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Ultrasonographic Assessment During Cardiopulmonary Resuscitation
Published on: October 24, 2020
Hemodynamic-Directed Cardiopulmonary Resuscitation Improves Neurologic Outcomes and Mitochondrial Function in the
Andrew J Lautz1,2, Ryan W Morgan1, Michael Karlsson1
1Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
Insights
Hemodynamic-directed cardiopulmonary resuscitation significantly improved survival with favorable neurologic outcomes in pediatric cardiac arrest models. This advanced CPR technique also enhanced brain and heart mitochondrial function 24 hours post-resuscitation.
Area of Science:
- Pediatric critical care medicine
- Cardiovascular research
- Neuroscience
Background:
- Pediatric in-hospital cardiac arrest has low survival rates, with neurologic injury being common.
- Standard depth-guided cardiopulmonary resuscitation (CPR) has limitations in improving long-term outcomes.
- The impact of hemodynamic-directed CPR on mitochondrial respiration, a potential neurotherapeutic target, is not well understood.
Purpose of the Study:
- To compare 24-hour survival rates with favorable neurologic outcomes between hemodynamic-directed CPR and standard depth-guided CPR.
- To assess differences in brain and heart mitochondrial respiration 24 hours after resuscitation between the two CPR groups.
Main Methods:
- A randomized preclinical large animal trial was conducted using 4-week-old piglets.
- Animals underwent asphyxia-induced cardiac arrest and were treated with either hemodynamic-directed CPR or depth-guided CPR.
- Primary outcomes included favorable neurologic outcome and mitochondrial maximal oxidative phosphorylation (OXPHOSCI+CII) in the cerebral cortex and hippocampus.
Main Results:
- Hemodynamic-directed CPR resulted in significantly higher rates of favorable neurologic outcome (7/10) compared to depth-guided CPR (1/12; p = 0.006).
- Animals receiving hemodynamic-directed CPR showed improved intra-arrest hemodynamics, including coronary perfusion pressure and brain tissue oxygenation.
- Higher mitochondrial respiration (OXPHOSCI+CII and complex I) was observed in the cerebral cortex, hippocampus, and ventricles of the hemodynamic-directed CPR group.
Conclusions:
- Hemodynamic-directed CPR significantly increases 24-hour survival with favorable neurologic outcomes in a pediatric cardiac arrest model.
- This CPR approach improves intra-arrest hemodynamics and enhances cerebral and myocardial mitochondrial respiration.
- These findings suggest hemodynamic-directed CPR as a promising neuroprotective strategy for pediatric cardiac arrest.
Objectives:
Less than half of the thousands of children who suffer in-hospital cardiac arrests annually survive, and neurologic injury is common among survivors. Hemodynamic-directed cardiopulmonary resuscitation improves short-term survival, but its impact on longer term survival and mitochondrial respiration-a potential neurotherapeutic target-remains unknown. The primary objectives of this study were to compare rates of 24-hour survival with favorable neurologic outcome after cardiac arrest treated with hemodynamic-directed cardiopulmonary resuscitation versus standard depth-guided cardiopulmonary resuscitation and to compare brain and heart mitochondrial respiration between groups 24 hours after resuscitation.
Design:
Randomized preclinical large animal trial.
Setting:
A large animal resuscitation laboratory at a large academic children's hospital.
Subjects:
Twenty-eight 4-week-old female piglets (8-11 kg).
Interventions:
Twenty-two swine underwent 7 minutes of asphyxia followed by ventricular fibrillation and randomized treatment with either hemodynamic-directed cardiopulmonary resuscitation (n = 10; compression depth titrated to aortic systolic pressure of 90 mm Hg, vasopressors titrated to coronary perfusion pressure ≥ 20 mm Hg) or depth-guided cardiopulmonary resuscitation (n = 12; depth 1/3 chest diameter, epinephrine every 4 min). Six animals (sham group) underwent anesthesia and instrumentation without cardiac arrest. The primary outcomes were favorable neurologic outcome (swine Cerebral Performance Category ≤ 2) and mitochondrial maximal oxidative phosphorylation utilizing substrate for complex I and complex II (OXPHOSCI+CII) in the cerebral cortex and hippocampus.
Measurements And Main Results:
Favorable neurologic outcome was more likely with hemodynamic-directed cardiopulmonary resuscitation (7/10) than depth-guided cardiopulmonary resuscitation (1/12; p = 0.006). Hemodynamic-directed cardiopulmonary resuscitation resulted in higher intra-arrest coronary perfusion pressure, aortic pressures, and brain tissue oxygenation. Hemodynamic-directed cardiopulmonary resuscitation resulted in higher OXPHOSCI+CII (pmol oxygen/s × mg/citrate synthase) in the cortex (6.00 ± 0.28 vs 3.88 ± 0.43; p < 0.05) and hippocampus (6.26 ± 0.67 vs 3.55 ± 0.65; p < 0.05) and higher complex I respiration (pmol oxygen/s × mg) in the right (20.62 ± 1.06 vs 15.88 ± 0.81; p < 0.05) and left ventricles (20.14 ± 1.40 vs 14.17 ± 1.53; p < 0.05).
Conclusions:
In a model of asphyxia-associated pediatric cardiac arrest, hemodynamic-directed cardiopulmonary resuscitation increases rates of 24-hour survival with favorable neurologic outcome, intra-arrest hemodynamics, and cerebral and myocardial mitochondrial respiration.
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