Esmolol during Cardiopulmonary Resuscitation Reduces Neurological Injury in a Porcine Model of Cardiac Arrest

Abstract Background. Primary vasopressor efficacy of epinephrine during cardiopulmonary resuscitation (CPR) is due to its α-adrenergic effects. However, epinephrine plays β1-adrenergic actions, which increasing myocardial oxygen consumption may lead to refractory ventricular fibrillation (VF) and poor outcome. Methods. Effects of a single dose of esmolol in addition to epinephrine during CPR were investigated in a porcine model of VF with an underlying acute myocardial infarction. VF was ischemically induced in 36 pigs and left untreated for 12min. During CPR, animals were randomized to receive epinephrine (30µg/kg) with either esmolol (0.5mg/kg) or saline (control). Pigs were then observed up to 96h. Results. Coronary perfusion pressure increased during CPR in the esmolol group compared to control (p<0.05). In both groups, 7 animals were successfully resuscitated and 4 survived up to 96h. No significant differences were observed between groups in the total number of defibrillations delivered prior to final resuscitation. Brain histology demonstrated reductions in cortical neuronal degeneration/necrosis (p<0.05) and hippocampal microglial activation (p<0.01) in the esmolol group compared to control. Lower circulating levels of neuron specific enolase were measured in esmolol animals compared to controls (p<0.01). Conclusions. In this preclinical model, β1-blockade during CPR did not facilitate VF termination but provided neuroprotection.

Download Full-text

Esmolol during cardiopulmonary resuscitation reduces neurological injury in a porcine model of cardiac arrest

Scientific Reports ◽

10.1038/s41598-021-90202-w ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Laura Ruggeri ◽

Francesca Nespoli ◽

Giuseppe Ristagno ◽

Francesca Fumagalli ◽

Antonio Boccardo ◽

...

Keyword(s):

Cardiopulmonary Resuscitation ◽

Porcine Model ◽

Neuronal Degeneration ◽

Neuron Specific Enolase ◽

Coronary Perfusion Pressure ◽

Neurological Injury ◽

Saline Control ◽

Preclinical Model ◽

Coronary Perfusion ◽

To Receive

AbstractPrimary vasopressor efficacy of epinephrine during cardiopulmonary resuscitation (CPR) is due to its α-adrenergic effects. However, epinephrine plays β1-adrenergic actions, which increasing myocardial oxygen consumption may lead to refractory ventricular fibrillation (VF) and poor outcome. Effects of a single dose of esmolol in addition to epinephrine during CPR were investigated in a porcine model of VF with an underlying acute myocardial infarction. VF was ischemically induced in 16 pigs and left untreated for 12 min. During CPR, animals were randomized to receive epinephrine (30 µg/kg) with either esmolol (0.5 mg/kg) or saline (control). Pigs were then observed up to 96 h. Coronary perfusion pressure increased during CPR in the esmolol group compared to control (47 ± 21 vs. 24 ± 10 mmHg at min 5, p < 0.05). In both groups, 7 animals were successfully resuscitated and 4 survived up to 96 h. No significant differences were observed between groups in the total number of defibrillations delivered prior to final resuscitation. Brain histology demonstrated reductions in cortical neuronal degeneration/necrosis (score 0.3 ± 0.5 vs. 1.3 ± 0.5, p < 0.05) and hippocampal microglial activation (6 ± 3 vs. 22 ± 4%, p < 0.01) in the esmolol group compared to control. Lower circulating levels of neuron specific enolase were measured in esmolol animals compared to controls (2[1–3] vs. 21[16–52] ng/mL, p < 0.01). In this preclinical model, β1-blockade during CPR did not facilitate VF termination but provided neuroprotection.

Download Full-text

Endobronchial Vasopressin Improves Survival during Cardiopulmonary Resuscitation in Pigs

Anesthesiology ◽

10.1097/00000542-199706000-00020 ◽

1997 ◽

Vol 86 (6) ◽

pp. 1375-1381 ◽

Cited By ~ 64

Author(s):

Volker Wenzel ◽

Karl H. Lindner ◽

Andreas W. Prengel ◽

Keith G. Lurie ◽

Hans U. Strohmenger

Keyword(s):

Placebo Group ◽

Cardiopulmonary Resuscitation ◽

Drug Administration ◽

Porcine Model ◽

Perfusion Pressure ◽

Coronary Perfusion Pressure ◽

Spontaneous Circulation ◽

Coronary Perfusion ◽

Successful Resuscitation ◽

Short Period

Background Intravenous administration of vasopressin during cardiopulmonary resuscitation (CPR) has been shown to be more effective than optimal doses of epinephrine. This study evaluated the effect of endobronchial vasopressin during CPR. Methods After 4 min of untreated ventricular fibrillation and 3 min of CPR, 21 pigs were randomized to be treated with 0.8 U/kg intravenous vasopressin (n = 7), 0.8 U/kg endobronchial vasopressin (n = 9), or an endobronchial placebo of normal saline (n = 5). Defibrillation was performed 5 min after drug administration to attempt return of spontaneous circulation. Results All animals in the intravenous and endobronchial vasopressin group were resuscitated successfully, but only two of five animals in the placebo group were. At 2 and 5 min after drug administration, coronary perfusion pressure in the intravenous and endobronchial vasopressin group was significantly higher than in the placebo group (50 +/- 10, 34 +/- 5 vs. 16 +/- 6 mmHg, respectively; and 35 +/- 10, 39 +/- 10 vs. 19 +/- 5 mmHg, respectively; P < 0.05). Conclusions Endobronchial vasopressin is absorbed during CPR, coronary perfusion pressure is increased significantly within a short period, and the chance of successful resuscitation is increased in this porcine model of CPR. Endobronchial vasopressin may be an alternative for vasopressor administration during CPR, when intravenous access is delayed or not available.

Download Full-text

NITRIC OXIDE SYNTHASE INHIBITION IMPROVES CORONARY PERFUSION PRESSURE AND OUTCOME DURING CARDIOPULMONARY RESUSCITATION (CPR) IN A PORCINE MODEL OF VENTRICULAR FIBRILLATION

Critical Care Medicine ◽

10.1097/00003246-199912001-00030 ◽

1999 ◽

Vol 27 (Supplement) ◽

pp. A30

Author(s):

Werner Lingnau ◽

Anette C Krismer ◽

Karl H Lindner ◽

Volker Wenzel ◽

Bernd Rainer ◽

...

Keyword(s):

Nitric Oxide ◽

Ventricular Fibrillation ◽

Nitric Oxide Synthase ◽

Cardiopulmonary Resuscitation ◽

Porcine Model ◽

Perfusion Pressure ◽

Coronary Perfusion Pressure ◽

Coronary Perfusion ◽

Oxide Synthase

Download Full-text

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.

Download Full-text

Coronary Perfusion Pressure During Cardiopulmonary Resuscitation After Spinal Anesthesia in Dogs

Anesthesia & Analgesia ◽

10.1213/00000539-199601000-00014 ◽

1996 ◽

Vol 82 (1) ◽

pp. 84-87

Author(s):

Jack M. Rosenberg ◽

Joyce A. Wahr ◽

Ho Choon Sung ◽

Young Suk Oh ◽

Lori J. Gilligan

Keyword(s):

Cardiopulmonary Resuscitation ◽

Spinal Anesthesia ◽

Perfusion Pressure ◽

Coronary Perfusion Pressure ◽

Coronary Perfusion

Download Full-text

Abstract 167: Epinephrine Plus Chest Compressions May Be Superior to Epinephrine Alone in a Hypoxia-Induced Porcine Model of Lifeless Shock

Circulation ◽

10.1161/circ.140.suppl_2.167 ◽

2019 ◽

Vol 140 (Suppl_2) ◽

Author(s):

Felipe Teran ◽

Claire Centeno ◽

Alex L Lindqwister ◽

William J Hunckler ◽

William Landis ◽

...

Keyword(s):

Chest Compression ◽

Porcine Model ◽

Contractile Activity ◽

Coronary Perfusion Pressure ◽

Spontaneous Circulation ◽

Swine Model ◽

Coronary Perfusion ◽

Chest Compressions ◽

Fraction Of Inspired Oxygen ◽

External Chest Compressions

Background: Lifeless shock (LS) (previously called EMD and pseudo-PEA) is a global hypotensive ischemic state with retained coordinated myocardial contractile activity and an organized ECG. We have previously described our hypoxic LS model. The role of standard external chest compressions remains unclear in the setting of LS and its associated intrinsic hemodynamics. Although it is known the patients with LS have better prognosis compared to PEA, it is unclear what is the best treatment strategy. Prior work has shown that chest compressions (CC) when synchronized with native systole results in significant hemodynamic improvement, most notably coronary perfusion pressure (CPP), and hence it is plausible that standard dyssynchronous CC may be detrimental to hemodynamics. Furthermore, retrospective clinical data has shown that LS patients treated with vasopressors and no CC, may have better outcomes. We compared epinephrine only versus epinephrine and chest compression, in a porcine model of LS. Methods: Our porcine model of hypoxic LS has previously been described. We randomized pigs to episodes of LS treated with epinephrine only (control) (0.0015 mg/kg) versus epinephrine plus standard external chest compressions (intervention). Animals were endotracheally intubated and mechanically ventilated, and the fraction of inspired oxygen (FiO 2 ) was gradually lowered from room air (20-30% O 2 ) to a target FiO 2 of 3-7% O 2 . This target FiO 2 was maintained until the systolic blood pressure (SBP) dropped to 30 mmHg for 30 seconds, or the animal became bradycardic (HR less than 40), which was defined as the start of LS. FiO 2 was then raised to 100%, and then animal would receive control or intervention. Return of spontaneous circulation (ROSC) was defined as SBP 60 mmHg, stable after 2 minutes. Results: Twenty-six episodes of LS in 11 animals received epinephrine only control and 21 episodes the epinephrine plus chest compression intervention. The rates of ROSC in two minutes or less were 5/26 (19%) in the control arm vs 14/21 (67%) in the intervention arm (P=0.001;95% CI 19.7 %-67.2%). Conclusions: In a swine model of hypoxia induced LS, epinephrine plus CPR may be superior to epinephrine alone.

Download Full-text