scholarly journals The Physiologic Response to Rescue Therapy with Vasopressin versus Epinephrine during Experimental Pediatric Cardiac Arrest

2020 ◽  
Author(s):  
Julia Slovis ◽  
Ryan Morgan ◽  
William Landis ◽  
Anna L Roberts ◽  
Constantine Mavroudis ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Perfusion Pressure ◽  
Rescue Therapy ◽  
Coronary Perfusion Pressure ◽  
Coronary Perfusion ◽  
Cerebral Vasculature ◽  
Chest Compressions ◽  
Rescue Dose ◽  
Physiologic Response ◽  
Hospital Cardiac Arrest

Abstract Background: While epinephrine is the mainstay of therapy during cardiopulmonary resuscitation, it is potentially detrimental to the cerebral vasculature and ineffective in certain populations. This study compares a rescue dose of vasopressin to a rescue dose of epinephrine after ineffective initial doses of epinephrine in diverse models of pediatric in-hospital cardiac arrest. 67 one- to three-month old female swine (10-30kg) in six experimental cohorts from one laboratory received hemodynamic-directed CPR, a resuscitation method where high quality chest compressions are provided and vasopressor administration is titrated to coronary perfusion pressure (CoPP) ³20 mmHg. Vasopressors are given when CoPP is <20 mmHg, in sequences of two doses of 0.02 mg/kg epinephrine separated by minimum one-minute, then a rescue dose of 0.4 U/kg vasopressin followed by minimum two-minutes. Invasive measurements were used to evaluate and compare the hemodynamic and neurologic effects of each vasopressor dose. Results: Increases in CoPP and cerebral blood flow (CBF) were greater with vasopressin rescue than epinephrine rescue (CoPP: +8.16 [4.35, 12.06] mmHg vs. +5.43 [1.56, 9.82] mmHg, p=0.022; CBF: +14.58 [-0.05, 38.12] vs. +0.00 [-0.77, 18.24] perfusion units (PFU), p=0.005). Twenty animals (30%) failed to achieve CoPP ³20 mmHg after two doses of epinephrine; 9/20 (45%) non-responders achieved CoPP ³20 mmHg after vasopressin. Among all animals, the increase in CBF was greater with vasopressin (+14.58 [-0.58, 38.12] vs. 0.00 [-0.77, 18.24] PFU, p=0.005).Conclusions: CoPP and CBF rose significantly more after rescue vasopressin than after rescue epinephrine. Importantly, CBF increased after vasopressin rescue, but not after epinephrine rescue. In the 30% that failed to meet CoPP of 20mmHg after two doses of epinephrine, 45% achieved target CoPP with a single rescue vasopressin dose.

Cardiac Arrest and Resuscitation

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.

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

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.

Abstract 17334: The Detrimental Effect of Chest Compression Interruptions on Coronary Perfusion Pressure Dynamics

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Norman A Paradis ◽  
Karen L Moodie ◽  
Christopher L Kaufman ◽  
Joshua W Lampe
Keyword(s):  
Blood Flow ◽  
Chest Compression ◽  
Detrimental Effect ◽  
Perfusion Pressure ◽  
Vena Cava ◽  
Coronary Perfusion Pressure ◽  
Right Atrial ◽  
Coronary Perfusion ◽  
Chest Compressions ◽  
Over Time

Introduction: Guidelines for treatment of cardiac arrest recommend minimizing interruptions in chest compressions based on research indicating that interruptions compromise coronary perfusion pressure (CPP) and blood flow and reducing the likelihood of successful defibrillation. We investigated the dynamics of CPP before, during, and after compression interruptions and how they change over time. Methods: CPR was performed on domestic swine (~30 Kg) using standard physiological monitoring. Blood flow was measured in the abdominal aorta (AAo), the inferior vena cava, the right common carotid and external jugular. Ventricular fibrillation (VF) was electrically induced. Mechanical chest compressions (CC) were started after four minutes of VF. CC were delivered at a rate of 100 compressions per minute (cpm) and at a depth of 2” for a total of 12 min. CPP was calculated as the difference between aortic and right atrial pressure at end-diastole per Utstein guidelines. CPP was determined for 5 compressions prior to the interruption, every 2 seconds during the CC interruption, and for 7 compressions after the interruption. Per protocol, 12 interruptions occurred at randomized time points. Results: Across 12 minutes of CPR, averaged CPP prior to interruption was significantly greater than the averaged CPP after the interruption (22.4±1.0 vs. 15.5±0.73 mmHg). As CPR continued throughout the 12 minutes, CPP during compressions decreased (First 6 min = 24.1±1.4 vs. Last 6 min = 20.1±1.3 mmHg, p=0.05), but the effect of interruptions remained constant resulting in a 20% drop in CPP for every 2 seconds irrespective of the prior CPP. The increase (slope) of CPP after resumption of compressions was significantly reduced over time (First 6 min = 1.47±0.18 vs. Last 6 min = 0.82±0.13 mmHg/compression). Conclusions: Chest compression interruptions have a detrimental effect on coronary perfusion and blood flow. The magnitude of this effect increases over time as a resuscitation effort continues. These data confirm the importance of providing uninterrupted CPR particularly in long duration resuscitations.

REPEATED DOSES OF EPINEPHRINE DO NOT IMPROVE CORONARY PERFUSION PRESSURE AFTER 5 MIN CARDIAC ARREST IN PIGS

1999 ◽  
Vol 27 (Supplement) ◽  
pp. 45A
Author(s):  
Wilhelm Behringer ◽  
Michael Holzer ◽  
Fritz Sterz ◽  
Elisabeth Oschatz ◽  
Julia Kofler ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Perfusion Pressure ◽  
Coronary Perfusion Pressure ◽  
Coronary Perfusion ◽  
Repeated Doses

Abstract 268: Evaluation of the Abdominal Aortic and Junctional Tourniquet as an Adjunct to Chest Compressions in a Swine Model of Out-Of-Hospital Cardiac Arrest

Circulation ◽  
2019 ◽  
Vol 140 (Suppl_2) ◽  
Author(s):  
Jason Rall ◽  
Chris Hewitt ◽  
Matthew Pombo ◽  
Maria Castaneda ◽  
Perry Blough
Keyword(s):  
Cardiac Arrest ◽  
Repeated Measures ◽  
Life Support ◽  
Diastolic Pressure ◽  
Laboratory Animals ◽  
Swine Model ◽  
Coronary Perfusion ◽  
Chest Compressions ◽  
Abdominal Aortic ◽  
Hospital Cardiac Arrest

Introduction: Overall success in treating out-of-hospital cardiac arrest using traditional chest compressions is low. The abdominal aortic and junctional tourniquet (AAJT) is a device with a wedge-shaped air bladder that can be used to occlude the descending aorta at the level of bifurcation. In addition to shunting blood away from the lower extremities, this device may increase pleural pressures by inhibiting movement of the diaphragm during compressions. We have previously shown that the addition of an AAJT to mechanical chest compression leads to an increase in rate of survival in a model of traumatic cardiac arrest. Hypothesis: This study was designed to determine if application of the AAJT would lead to more effective chest compressions as measured by an increased rate of return of spontaneous circulation (ROSC) and hemodynamic parameters. Methods: Yorkshire swine (n=6 per group) underwent general anesthesia and instrumentation. Ventricular fibrillation was electrically induced using spinal needles placed in contact with the left ventricle. After eight minutes of arrest, chest compressions were initiated. Animals were then allocated into groups with or without the AAJT. Following a total of ten minutes of compressions, the animals entered into a ten-minute advanced cardiac life support phase. Results: A ROSC was not achieved in either group. No significant differences were observed with coronary perfusion pressure or end tidal CO 2 . However, the AAJT group had a significantly higher carotid diastolic pressure and higher blood flow in the carotid as compared with repeated-measures ANOVA (p = 0.016 and 0.028 respectively). Conclusion: The AAJT did not confer a survival advantage during chest compressions in our swine model of cardiac arrest. However, while the AAJT was in place, improvement was observed in some measures of CPR efficacy. Disclaimer: The views expressed are those of the authors and do not reflect the official views or policy of the Department of Defense or its Components. The experiments reported herein were conducted according to the principles set forth in the National Institute of Health Publication No. 80-23, Guide for the Care and Use of Laboratory Animals and the Animal Welfare Act of 1966, as amended.

Abstract 2043: Even Minimal Interruptions in Chest Compression for Ventilation Significantly Decreases Coronary Perfusion Pressure

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Tao Yu ◽  
Giuseppe Ritagno ◽  
Jun H Cho ◽  
Shijie Sun ◽  
Max H Weil ◽  
...  
Keyword(s):  
Ventricular Fibrillation ◽  
Chest Compression ◽  
Left Atrial ◽  
Perfusion Pressure ◽  
Experimental Studies ◽  
Coronary Perfusion Pressure ◽  
Coronary Perfusion ◽  
Significant Delay ◽  
Chest Compressions ◽  
The Difference

We have previously reported, on the basis of experimental studies, that interruptions of CPR as little as 10 seconds adversely affect the outcomes of CPR. We therefore investigated interruptions of only 5 seconds for delivering ventilation, which corresponds to the current AHA algorithm in which of 30 compressions followed by 2 ventilations are mandated. We hypothesized that even 5 seconds interruption significantly reduces CPP and with significant delay prior to restoring pre-interruption levels. Ventricular fibrillation (VF) was induced and untreated for 15 minutes in 33 male domestic pigs weighting 40±3 Kg. Chest compressions delivered with the aid of mechanical compressor (Thumper, 1000, MI Instruments) with a rate of 100/min. Ventilations were administrated with a compression / ventilation ratio of 30:2 such that 2 ventilations were delivered over a 5 seconds interval. CPP was continuously measured as the difference between comparison diastolic and simultaneous left atrial pressure. CPP significantly decreased during interruptions for ventilation from 20.5±12.8 mmHg to 9.8±6.7 mmHg( P <0.001). After chest compressions were restarted, the CPP increased to 12.5±7.6 mmHg after first compression( P <0.001). A total of 12±7 compressions over a mean interval of 7.2±4.3 seconds was required prior to restoration of CPP to levels corresponding to those that preceded the interruption. As little as the five seconds of interruption in chest compression currently mandated for 30 to 2 ventilations during CPR significantly reduced CPP and delayed restoration of CPP to its pre-interruption level.

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

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Johanna C Moore ◽  
Ryu Hyun Ho ◽  
Michael Lick ◽  
Adamantios Tsangaris ◽  
Scott McKnite ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Cerebral Perfusion Pressure ◽  
Cerebral Perfusion ◽  
Perfusion Pressure ◽  
Coronary Perfusion Pressure ◽  
Coronary Perfusion ◽  
Entire Body ◽  
Significant Difference ◽  
Group A ◽  
Group B

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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