Early goal-directed hemodynamic optimization combined with therapeutic hypothermia in comatose survivors of out-of-hospital cardiac arrest

Department of Emergency Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
Resuscitation (Impact Factor: 4.17). 02/2009; 80(4):418-24. DOI: 10.1016/j.resuscitation.2008.12.015
Source: PubMed


Comatose survivors of out-of-hospital cardiac arrest (OHCA) have high in-hospital mortality due to a complex pathophysiology that includes cardiovascular dysfunction, inflammation, coagulopathy, brain injury and persistence of the precipitating pathology. Therapeutic hypothermia (TH) is the only intervention that has been shown to improve outcomes in this patient population. Due to the similarities between the post-cardiac arrest state and severe sepsis, it has been postulated that early goal-directed hemodyamic optimization (EGDHO) combined with TH would improve outcome of comatose cardiac arrest survivors.
We examined the feasibility of establishing an integrated post-cardiac arrest resuscitation (PCAR) algorithm combining TH and EGDHO within 6h of emergency department (ED) presentation.
In May, 2005 we began prospectively identifying comatose (Glasgow Motor Score<6) survivors of OHCA treated with our PCAR protocol. The PCAR patients were compared to matched historic controls from a cardiac arrest database maintained at our institution.
Between May, 2005 and January, 2008, 18/20 (90%) eligible patients were enrolled in the PCAR protocol. They were compared to historic controls from 2001 to 2005, during which time 18 patients met inclusion criteria for the PCAR protocol. Mean time from initiation of TH to target temperature (33 degrees C) was 2.8h (range 0.8-23.2; SD=h); 78% (14/18) had interventions based upon EGDHO parameters; 72% (13/18) of patients achieved their EGDHO goals within 6h of return of spontaneous circulation (ROSC). Mortality for historic controls who qualified for the PCAR protocol was 78% (14/18); mortality for those treated with the PCAR protocol was 50% (9/18) (p=0.15).
In patients with ROSC after OHCA, EGDHO and TH can be implemented simultaneously.

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    • "It has been well demonstrated that brain temperatures during the first 24 hours after ROSC have a significant effect on survival and neurological recovery in patients who remain comatose soon after ROSC [22]. Preclinical and clinical evidence strongly supports mild therapeutic hypothermia as an effective therapy for the postcardiac arrest syndrome [23]. Unconscious adult patients with spontaneous circulation after out-of-hospital VF cardiac arrest should be cooled to 32–34°C for at least 12 to 24 hours. "
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    ABSTRACT: Survival rates following in-hospital and out-of-hospital cardiac arrests remain disappointingly low. Organ injury caused by ischemia and hypoxia during prolonged cardiac arrest is compounded by reperfusion injury that occurs when a spontaneous circulation is restored. A bundle of procedures, which may need to be administered simultaneously, is required. The procedures include prompt identification and treatment of the cause of cardiac arrest, as well as a definitive airway and ventilation together. Additional benefit is possible with appropriate forms of early goal-directed therapy and achieving therapeutic hypothermia within the first few hours, followed by gradual rewarming and ensuring glycaemic control to be within a range of 6 to 10 mmol/L. All these would be important and need to be continued for at least 24 hours. Previous studies have showed that the effects of Shen-Fu injection (SFI) are based on aconitine properties, supplemented by ginsenoside, which can scavenge free radicals, improve energy metabolism, inhibit inflammatory mediators, suppress cell apoptosis, and alleviate mitochondrial damage. SFI, like many other complex prescriptions of traditional Chinese medicine, was also found to be more effective than any of its ingredient used separately in vivo. As the postresuscitation care bundle is known to be, the present paper focuses on the role of SFI played on the postresuscitation care bundle.
    Full-text · Article · Aug 2013 · Evidence-based Complementary and Alternative Medicine
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    • "ROSC (return of spontaneous circulation) was reached in 56% of cases, 43% survived the episode, 15% were discharged home with favourable neurological outcome, however, back to the fully active life including job attendance returned only 7% of the original cohort [4]. A key prerequisite for a successful outcome is minimalization of time delays, resuscitation quality, complex intensive care and treatment of cardiac arrest cause [5-7]. So far, the only proven method for increased survival with good neurological outcome is early initiation of mild hypothermia and probably also the rapidly reached target temperature [3,8]. "
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    ABSTRACT: Background: Out of hospital cardiac arrest (OHCA) has a poor outcome. Recent non-randomized studies of ECLS (extracorporeal life support) in OHCA suggested further prospective multicenter studies to define population that would benefit from ECLS. We aim to perform a prospective randomized study comparing prehospital intraarrest hypothermia combined with mechanical chest compression device, intrahospital ECLS and early invasive investigation and treatment in all patients with OHCA of presumed cardiac origin compared to a standard of care. Methods: This paper describes methodology and design of the proposed trial. Patients with witnessed OHCA without ROSC (return of spontaneous circulation) after a minimum of 5 minutes of ACLS (advanced cardiac life support) by emergency medical service (EMS) team and after performance of all initial procedures (defibrillation, airway management, intravenous access establishment) will be randomized to standard vs. hyperinvasive arm. In hyperinvasive arm, mechanical compression device together with intranasal evaporative cooling will be instituted and patients will be transferred directly to cardiac center under ongoing CPR (cardiopulmonary resuscitation). After admission, ECLS inclusion/exclusion criteria will be evaluated and if achieved, veno-arterial ECLS will be started. Invasive investigation and standard post resuscitation care will follow. Patients in standard arm will be managed on scene. When ROSC achieved, they will be transferred to cardiac center and further treated as per recent guidelines. Primary outcome: 6 months survival with good neurological outcome (Cerebral Performance Category 1-2). Secondary outcomes will include 30 day neurological and cardiac recovery. Discussion: Authors introduce and offer a protocol of a proposed randomized study comparing a combined "hyperinvasive approach" to a standard of care in refractory OHCA. The protocol is opened for sharing by other cardiac centers with available ECLS and cathlab teams trained to admit patients with refractory cardiac arrest under ongoing CPR. A prove of concept study will be started soon. The aim of the authors is to establish a net of centers for a multicenter trial initiation in future. ETHICS AND REGISTRATION: The protocol has been approved by an Institutional Review Board, will be supported by a research grant from Internal Grant Agency of the Ministry of Health, Czech Republic NT 13225-4/2012 and has been registered under identifier: NCT01511666.
    Full-text · Article · Aug 2012 · Journal of Translational Medicine
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    • "Other treatments, such as early hemodynamic optimization [1], controlled reoxygenation [4], supportive care, and disease-specific interventions guided by the patients' conditions, have potential benefit for patients with post– cardiac arrest syndrome. One possible benefit of the above treatments is the prevention of an increase in the oxygen debt and a decrease in the systemic and cerebral metabolic rates of oxygen consumption [5]. The restoration of blood perfusion to vital organs and the capacity for oxygen delivery are strongly associated with ischemia and reperfusion injuries during cardiac arrest and ⁎ Members listed at end of paper. "
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