Microvascular perfusion in cardiac arrest: a review of microcirculatory imaging studies

Perfusion ◽  
2017 ◽  
Vol 33 (1) ◽  
pp. 8-15 ◽  
Author(s):  
Petra Krupičková ◽  
Zuzana Mormanová ◽  
Tomáš Bouček ◽  
Tomáš Belza ◽  
Jana Šmalcová ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Therapy Monitoring ◽  
Developed Countries ◽  
Dark Field ◽  
Therapeutic Interventions ◽  
Orthogonal Polarization ◽  
Sidestream Dark Field ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
Orthogonal Polarization Spectral ◽  
The Impact

Cardiac arrest represents a leading cause of mortality and morbidity in developed countries. Extracorporeal cardiopulmonary resuscitation (ECPR) increases the chances for a beneficial outcome in victims of refractory cardiac arrest. However, ECPR and post-cardiac arrest care are affected by high mortality rates due to multi-organ failure syndrome, which is closely related to microcirculatory disorders. Therefore, microcirculation represents a key target for therapeutic interventions in post-cardiac arrest patients. However, the evaluation of tissue microcirculatory perfusion is still demanding to perform. Novel videomicroscopic technologies (Orthogonal polarization spectral, Sidestream dark field and Incident dark field imaging) might offer a promising way to perform bedside microcirculatory assessment and therapy monitoring. This review aims to summarise the recent body of knowledge on videomicroscopic imaging in a cardiac arrest setting and to discuss the impact of extracorporeal reperfusion and other therapeutic modalities on microcirculation.

Abstract 363: Examination of the Effects of Extracorporeal Cardiopulmonary Resuscitation on Sublingual Microcirculation in a Swine Model of Cardiac Arrest

Circulation ◽  
2018 ◽  
Vol 138 (Suppl_2) ◽  
Author(s):  
Brendan M McCracken ◽  
Mohamad H Tiba ◽  
Brandon C Cummings ◽  
Carmen I Colmenero ◽  
Alvaro Rojas-Pena ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Real Time ◽  
Tissue Perfusion ◽  
Dark Field ◽  
Swine Model ◽  
Sidestream Dark Field ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
Significant Difference ◽  
Highly Correlated ◽  
Time Assessment

Background: Extracorporeal CPR (ECPR) is used to provide circulatory stability for organ perfusion and oxygen delivery (DO 2 ) after refractory cardiac arrest (CA). Hemodynamic measurements during ECPR may not necessarily indicate adequate perfusion at the microcirculatory level where DO 2 , oxygen consumption (VO 2 ), and oxygen exchange (O 2 ER) are most critical. In this study, we used sidestream dark-field imaging to measure total vessel density (TVD) to evaluate sublingual microcirculatory flow in a swine model of refractory CA and ECPR. Hypothesis: We hypothesize that TVD can provide real-time assessment of tissue perfusion during post-cardiac arrest ECPR that correlates with traditional measures of tissue oxygenation. Methods: Swine (8) were anesthetized and instrumented for hemodynamic monitoring. Ventricular fibrillation (VF) was induced and CPR initiated after 8min. CPR was administered using a combination of manual and mechanical chest compressions. During CPR the femoral vessels were instrumented for delivery of veno-arterial ECPR. ECPR was initiated 45min after arrest to simulate refractory CA. Sublingual TVD was measured at baseline and after 15min, 1, 2, and 3 hours of ECPR. Results: A one-way ANOVA showed significant difference between baseline TVD: 12.2(2.3)mm -1 and at 3 hours into ECPR: 6.4(3.0)mm -1 (p=0.005). TVD was highly correlated with circuit flow but not with Mean Arterial Pressure (MAP) (r=0.903, p=0.036; r=0.063, p=0.920). In addition, TVD was highly correlated with DO 2 , and lactate, (r= 0.897, p=0.039; r=-0.883, p=0.047) and moderately with VO 2 , O 2 ER, and ScvO 2 (r= 0.776, -0.370, 0.558) respectively. Conclusion: TVD appears to provide a reliable real-time assessment of tissue perfusion during post-cardiac arrest ECPR. The relationships between TVD and MAP, and TVD and flow also suggest that optimization of flow may be more important than optimizing pressure to achieve adequate tissue perfusion during ECPR.

scholarly journals Lactate Clearance Predicts Good Neurological Outcomes in Cardiac Arrest Patients Treated with Extracorporeal Cardiopulmonary Resuscitation

2019 ◽  
Vol 8 (3) ◽  
pp. 374 ◽  
Author(s):  
Christian Jung ◽  
Sandra Bueter ◽  
Bernhard Wernly ◽  
Maryna Masyuk ◽  
Diyar Saeed ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Cardiopulmonary Resuscitation ◽  
Cox Regression ◽  
Lactate Concentration ◽  
Lactate Clearance ◽  
Serum Lactate ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
Neurological Outcomes ◽  
Baseline Characteristics ◽  
The Impact

Background: We evaluated critically ill patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR) due to cardiac arrest (CA) with respect to baseline characteristics and laboratory assessments, including lactate and lactate clearance for prognostic relevance. Methods: The primary endpoint was 30-day mortality. The impact on 30-day mortality was assessed by uni- and multivariable Cox regression analyses. Neurological outcome assessed by Glasgow Outcome Scale (GOS) was pooled into two groups: scores of 1–3 (bad GOS score) and scores of 4–5 (good GOS score). Results: A total of 93 patients were included in the study. Serum lactate concentration (hazard ratio (HR) 1.09; 95% confidence interval (CI) 1.04–1.13; p < 0.001), hemoglobin, (Hb; HR 0.87; 95% CI 0.79–0.96; p = 0.004), and catecholamine use were associated with 30-day-mortality. In a multivariable model, only lactate clearance (after 6 h; OR 0.97; 95% CI 0.94–0.997; p = 0.03) was associated with a good GOS score. The optimal cut-off of lactate clearance at 6 h for the prediction of a bad GOS score was at ≤13%. Patients with a lactate clearance at 6 h ≤13% evidenced higher rates of bad GOS scores (97% vs. 73%; p = 0.01). Conclusions: Whereas lactate clearance does not predict mortality, it was the sole predictor of good neurological outcomes and might therefore guide clinicians when to stop ECPR.

scholarly journals Pharmacological Approach for Neuroprotection After Cardiac Arrest—A Narrative Review of Current Therapies and Future Neuroprotective Cocktail

2021 ◽  
Vol 8 ◽  
Author(s):  
Rishabh C. Choudhary ◽  
Muhammad Shoaib ◽  
Samantha Sohnen ◽  
Daniel M. Rolston ◽  
Daniel Jafari ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Brain Injury ◽  
Ischemia Reperfusion Injury ◽  
Ischemia Reperfusion ◽  
Global Scale ◽  
Narrative Review ◽  
Therapeutic Interventions ◽  
Endoplasmic Reticulum Stress Response ◽  
Whole Body ◽  
Extracorporeal Cardiopulmonary Resuscitation

Cardiac arrest (CA) results in global ischemia-reperfusion injury damaging tissues in the whole body. The landscape of therapeutic interventions in resuscitation medicine has evolved from focusing solely on achieving return of circulation to now exploring options to mitigate brain injury and preserve brain function after CA. CA pathology includes mitochondrial damage and endoplasmic reticulum stress response, increased generation of reactive oxygen species, neuroinflammation, and neuronal excitotoxic death. Current non-pharmacologic therapies, such as therapeutic hypothermia and extracorporeal cardiopulmonary resuscitation, have shown benefits in protecting against ischemic brain injury and improving neurological outcomes post-CA, yet their application is difficult to institute ubiquitously. The current preclinical pharmacopeia to address CA and the resulting brain injury utilizes drugs that often target singular pathways and have been difficult to translate from the bench to the clinic. Furthermore, the limited combination therapies that have been attempted have shown mixed effects in conferring neuroprotection and improving survival post-CA. The global scale of CA damage and its resultant brain injury necessitates the future of CA interventions to simultaneously target multiple pathways and alleviate the hemodynamic, mitochondrial, metabolic, oxidative, and inflammatory processes in the brain. This narrative review seeks to highlight the current field of post-CA neuroprotective pharmaceutical therapies, both singular and combination, and discuss the use of an extensive multi-drug cocktail therapy as a novel approach to treat CA-mediated dysregulation of multiple pathways, enhancing survival, and neuroprotection.

Abstract 11597: Characterization of Epinephrine Use During Extracorporeal Cardiopulmonary Resuscitation

Circulation ◽  
2021 ◽  
Vol 144 (Suppl_2) ◽  
Author(s):  
Nicholas Kucher ◽  
Alexandra Marquez ◽  
Anne M Guerguerian ◽  
Michael-Alice Moga ◽  
Mariella Vargas-Gutierrez ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Total Dose ◽  
Ecmo Support ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
Vasodilator Therapy ◽  
Pump Speed ◽  
Inotrope Score ◽  
Clinically Significant ◽  
The Impact

Introduction: Guidelines recommend dosing Epinephrine (Epi) at regular intervals during pediatric cardiac arrest, including patients requiring extracorporeal membrane oxygenation (ECMO). The impact of Epi-induced vasoconstriction on systemic afterload and veno-arterial ECMO support is poorly understood. Hypothesis: Higher total dose of Epi and shorter interval between Epi dose and ECMO flow during cardiac arrest will increase systemic afterload and interfere with ECMO support. Methods: This is an ancillary study to a single-center, retrospective observational study of patients 0-18 years old who required ECMO cannulation during resuscitation over a six-year period. Patients were excluded if ECMO was initiated prior to arrest or if the resuscitation record was incomplete. The primary exposure was time from last dose of Epi to initiation of ECMO flows; secondary exposures included cumulative Epi dose delivered and indexed to arrest time. Mean arterial pressure (MAP) and systemic vasodilator therapy were used as surrogates for systemic afterload; ECMO pump speed and vasoactive-inotrope score (VIS) were used as measures of ECMO support. Results: A total 92 events in 87 patients analyzed. The patient cohort was 53% female with median (IQR) age of 122 (30-478) days, weight 4.4 (3.3 - 8.7) kg, and 43% single ventricle physiology. On average, Epi was given 7 (4 - 10) times during a 35 (27 - 44) min arrest, for a total dose of 65 (37 - 101) mcg/kg; the last dose was given 6 (2 -16) min prior to the initiation of ECMO flows. In the 6 hours following initiation of ECMO, MAP increased from 42 (36 - 56) mmHg to 57 (47 - 70) mmHg, (p<0.0001). Shorter interval between last Epi dose and ECMO initiation trended with higher MAP after 1 hour of support (estimate -0.43, p=0.06) and associated with increased of vasodilators within 6 hours of ECMO (vasodilators used (1 - 6) vs not used 9 (3 - 16) min, p=0.05). No other associations were found between Epi delivery, MAP, vasodilator use, pump speed or VIS. Conclusion: There is limited evidence to support that regular dosing of Epi throughout a cardiac arrest is associated with clinically significant increases in afterload after ECMO cannulation. Additional studies are needed to validate findings against ECMO flows and clinically relevant outcomes.

Abstract 259: Outcomes of Targeted Temperature Management in Patients with Out-of-hospital Refractory Ventricular Fibrillation/ventricular Tachycardia Cardiac Arrest

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_4) ◽  
Author(s):  
Kellen Albrecht ◽  
Jason Bartos ◽  
Demetris Yannopoulos
Keyword(s):  
Cardiac Arrest ◽  
Brain Death ◽  
Initial Temperature ◽  
Bleeding Risk ◽  
Targeted Temperature Management ◽  
Adult Patients ◽  
Temperature Management ◽  
Passive Cooling ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
The Impact

Background: Current guidelines recommend use of targeted temperature management (TTM) with goal between 32 and 36°C for all comatose adult patients with ROSC after cardiac arrest. However, refractory cardiac arrest with prolonged hypoperfusion, may cause passive cooling below goal temperature. The impact of this passive cooling and subsequent cooling strategies remains unknown. This study aims to describe the association between passive intra-arrest cooling and survival in patients suffering refractory VF/VT cardiac arrest treated with the University of Minnesota extracorporeal cardiopulmonary resuscitation (ECPR) protocol. Methods: Between December 2015 and October 2019, consecutive adult patients with refractory VF/VT arrest requiring ongoing CPR were transported by EMS to the CCL where ECPR, coronary angiography, and PCI were performed, as appropriate. TTM was initiated with goal temperature of 34°C unless clinically significant bleeding occurred, where a goal of 36°C was used. Patient and arrest characteristics, temperature data, and survival were collected retrospectively. Results: Data was gathered for 153 consecutive patients transferred for ECPR; 12 were excluded due to death in CCL prior to TTM. Of the remaining patients, 63 (41%) survived to discharge, where 55 (36%) had CPC scores of 1-2. Among deceased patients, 25 died from acute brain death while 47 died from other causes. Patients with CPC 1-2 had an initial temperature of 34.1°C versus 32.7°C in patients developing acute brain death (p=0.002). Survivors had shorter (p=0.0001) CPR time (52 minutes) versus deceased patients (65 minutes). If the initial temperature was below goal, patients were actively warmed to goal due to bleeding risk with ECPR. Survival to hospital discharge with CPC 1-2 was associated with lower peak warming rate compared with acute brain death (0.37°C/hr vs 0.69°C/hr; p=0.014) Conclusions: Survivors with CPC 1-2 after refractory VF/VT cardiac arrest and ECPR have preserved initial temperatures compared to more severe passive cooling in patients with acute brain death. This may be due to shorter duration of CPR. However, patients with acute brain death were noted to have higher peak rate of rewarming during TTM.

Extracorporeal Membrane Oxygenation for Pediatric Cardiac Arrest

2015 ◽  
Vol 35 (1) ◽  
pp. 60-69 ◽  
Author(s):  
Jennie Ryan
Keyword(s):  
Cardiac Arrest ◽  
Cardiopulmonary Resuscitation ◽  
Extracorporeal Membrane Oxygenation ◽  
Life Support ◽  
Survival Rates ◽  
Underlying Disease ◽  
The Body ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
Membrane Oxygenation ◽  
The Impact

Extracorporeal cardiopulmonary resuscitation (ECPR) remains a promising treatment for pediatric patients in cardiac arrest unresponsive to traditional cardiopulmonary resuscitation. With venoarterial extracorporeal support, blood is drained from the right atrium, oxygenated through the extracorporeal circuit, and transfused back to the body, bypassing the heart and lungs. The use of artificial oxygenation and perfusion thus provides the body a period of hemodynamic stability, while allowing resolution of underlying disease processes. Survival rates for ECPR patients are higher than those for traditional cardiopulmonary resuscitation (CPR), although neurological outcomes require further investigation. The impact of duration of CPR and length of treatment with extracorporeal membrane oxygenation vary in published reports. Furthermore, current guidelines for the initiation and use of ECPR are limited and may lead to confusion about appropriate use of this support. Many ethical concerns arise with this advanced form of life support. More often than not, the dilemma is not whether to withhold ECPR, but rather when to withdraw it. Although clinicians must decide if ECPR is appropriate and when further intervention is futile, the ultimate burden of choice is left to the patient’s caregivers. Offering support and guidance to the patient’s family as well as the patient is essential.

Abstract 214: Cardiac Arrest and Extracorporeal Cardiopulmonary Resuscitation Impairs Left Ventricle Hemodynamic Function in a Ventricular Fibrillation Cardiac Arrest Model in Rats

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_4) ◽  
Author(s):  
Alexandra Maria Warenits ◽  
Matthias Müller ◽  
Ingrid Anna Maria Magnet ◽  
Florian Ettl ◽  
Ouafa Hamza ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Cardiac Output ◽  
Ventricular Fibrillation ◽  
Cardiopulmonary Resuscitation ◽  
Left Ventricular ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
Hemodynamic Stress ◽  
Hemodynamic Function ◽  
The Right ◽  
The Impact

Introduction: Extracorporeal Cardiopulmonary Resuscitation (ECPR) may achieve ROSC after prolonged CA when conventional cardiopulmonary resuscitation fails. We investigated the impact of ECPR on cardiac hemodynamic recovery and hypothesized, that left ventricular hemodynamic function is impaired in resuscitated hearts. Methods: Adult male Sprague-Dawley rats (500 g, n=36) were subjected to 6 or 8 min of ventricular fibrillation CA, thereafter resuscitated with ECPR (open reservoir, roller pump, membrane oxygenator, draining catheter in the right jugular vein, inflow catheter in the right femoral artery; custom made bypass system), mechanical ventilation and drugs (epinephrine, bicarbonate, heparin). After defibrillation and ROSC, rats survived for 14 days and were compared to 7 sham animals. The hearts were isolated and mounted onto an erythrocyte-perfused, isolated working heart (WH) system. Cardiac output, left ventricular systolic pressure (LVSP), coronary flow and pressure-volume (P-V) relationships (by increasing the afterload in 10 mmHg increments) were measured. Myocardium of all rats was evaluated pathohistological in hematoxylin-eosin staining. Results: ROSC was achieved in 18 animals after 6 min of CA, of which 10 survived 14 d and 7 were investigated in WH, in 8 min CA group 15 achieved ROSC of which 5 survived to 14 d and 2 were investigated in WH and compared to the hearts of 7 sham animals. At defined afterload (60 mm Hg; baseline) there was no difference in cardiac hemodynamics between sham and 6 min CA group. In contrast, 8 min CA rats showed a tendency towards decrease in cardiac output and LVSP compared to sham animals. Notably, both CA groups showed impaired P-V loop relationship and subsequently less tolerance to hemodynamic stress. Histologically all 8 min CA rats showed multiple foci of myocardial scarring. Conclusions: CA led to impaired left ventricular hemodynamics in 8 min CA rats resuscitated with ECPR. In addition, hearts were more vulnerable to hemodynamic stress after successful resuscitation. For investigating the effects of future therapy approaches during and after resuscitation from CA on the heart function, isolated WH might be a promising approach in resuscitation research.

scholarly journals Noninvasive in vivo assessment of the skeletal muscle and small intestine serous surface microcirculation in rat: sidestream dark-field (SDF) imaging

2008 ◽  
pp. 365-371
Author(s):  
Z Turek ◽  
V Černý ◽  
R Pařízková
Keyword(s):  
Skeletal Muscle ◽  
Interindividual Variability ◽  
Experimental Studies ◽  
Dark Field ◽  
Sidestream Dark Field ◽  
Small Vessels ◽  
Sdf Imaging ◽  
Orthogonal Polarization Spectral ◽  
Custom Made ◽  
Significant Difference

The pathophysiology of microcirculation is intensively investigated to understand disease development at the microscopic level. Orthogonal polarization spectral (OPS) imaging and its successor sidestream dark-field (SDF) imaging are relatively new noninvasive optical techniques allowing direct visualization of microcirculation in both clinical and experimental studies. The goal of this experimental study was to describe basic microcirculatory parameters of skeletal muscle and ileal serous surface microcirculation in the rat using SDF imaging and to standardize the technical aspects of the protocol. Interindividual variability in functional capillary density (FCD) and small vessels (<25 μm in diameter) proportion was determined in anesthetized rats on the surface of quadriceps femoris (m. rectus femoris and m. vastus medialis) and serous surface of ileum. Special custom made flexible arm was used to fix the SDF probe minimizing the pressure movement artifacts. Clear high contrast images were analyzed off-line. The mean FCD obtained from the surface of skeletal muscle and ileal serous surface was 219 (213-225 cm/cm2) and 290 (282-298 cm/cm2) respectively. There was no statistically significant difference between rats in mean values of FCD obtained from the muscle (P = 0.273) in contrast to ileal serous surface, where such difference was statistically significant (P = 0.036). No statistically significant differences in small vessels percentage was detected on either the muscle surface (P = 0.739) or on ileal serous surface (P = 0.659). Our study has shown that interindividual variability of basic microcirculatory parameters in rat skeletal muscle and ileum is acceptable when using SDF imaging technique according to a highly standardized protocol and with appropriate fixation device. SDF imaging represents promising technology for experimental and clinical studies.

Reducing the Risks of the Financial Sector to Ensure Sustainable Growth of the Russian Еconomy

2019 ◽  
Vol 12 (3) ◽  
pp. 86-92
Author(s):  
T. I. Minina ◽  
V. V. Skalkin
Keyword(s):  
Economic Growth ◽  
Monetary Policy ◽  
Financial Sector ◽  
Developed Countries ◽  
Sustainable Growth ◽  
Necessary Condition ◽  
Real Sector ◽  
Financial Instruments ◽  
The Real ◽  
The Impact

Russia’s entry into the top five economies of the world depends, among other things, on the development of the financial sector, being a necessary condition for the economic growth of a developed macroeconomic and macro-financial system. The financial sector represents a system of relationships for the effective collection and distribution of economic resources, their deployment according to public demand, reducing the risk of overproduction and overheating of the economy.Therefore, the subject of the research is the financial sector of the Russian economy.The purpose of the research was to formulate an approach to alleviating the risks of increasing financial costs in the real sector of the economy by reducing the impact of endogenous risks expressed as financial asset “bubbles” using the experience of developed countries in the monetary policy.The paper analyzes a macroeconomic model applied to the financial sector. It is established that the economic growth is determined by the growth and, more important, the qualitative development of the financial sector, which leads to two phenomena: overproduction in the real sector and an increase in asset prices in the financial sector, with a debt load in both the real and financial sectors. This results in decreasing the interest rate of the mega-regulator to near-zero values. In this case, since the mechanisms of the conventional monetary policy do not work, the unconventional monetary policy is used when the mega-regulator buys out derivative financial instruments from systemically important institutions. As a conclusion, given deflationally low rates, it is proposed that the megaregulator should issue its own derivative financial instruments and place them in the financial market.

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