscitation ◽

Left Ventricle ◽

Cardiogenic Shock ◽

Takotsubo Cardiomyopathy ◽

Perfusion Pressure ◽

Coronary Perfusion Pressure ◽

Left Ventricular ◽

Coronary Perfusion ◽

Refractory Cardiac Arrest

Abstract Background A ‘catecholamine storm’ in a case of pheochromocytoma can lead to a transient left ventricular dysfunction similar to Takotsubo cardiomyopathy. A cardiogenic shock can thus develop, with high left ventricular end-diastolic pressure and a reduction in coronary perfusion pressure. This scenario can ultimately lead to a cardiac arrest, in which unloading the left ventricle with a peripheral left ventricular assist device (Impella®) could help in achieving the return of spontaneous circulation (ROSC). Case summary A patient affected by Takotsubo cardiomyopathy caused by a pheochromocytoma presented with cardiogenic shock that finally evolved into refractory cardiac arrest. Cardiopulmonary resuscitation was performed but ROSC was achieved only after Impella® placement. Discussion In the clinical scenario of Takotsubo cardiomyopathy due to pheochromocytoma, when cardiogenic shock develops treatment is difficult because exogenous catecholamines, required to maintain organ perfusion, could exacerbate hypertension and deteriorate the cardiomyopathy. Moreover, as the coronary perfusion pressure is critically reduced, refractory cardiac arrest could develop. Although veno-arterial extra-corporeal membrane oxygenation (va-ECMO) has been advocated as the treatment of choice for in-hospital refractory cardiac arrest, in the presence of left ventricular overload a device like Impella®, which carries fewer complications as compared to ECMO, could be effective in obtaining the ROSC by unloading the left ventricle.

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Coronary perfusion pressure in a pig model of prolonged cardiac arrest treated by different modes of venoarterial extracorporeal membrane oxygenation and intraaortic balloon counterpulsation

Critical Care ◽

10.1186/cc10880 ◽

2012 ◽

Vol 16 (S1) ◽

Cited By ~ 3

Author(s):

J Bělohlávek ◽

M Mlcek ◽

M Huptych ◽

S Havranek ◽

P Ostadal ◽

...

Keyword(s):

Cardiac Arrest ◽

Extracorporeal Membrane Oxygenation ◽

Perfusion Pressure ◽

Coronary Perfusion Pressure ◽

Pig Model ◽

Coronary Perfusion ◽

Intraaortic Balloon ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Intraaortic Balloon Counterpulsation ◽

Balloon Counterpulsation

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Hypertonic versus isotonic crystalloid infusion for cerebral perfusion pressure in a porcine experimental cardiac arrest model

The American Journal of Emergency Medicine ◽

10.1016/j.ajem.2021.08.014 ◽

2021 ◽

Author(s):

Ki Hong Kim ◽

Ki Jeong Hong ◽

Sang Do Shin ◽

Kyoung Jun Song ◽

Young Sun Ro ◽

...

Keyword(s):

Cardiac Arrest ◽

Cerebral Perfusion Pressure ◽

Cerebral Perfusion ◽

Perfusion Pressure ◽

Crystalloid Infusion

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Intratracheal Suctioning in Sick Preterm Infants: Prevention of Intracranial Hypertension and Cerebral Hypoperfusion by Muscle Paralysis

PEDIATRICS ◽

10.1542/peds.79.4.538 ◽

1987 ◽

Vol 79 (4) ◽

pp. 538-543

Author(s):

Sergio Fanconi ◽

Gabriel Duc

Keyword(s):

Heart Rate ◽

Intracranial Pressure ◽

Cerebral Perfusion Pressure ◽

Preterm Infants ◽

Cerebral Perfusion ◽

Perfusion Pressure ◽

Muscle Paralysis ◽

Endotracheal Suctioning ◽

Significant Difference ◽

Transcutaneous Po2

In a prospective nonrandomized study, using each baby as his or her own control, we compared intracranial pressure (anterior fontanel pressure as measured with the Digilab pneumotonometer), cerebral perfusion pressure, BP, heart rate, transcutaneous Po2, and transcutaneous Pco2 before, during, and after endotracheal suctioning, with and without muscle paralysis, in 28 critically ill preterm infants with respiratory distress syndrome. With suctioning, there was a small but significant increase in intracranial pressure in paralyzed patients (from 13.7 [mean] ± 4.4 mm Hg [SD] to 15.8 ± 5.2 mm Hg) but a significantly larger (P < .001) increase when they were not paralyzed (from 12.5 ± 3.6 to 28.5 ± 8.3 mm Hg). Suctioning led to a slight increase in BP with (from 45.3 ± 9.1 to 48.0 ± 8.7 mm Hg) and without muscle paralysis (from 45.1 ± 9.4 to 50.0 ± 11.7 mm Hg); but there was no significant difference between the two groups. The cerebral perfusion pressure in paralyzed infants did not show any significant change before, during, and after suctioning (31.5 ± 9.1 mm Hg before v 32.0 ± 8.7 mm Hg during suctioning), but without muscle paralysis cerebral perfusion pressure decreased (P < .001) from 32.8 ± 9.7 to 21.3 ± 13.1 mm Hg. Suctioning induced a slight decrease in mean heart rate and transcutaneous Po2, but pancuronium did not alter these changes. There was no statistical difference in transcutaneous Pco2, before, during, and after suctioning with and without muscle paralysis. Our data demonstrate that muscle paralysis in sick preterm infants can significantly minimize the increase in intracranial pressure and can stabilize the cerebral perfusion pressure without having any effect on the BP increase during suctioning.

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Cardiac Arrest and Resuscitation

10.2310/im.4155 ◽

2015 ◽

Author(s):

Charles N. Pozner ◽

Jennifer L Martindale

Keyword(s):

Cardiac Arrest ◽

Ventricular Arrhythmias ◽

Perfusion Pressure ◽

Pulseless Electrical Activity ◽

Coronary Perfusion Pressure ◽

Spontaneous Circulation ◽

Coronary Perfusion ◽

Chest Compressions ◽

Cardiac Resuscitation ◽

Neurologic Function

The most effective treatment for cardiac arrest is the administration of high-quality chest compressions and early defibrillation; once spontaneous circulation is restored, post–cardiac arrest care is essential to support full return of neurologic function. This review summarizes the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes of cardiac arrest and resuscitation. Figures show the foundations of cardiac resuscitation, ventricular arrhythmias, coronary perfusion pressure as a function of time, an algorithm for initial treatment of cardiac arrest, sample capnographs, and the electrocardiographic appearance of varying degrees of hyperkalemia. Tables include components of suboptimal cardiac resuscitation and corrective actions, recommended doses of medications commonly used in cardiac resuscitation, causes of pulseless electrical activity/asystolic arrest to consider, immediate post–return of spontaneous circulation checklist, and resuscitation goals during post–cardiac arrest care. This review contains 6 highly rendered figures, 5 tables, and 142 references.

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