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Smalcova J, Krupickova P, Pokorna E, Franek O, Huptych M, Kavalkova P, Balik M, Malik J, Smid O, Svobodova E, Keleman R, Belohlavek J. Impact of routine extracorporeal cardiopulmonary resuscitation service on the availability of donor organs. J Heart Lung Transplant 2025; 44:872-879. [PMID: 39293550 DOI: 10.1016/j.healun.2024.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Revised: 08/06/2024] [Accepted: 09/06/2024] [Indexed: 09/20/2024] Open
Abstract
BACKGROUND In refractory cardiac arrest, extracorporeal cardiopulmonary resuscitation may increase the survival chance. However, in cases of unsuccessful treatment, extracorporeal cardiopulmonary resuscitation may additionally provide an important source of organ donors. Therefore, we hypothesized that implementing extracorporeal cardiopulmonary resuscitation service into a high-volume cardiac arrest center's routine would increases organ donors' availability. METHODS Our retrospective observational study analyzed out-of-hospital cardiac arrest patients admitted to the General University Hospital in Prague between 2007 and 2020. The following groups were analyzed regarding the recruitment of donors: before and after extracorporeal cardiopulmonary resuscitation implementation. We assessed the number of donors referred, the number of organs harvested, and the organ's survival. RESULTS We analyzed the results of 1,158 patients after out-of-hospital cardiac arrest. In the conventional approach period, 11 donors were referred, of which 7 were accepted. During the extracorporeal cardiopulmonary resuscitation period, the number of donors increased to 80, of whom 42 were accepted. The number of donated organs was 18 and 119 in the respective periods, corresponding to 3.6 vs 13.2 (p = 0.033) harvested organs per year. One-year survival of transplanted organs was 94.4% vs 99.2%, and 5-year survival was 94.4% vs 95.9% in relevant periods. Conventional and extracorporeal cardiopulmonary resuscitation did not affect donor organ survival. CONCLUSION Establishing a high-volume cardiac arrest center providing an extracorporeal cardiopulmonary resuscitation service may increase not only the number of prolonged cardiac arrest survivors but also the number of organ donors. In addition, the performances of donated organs were high and comparable between both treatment methods.
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Affiliation(s)
- Jana Smalcova
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic; Emergency Medical Service, Prague, Czech Republic
| | - Petra Krupickova
- Department of Neonatology with NICUs, University Hospital in Motol, Prague, Czech Republic; Institute of Physiology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Eva Pokorna
- Institute for Clinical and Experimental Medicine, Transplant Center, Prague, Czech Republic
| | | | - Michal Huptych
- Czech Institute of Informatics, Robotics and Cybernetics (CIIRC), Czech Technical University, Prague, Czech Republic
| | - Petra Kavalkova
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Martin Balik
- Department of Anesthesiology, Resuscitation and Intensive Care Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Jan Malik
- 3rd Department of Medicine, Clinic of Endocrinology and Metabolism, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Ondrej Smid
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Eva Svobodova
- Department of Anesthesiology, Resuscitation and Intensive Care Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Roman Keleman
- Institute for Clinical and Experimental Medicine, Transplant Center, Prague, Czech Republic
| | - Jan Belohlavek
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic; Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland.
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Sandroni C, Scquizzato T, Cacciola S, Bonizzoni MA, West S, D'Arrigo S, Soar J, International Liaison Committee on Resuscitation ILCOR Advanced Life Support Task Force. Does cardiopulmonary resuscitation before donor death affect solid organ transplant function? A systematic review and meta-analysis. Resuscitation 2025:110654. [PMID: 40409674 DOI: 10.1016/j.resuscitation.2025.110654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2025] [Revised: 05/04/2025] [Accepted: 05/14/2025] [Indexed: 05/25/2025]
Abstract
INTRODUCTION Patients who die after cardiopulmonary resuscitation (CPR) are an important source of solid organs, but ischaemia-reperfusion injury may lead to worse recipient outcomes. This systematic review and meta-analysis assessed if solid organs transplanted from donors who underwent CPR had worse outcomes compared to organs from donors who did not receive CPR. METHODS PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched until January 1, 2025. The primary outcome (graft survival at the longest follow-up) and secondary outcomes (30-day and 1-year graft survival) were calculated separately for each organ and pathway (brain/circulatory death). RESULTS We included 33 studies (26 in adults; 72,994 donors), of which three compared multiple organs and pathways. In 24 studies comparing brain-dead donors with vs without CPR in all organs, outcomes did not differ between groups. In nine studies, donation after uncontrolled circulatory death compared to donation after brain death showed a lower long-term survival for livers (OR 0.51 [0.32-0.83]) and lower short-term but not long-term survival (OR 0.64[0.36-1.15]) for kidneys. Two studies in kidneys compared donation in controlled vs uncontrolled circulatory death showing no different long-term survival (OR 0.73[0.27-1.99]). CONCLUSIONS Organs transplanted from donors who received CPR demonstrated comparable outcomes at the longest follow-up compared to organs from donors who did not receive CPR. Kidneys and livers after uncontrolled donation after circulatory death showed worse outcomes compared to donation after brain death.
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Affiliation(s)
- Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy; Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Tommaso Scquizzato
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sofia Cacciola
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
| | - Matteo Aldo Bonizzoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stephen West
- Intensive Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB, UK
| | - Sonia D'Arrigo
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy.
| | - Jasmeet Soar
- Intensive Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB, UK
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Paul M, Hickel C, Troché G, Laurent V, Richard O, Merceron S, Legriel S. Association of targeted temperature management on progression to brain death after severe anoxic brain injury following cardiac arrest: an observational study. BMJ Open 2025; 15:e085851. [PMID: 40010829 PMCID: PMC11865772 DOI: 10.1136/bmjopen-2024-085851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 01/31/2025] [Indexed: 02/28/2025] Open
Abstract
OBJECTIVE Targeted temperature management (TTM), through its physiological effects on intracranial pressure, may impede the progression to brain death (BD) in severe anoxic brain injury post-cardiac arrest (CA). We examined the potential association between the use of TTM and the occurrence of BD after CA. DESIGN Monocentric, retrospective study. SETTING Intensive care unit, Versailles Hospital, France. PARTICIPANTS Comatose survivors of CA who died from BD or postanoxic encephalopathy (PAE) after 24 hours. MAIN OUTCOME MEASURES PAE deaths corresponded to withdrawal of life-sustaining therapy (WLST) due to irreversible postanoxic coma or vegetative state according to prognostication guidelines. BD corresponded to the cessation of cerebral vascularisation secondary to intracranial hypertension. The diagnosis of BD was definite by clinical diagnosis of deep coma according to the Glasgow Coma Scale 3, loss of all brainstem reflexes and the demonstration of apnoea during a hypercapnia test. A cerebral omputed tomography (CT) scan or two isoelectric and unreactive electroencephalograms were used to confirm BD. To identify the independent association between TTM and BD, we conducted a multivariable logistic regression analysis. RESULTS Out of 256 patients included between 2005 and 2021, 54.3% received TTM for at least 24 hours, and 56 patients (21.9%) died from BD. In the multivariable analysis, TTM for 24 hours or more was not associated with a decrease in BD (Odds Ratio 1.08, 95% CI 0.51 to 2.32). Factors associated with BD included a total duration of no-flow plus low-flow exceeding 30 min, CA due to neurological causes or hanging and a high arterial partial pressure of carbon dioxide between days 1 and 2 after admission. CONCLUSIONS This exploratory analysis of post-CA patients with severe anoxic brain injury did not find an association between TTM ≥24 hours and a reduction in BD. Further studies are needed to identify specific subgroups of post-CA patients for whom TTM may be especially futile or even harmful.
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Affiliation(s)
- Marine Paul
- ICU, Centre Hospitalier de Versailles, Le Chesnay, France
- AfterROSC Network Group, Paris, France
| | - Charles Hickel
- ICU, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Gilles Troché
- ICU, Centre Hospitalier de Versailles, Le Chesnay, France
| | | | - Olivier Richard
- SAMU 78, Centre Hospitalier de Versailles, Le Chesnay, France
| | | | - Stephane Legriel
- ICU, Centre Hospitalier de Versailles, Le Chesnay, France
- University Paris Saclay UVSQ, INSERM, CESP, university Paris Saclay, Villejuif, France
- IctalGroup Research Network, Le Chesnay, France
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Smalcova J, Havranek S, Pokorna E, Franek O, Huptych M, Kavalkova P, Pudil J, Rob D, Dusik M, Belohlavek J. Extracorporeal cardiopulmonary resuscitation-based approach to refractory out-of-hospital cardiac arrest: A focus on organ donation, a secondary analysis of a Prague OHCA randomized study. Resuscitation 2023; 193:109993. [PMID: 37806620 DOI: 10.1016/j.resuscitation.2023.109993] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 10/01/2023] [Accepted: 10/02/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Refractory out-of-hospital cardiac arrest (OHCA) has a poor outcome. In patients, who cannot be rescued despite using advanced techniques like extracorporeal cardiopulmonary resuscitation (ECPR), organ donation may be considered. This study aims to evaluate, in refractory OHCA, how ECPR versus a standard-based approach allows organ donorship. METHODS The Prague OHCA trial randomized adults with a witnessed refractory OHCA of presumed cardiac origin to either an ECPR-based or standard approach. Patients who died of brain death or those who died of primary circulatory reasons and were not candidates for cardiac transplantation or durable ventricle assist device were evaluated as potential organ donors by a transplant center. In this post-hoc analysis, the effect on organ donation rates and one-year organ survival in recipients was examined. RESULTS Out of 256 enrolled patients, 75 (29%) died prehospitally or within 1 hour after admission and 107 (42%) during the hospital stay. From a total of 24 considered donors, 21 and 3 (p = 0.01) were recruited from the ECPR vs standard approach arm, respectively. Fifteen brain-dead and none cardiac-dead subjects were ultimately accepted, 13 from the ECPR and two from the standard strategy group. A total of 36 organs were harvested. The organs were successfully transplanted into 34 recipients. All transplanted organs were fully functional, and none of the recipients died due to graft failure within the one-year period post-transplant. CONCLUSION The ECPR-based approach in the refractory OHCA trial is associated with increased organ donorship and an excellent outcome of transplanted organs. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01511666. Registered January 19, 2012.
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Affiliation(s)
- J Smalcova
- 2(nd) Department of Cardiovascular Medicine, General University Hospital in Prague, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic; Emergency Medical Service Prague, Prague, Czech Republic
| | - S Havranek
- 2(nd) Department of Cardiovascular Medicine, General University Hospital in Prague, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - E Pokorna
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - O Franek
- Emergency Medical Service Prague, Prague, Czech Republic
| | - M Huptych
- Czech Institute of Informatics, Robotics and Cybernetics (CIIRC), Czech Technical University in Prague, Prague, Czech Republic
| | - P Kavalkova
- 2(nd) Department of Cardiovascular Medicine, General University Hospital in Prague, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - J Pudil
- 2(nd) Department of Cardiovascular Medicine, General University Hospital in Prague, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - D Rob
- 2(nd) Department of Cardiovascular Medicine, General University Hospital in Prague, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - M Dusik
- 2(nd) Department of Cardiovascular Medicine, General University Hospital in Prague, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - J Belohlavek
- 2(nd) Department of Cardiovascular Medicine, General University Hospital in Prague, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic.
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Kitlen E, Kim N, Rubenstein A, Keenan C, Garcia G, Khosla A, Johnson J, Miller PE, Wira C, Greer D, Gilmore EJ, Beekman R. Development and validation of a novel score to predict brain death after out-of-hospital cardiac arrest. Resuscitation 2023; 192:109955. [PMID: 37661012 DOI: 10.1016/j.resuscitation.2023.109955] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/21/2023] [Accepted: 08/27/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND AND OBJECTIVES Brain death (BD) occurs in 9-24% of successfully resuscitated out-of-hospital cardiac arrests (OHCA). To predict BD after OHCA, we developed a novel brain death risk (BDR) score. METHODS We identified independent predictors of BD after OHCA in a retrospective, single academic center cohort between 2011 and 2021. The BDR score ranges from 0 to 7 points and includes: non-shockable rhythm (1 point), drug overdose as etiology of arrest (1 point), evidence of grey-white differentiation loss or sulcal effacement on head computed tomography (CT) radiology report within 24 hours of arrest (2 points), Full-Outline-Of-UnResponsiveness (FOUR) score of 0 (2 points), FOUR score 1-5 (1 point), and age <45 years (1 point). We internally validated the BDR score using k-fold cross validation (k = 8) and externally validated the score at an independent academic center. The main outcome was BD. RESULTS The development cohort included 362OHCA patients, of whom 18% (N = 58) experienced BD. Internal validation provided an area under the receiving operator characteristic curve (AUC) (95% CI) of 0.931 (0.905-0.957). In the validation cohort, 19.8% (N = 17) experienced BD. The AUC (95% CI) was 0.849 (0.765-0.933). In both cohorts, a BDR score >4 was the optimal cut off (sensitivity 0.903 and 0.882, specificity 0.830 and 0.652, in the development and validation cohorts respectively). DISCUSSION The BDR score identifies those at highest risk for BD after OHCA. Our data suggest that a BDR score >4 is the optimal cut off.
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Affiliation(s)
- Eva Kitlen
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States
| | - Noah Kim
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States
| | - Alexandra Rubenstein
- Department of Neurology, Boston University Medical Center, Boston, MA, United States
| | - Caitlyn Keenan
- Department of Neurology, Boston University Medical Center, Boston, MA, United States
| | - Gabriella Garcia
- Department of Neurology, University of Pennsylvania, PA, United States
| | - Akhil Khosla
- Department of Pulmonary Critical Care, Yale School of Medicine, New Haven, CT, United States
| | | | - P Elliott Miller
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States
| | - Charles Wira
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States
| | - David Greer
- Department of Neurology, Boston University Medical Center, Boston, MA, United States
| | - Emily J Gilmore
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States
| | - Rachel Beekman
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States.
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Morrison LJ, Sandroni C, Grunau B, Parr M, Macneil F, Perkins GD, Aibiki M, Censullo E, Lin S, Neumar RW, Brooks SC. Organ Donation After Out-of-Hospital Cardiac Arrest: A Scientific Statement From the International Liaison Committee on Resuscitation. Circulation 2023; 148:e120-e146. [PMID: 37551611 DOI: 10.1161/cir.0000000000001125] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
AIM OF THE REVIEW Improving rates of organ donation among patients with out-of-hospital cardiac arrest who do not survive is an opportunity to save countless lives. The objectives of this scientific statement were to do the following: define the opportunity for organ donation among patients with out-of-hospital cardiac arrest; identify challenges and opportunities associated with organ donation by patients with cardiac arrest; identify strategies, including a generic protocol for organ donation after cardiac arrest, to increase the rate and consistency of organ donation from this population; and provide rationale for including organ donation as a key clinical outcome for all future cardiac arrest clinical trials and registries. METHODS The scope of this International Liaison Committee on Resuscitation scientific statement was approved by the International Liaison Committee on Resuscitation board and the American Heart Association, posted on ILCOR.org for public comment, and then assigned by section to primary and secondary authors. A unique literature search was completed and updated for each section. RESULTS There are a number of defining pathways for patients with out-of-hospital cardiac arrest to become organ donors; however, modifications in the Maastricht classification system need to be made to correctly identify these donors and to report outcomes with consistency. Suggested modifications to the minimum data set for reporting cardiac arrests will increase reporting of organ donation as an important resuscitation outcome. There are a number of challenges with implementing uncontrolled donation after cardiac death protocols, and the greatest impediment is the lack of legislation in most countries to mandate organ donation as the default option. Extracorporeal cardiopulmonary resuscitation has the potential to increase organ donation rates, but more research is needed to derive neuroprognostication rules to guide clinical decision-making about when to stop extracorporeal cardiopulmonary resuscitation and to evaluate cost-effectiveness. CONCLUSIONS All health systems should develop, implement, and evaluate protocols designed to optimize organ donation opportunities for patients who have an out-of-hospital cardiac arrest and failed attempts at resuscitation.
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Raphalen JH, Soumagnac T, Blanot S, Bougouin W, Bourdiault A, Vimpere D, Ammar H, Dagron C, An K, Mungur A, Carli P, Hutin A, Lamhaut L. Kidneys recovered from brain dead cardiac arrest patients resuscitated with ECPR show similar one-year graft survival compared to other donors. Resuscitation 2023; 190:109883. [PMID: 37355090 DOI: 10.1016/j.resuscitation.2023.109883] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/27/2023] [Accepted: 06/13/2023] [Indexed: 06/26/2023]
Abstract
INTRODUCTION Among patients treated with extracorporeal cardiopulmonary resuscitation (ECPR) as a second line of treatment for refractory out-of-hospital cardiac arrest (OHCA), some may develop brain death and become eligible for organ donation. The objective of this study was to evaluate long-term outcomes of kidney grafts recovered from these patients. MATERIAL AND METHODS We conducted a retrospective monocentric observational study between January 1, 2011, and December 31, 2017. We exclusively included patients eligible for planned donation after brainstem death and from whom at least one organ graft was retrieved and transplanted. We compared two groups of brain dead patients: those treated with ECPR for refractory OHCA (ECPR group) and a diverse group of patients who did not receive ECPR, from which only 5/23 (22%) had OHCA (control group). The primary outcome was one-year kidney graft survival. RESULTS We included 45 patients, 23 in the control group and 22 in the ECPR group. Although patients in the ECPR group were younger and had a lower prevalence of chronic renal disease (p = 0.01), their kidney function was more severely impaired upon admission in the ICU. A total of 68 kidney grafts were retrieved, transplanted, and studied, 34 in each study group. There was no significant difference between the two groups in terms of one-year kidney graft survival (p = 0.52). CONCLUSION Organ transplantation from patients treated with ECPR after refractory OHCA showed one-year kidney graft survival rates comparable to those of patients not treated with ECPR.
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Affiliation(s)
- Jean-Herlé Raphalen
- SAMU de Paris-ICU, Necker University Hospital, Greater Paris University Hospitals, Paris, France
| | - Tal Soumagnac
- SAMU de Paris-ICU, Necker University Hospital, Greater Paris University Hospitals, Paris, France
| | - Stéphane Blanot
- Pediatric and Obstetric ICU, Necker University Hospital, Greater Paris University Hospitals, Paris, France
| | - Wulfran Bougouin
- INSERM U970, Team 4 "Sudden Death Expertise Center", Paris, France; Jacques Cartier Hospital, Massy, France
| | - Alexandre Bourdiault
- SAMU de Paris-ICU, Necker University Hospital, Greater Paris University Hospitals, Paris, France
| | - Damien Vimpere
- SAMU de Paris-ICU, Necker University Hospital, Greater Paris University Hospitals, Paris, France
| | - Hatem Ammar
- SAMU de Paris-ICU, Necker University Hospital, Greater Paris University Hospitals, Paris, France
| | - Christelle Dagron
- SAMU de Paris-ICU, Necker University Hospital, Greater Paris University Hospitals, Paris, France
| | - Kim An
- SAMU de Paris-ICU, Necker University Hospital, Greater Paris University Hospitals, Paris, France
| | - Akshay Mungur
- SAMU de Paris-ICU, Necker University Hospital, Greater Paris University Hospitals, Paris, France
| | - Pierre Carli
- SAMU de Paris-ICU, Necker University Hospital, Greater Paris University Hospitals, Paris, France; Paris Cité University, Paris, France
| | - Alice Hutin
- SAMU de Paris-ICU, Necker University Hospital, Greater Paris University Hospitals, Paris, France; INSERM U955, Team 3, Créteil, France
| | - Lionel Lamhaut
- SAMU de Paris-ICU, Necker University Hospital, Greater Paris University Hospitals, Paris, France; INSERM U970, Team 4 "Sudden Death Expertise Center", Paris, France; Paris Cité University, Paris, France.
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Morrison LJ, Sandroni C, Grunau B, Parr M, Macneil F, Perkins GD, Aibiki M, Censullo E, Lin S, Neumar RW, Brooks SC. Organ Donation After Out-of-Hospital Cardiac Arrest: A Scientific Statement From the International Liaison Committee on Resuscitation. Resuscitation 2023; 190:109864. [PMID: 37548950 DOI: 10.1016/j.resuscitation.2023.109864] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
AIM OF THE REVIEW Improving rates of organ donation among patients with out-of-hospital cardiac arrest who do not survive is an opportunity to save countless lives. The objectives of this scientific statement were to do the following: define the opportunity for organ donation among patients with out-of-hospital cardiac arrest; identify challenges and opportunities associated with organ donation by patients with cardiac arrest; identify strategies, including a generic protocol for organ donation after cardiac arrest, to increase the rate and consistency of organ donation from this population; and provide rationale for including organ donation as a key clinical outcome for all future cardiac arrest clinical trials and registries. METHODS The scope of this International Liaison Committee on Resuscitation scientific statement was approved by the International Liaison Committee on Resuscitation board and the American Heart Association, posted on ILCOR.org for public comment, and then assigned by section to primary and secondary authors. A unique literature search was completed and updated for each section. RESULTS There are a number of defining pathways for patients with out-of-hospital cardiac arrest to become organ donors; however, modifications in the Maastricht classification system need to be made to correctly identify these donors and to report outcomes with consistency. Suggested modifications to the minimum data set for reporting cardiac arrests will increase reporting of organ donation as an important resuscitation outcome. There are a number of challenges with implementing uncontrolled donation after cardiac death protocols, and the greatest impediment is the lack of legislation in most countries to mandate organ donation as the default option. Extracorporeal cardiopulmonary resuscitation has the potential to increase organ donation rates, but more research is needed to derive neuroprognostication rules to guide clinical decision-making about when to stop extracorporeal cardiopulmonary resuscitation and to evaluate cost-effectiveness. CONCLUSIONS All health systems should develop, implement, and evaluate protocols designed to optimise organ donation opportunities for patients who have an out-of-hospital cardiac arrest and failed attempts at resuscitation.
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Lazzeri C, Bonizzoli M, Batacchi S, Guetti C, Vessella W, Valletta A, Ottaviano A, Peris A. Haemodynamic management in brain death donors: Influence of aetiology of brain death. World J Transplant 2023; 13:183-189. [PMID: 37388386 PMCID: PMC10303410 DOI: 10.5500/wjt.v13.i4.183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/28/2023] [Accepted: 04/21/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND In brain death donors (BDDs), donor management is the key in the complex donation process. Donor management goals, which are standards of care or clinical parameters, have been considered an acceptable barometer of successful donor management.
AIM To test the hypothesis that aetiology of brain death could influence haemodynamic management in BDDs.
METHODS Haemodynamic data (blood pressure, heart rate, central venous pressure, lactate, urine output, and vasoactive drugs) of BDDs were recorded on intensive care unit (ICU) admission and during the 6-h observation period (Time 1 at the beginning; Time 2 at the end).
RESULTS The study population was divided into three groups according to the aetiology of brain death: Stroke (n = 71), traumatic brain injury (n = 48), and postanoxic encephalopathy (n = 19). On ICU admission, BDDs with postanoxic encephalopathy showed the lowest values of systolic and diastolic blood pressure associated with higher values of heart rate and lactate and a higher need of norepinephrine and other vasoactive drugs. At the beginning of the 6-h period (Time 1), BDDs with postanoxic encephalopathy showed higher values of heart rate, lactate, and central venous pressure together with a higher need of other vasoactive drugs.
CONCLUSION According to our data, haemodynamic management of BDDs is affected by the aetiology of brain death. BDDs with postanoxic encephalopathy have higher requirements for norepinephrine and other vasoactive drugs.
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Affiliation(s)
- Chiara Lazzeri
- Department of Emergency, Intensive Care Unit and Extracorporeal Membrane Oxygenation Center, Florence 50134, Italy
| | - Manuela Bonizzoli
- Department of Emergency, Intensive Care Unit and Extracorporeal Membrane Oxygenation Center, Florence 50134, Italy
| | - Stefano Batacchi
- Department of Emergency, Intensive Care Unit and Extracorporeal Membrane Oxygenation Center, Florence 50134, Italy
| | - Cristiana Guetti
- Department of Emergency, Intensive Care Unit and Extracorporeal Membrane Oxygenation Center, Florence 50134, Italy
| | - Walter Vessella
- Department of Emergency, Intensive Care Unit and Extracorporeal Membrane Oxygenation Center, Florence 50134, Italy
| | - Alessandra Valletta
- Department of Emergency, Intensive Care Unit and Extracorporeal Membrane Oxygenation Center, Florence 50134, Italy
| | - Alessandra Ottaviano
- Department of Emergency, Intensive Care Unit and Extracorporeal Membrane Oxygenation Center, Florence 50134, Italy
| | - Adriano Peris
- Department of Emergency, Intensive Care Unit and Extracorporeal Membrane Oxygenation Center, Florence 50134, Italy
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Donors brain-dead after successful resuscitation of cardiac arrest: Early outcome and postoperative complications of lung recipients. Resuscitation 2023; 184:109720. [PMID: 36740093 DOI: 10.1016/j.resuscitation.2023.109720] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 01/03/2023] [Accepted: 01/27/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND The outcomes of lung transplantation (LT) recipients who received a graft from a brain-dead donor after successful resuscitation from cardiac arrest (CA donors) have been poorly described. This study compared the one-year survival of LT recipients depending on the CA status of the donor. METHODS This prospective observational single-centre study analysed all consecutive patients who underwent LT at Bichat Claude Bernard Hospital, Paris, between January 2016 and December 2020. All donors who experienced CA prior to organ donation, regardless of rhythm or duration, were considered CA donors. The postoperative complications and outcomes of LT recipients were analysed. The one-year survival was compared using Kaplan-Meier curves and log-rank tests. Independent risk factors for one-year mortality were assessed using multivariate analysis (p < 0.05 was considered significant). The Paris North Hospitals Institutional Review Board approved the study. RESULTS A total of 236 LT recipients were analysed and 66 (28%) received a graft from a CA donor. The median durations of no/low flow were 4 [0-10]/20 [15-30] minutes, respectively. Shockable and non-shockable rhythms were observed in 11 (17%) and 47 (72%) of the CA donors, respectively. The characteristics of the grafts and early postoperative complications were not different in the CA and non-CA groups. Receiving a graft from a CA donor was not an independent risk factor for recipient one-year mortality. CONCLUSION Receiving a graft from a CA donor did not worsen the outcome of LT recipients. Acceptation of these grafts must be systematically considered to increase the pool of available grafts.
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11
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Jensen CW, Jawitz OK, Benkert AR, Spencer PJ, Bryner BS, Schroder JN, Milano CA. Cardiovascular mechanism of donor brain death and heart recipient survival. J Card Surg 2022; 37:4621-4627. [PMID: 36378929 DOI: 10.1111/jocs.17150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/25/2022] [Accepted: 10/02/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Heart donation after donor brain death from cardiac arrest despite successful resuscitation may be associated with worse recipient outcomes due to potential graft ischemia or underlying rhythmic/structural defects. However, selected grafts from such donors often have normal cardiac function and anatomy. We investigated whether a cardiovascular mechanism of donor brain death (CV-DBD) was associated with worse recipient outcomes. METHODS We queried the United Network for Organ Sharing (UNOS) database for first-time, single-organ, adult (age 18+) heart transplant recipients and their associated donors between January 2005 and March 2021. Recipients were stratified by donor status (CV-DBD vs. non-CV-DBD). We performed multivariable Cox proportional hazards modeling to ascertain whether receiving a CV-DBD graft was independently associated with mortality. RESULTS Of 35,833 included recipients, 2,702 (7.5%) received CV-DBD grafts. The associated donors were significantly more likely to be female, older, and have a history of diabetes, hypertension, and substance use (all p < .001). On unadjusted Kaplan-Meier analysis, CV-DBD recipients had a significantly reduced median survival than non-CV-DBD recipients (12.0 vs. 13.1 years, log-rank p = .04). However, after adjusting for donor/recipient age, recipient comorbidities, annualized center volume, and transplantation era, CV-DBD organ status was not associated with recipient mortality (hazard ratio: 1.05, 95% confidence interval: 0.96-1.13, p = .28). CONCLUSION In this analysis of over 35,000 heart transplants, CV-DBD status was not associated with adjusted recipient survival. Donor brain death due to cardiac arrest should not be an absolute contraindication to heart donation, although graft function should be carefully assessed before transplantation.
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Affiliation(s)
- Christopher W Jensen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Oliver K Jawitz
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Clinical Research Institute, Duke University Health System, Durham, North Carolina, USA
| | - Abigail R Benkert
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Philip J Spencer
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Benjamin S Bryner
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jacob N Schroder
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Carmelo A Milano
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
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12
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Busl KM, Maciel CB. When the heart comes back but the brain is lost-are we ready to predict brain death after cardiac arrest? Resuscitation 2022; 179:256-258. [PMID: 36089161 DOI: 10.1016/j.resuscitation.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 09/02/2022] [Indexed: 10/14/2022]
Affiliation(s)
- Katharina M Busl
- Department of Neurology, Division of Neurocritical Care, University of Florida College of Medicine, Gainesville, FL 32611, USA.
| | - Carolina B Maciel
- Department of Neurology, Division of Neurocritical Care, University of Florida College of Medicine, Gainesville, FL 32611, USA; Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA; Department of Neurology, University of Utah, Salt Lake City, UT 84132, USA.
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13
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Coppler PJ, Flickinger KL, Darby JM, Doshi A, Guyette FX, Faro J, Callaway CW, Elmer J. Early risk stratification for progression to death by neurological criteria following out-of-hospital cardiac arrest. Resuscitation 2022; 179:248-255. [PMID: 35914657 DOI: 10.1016/j.resuscitation.2022.07.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/27/2022] [Accepted: 07/22/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Some patients resuscitated from out-of-hospital cardiac arrest (OHCA) progress to death by neurological criteria (DNC). We hypothesized that initial brain imaging, electroencephalography (EEG), and arrest characteristics predict progression to DNC. METHODS We identified comatose OHCA patients from January 2010 to February 2020 treated at a single quaternary care facility in Western Pennsylvania. We abstracted demographics and arrest characteristics; Pittsburgh Cardiac Arrest Category, initial motor exam and pupillary light reflex; initial brain computed tomography (CT) grey-to-white ratio (GWR), sulcal or basal cistern effacement; initial EEG background and suppression ratio. We used two modeling approaches: fast and frugal tree (FFT) analysis to create an interpretable clinical risk stratification tool and ridge regression for comparison. We used bootstrapping to randomly partition cases into 80% training and 20% test sets and evaluated test set sensitivity and specificity. RESULTS We included 1,569 patients, of whom 147 (9%) had diagnosed DNC. Across bootstrap samples, >99% of FFTs included three predictors: sulcal effacement, and in cases without sulcal effacement, the combination of EEG background suppression and GWR ≤ 1.23. This tree had mean sensitivity and specificity of 87% and 81%. Ridge regression with all available predictors had mean sensitivity 91 % and mean specificity 83%. Subjects falsely predicted as likely to progress to DNC generally died of rearrest or withdrawal of life sustaining therapies due to poor neurological prognosis. Two of these cases awakened from coma during the index hospitalization. CONCLUSIONS Sulcal effacement on presenting brain CT or EEG suppression with GWR ≤ 1.23 predict progression to DNC after OHCA.
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Affiliation(s)
- Patrick J Coppler
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | | | - Joseph M Darby
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ankur Doshi
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - John Faro
- Department of Family Medicine, Soin Medical Center - Kettering Health Network, Beavercreek, OH, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
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14
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Renaudier M, Binois Y, Dumas F, Lamhaut L, Beganton F, Jost D, Charpentier J, Lesieur O, Marijon E, Jouven X, Cariou A, Bougouin W. Organ donation after out-of-hospital cardiac arrest: a population-based study of data from the Paris Sudden Death Expertise Center. Ann Intensive Care 2022; 12:48. [PMID: 35666323 PMCID: PMC9170852 DOI: 10.1186/s13613-022-01023-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/11/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Organ shortage is a major public health issue, and patients who die after out-of-hospital cardiac arrest (OHCA) could be a valuable source of organs. Here, our objective was to identify factors associated with organ donation after brain death complicating OHCA, in unselected patients entered into a comprehensive real-life registry covering a well-defined geographic area. METHODS We prospectively analyzed consecutive adults with OHCA who were successfully resuscitated, but died in intensive care units in the Paris region in 2011-2018. The primary outcome was organ donation after brain death. Independent risk factors were identified using logistic regression analysis. One-year graft survival was assessed using Cox and log-rank tests. RESULTS Of the 3061 included patients, 136 (4.4%) became organ donors after brain death, i.e., 28% of the patients with brain death. An interaction between admission pH and post-resuscitation shock was identified. By multivariate analysis, in patients with post-resuscitation shock, factors associated with organ donation were neurological cause of OHCA (odds ratio [OR], 14.5 [7.6-27.4], P < 0.001), higher pH (OR/0.1 increase, 1.3 [1.1-1.6], P < 0.001); older age was negatively associated with donation (OR/10-year increase, 0.7 [0.6-0.8], P < 0.001). In patients without post-resuscitation shock, the factor associated with donation was neurological cause of OHCA (OR, 6.9 [3.0-15.9], P < 0.001); higher pH (OR/0.1 increase, 0.8 [0.7-1.0], P = 0.04) and OHCA at home (OR, 0.4 [0.2-0.7], P = 0.006) were negatively associated with organ donation. One-year graft survival did not differ according to Utstein characteristics of the donor. CONCLUSIONS 4% of patients who died in ICU after OHCA led to organ donation. Patients with OHCA constitute a valuable source of donated organs, and special attention should be paid to young patients with OHCA of neurological cause.
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Affiliation(s)
- M Renaudier
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France.,Paris Sudden Death Expertise Center, Paris, France
| | - Y Binois
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France.,Paris Sudden Death Expertise Center, Paris, France
| | - F Dumas
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France.,Paris Sudden Death Expertise Center, Paris, France.,Emergency Department, Cochin-Hotel-Dieu Hospital, AP-HP, Paris, France.,Université de Paris, Paris, France
| | - L Lamhaut
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France.,Paris Sudden Death Expertise Center, Paris, France.,Université de Paris, Paris, France.,Intensive Care Unit and SAMU 75, Necker Enfants-Malades Hospital, Paris, France
| | - F Beganton
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France.,Paris Sudden Death Expertise Center, Paris, France
| | - D Jost
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France.,Paris Sudden Death Expertise Center, Paris, France.,Brigade Des Sapeurs-Pompiers de Paris (BSPP), Paris, France
| | - J Charpentier
- Medical Intensive Care Unit, AP-HP, Cochin Hospital, Paris Cedex 14, France
| | - O Lesieur
- Université de Paris, Paris, France.,Intensive Care Unit, Saint Louis General Hospital, La Rochelle, France
| | - E Marijon
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France.,Paris Sudden Death Expertise Center, Paris, France.,Université de Paris, Paris, France.,Cardiology Department, European Georges Pompidou Hospital, AP-HP, Paris, France
| | - X Jouven
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France.,Paris Sudden Death Expertise Center, Paris, France.,Université de Paris, Paris, France.,Cardiology Department, European Georges Pompidou Hospital, AP-HP, Paris, France
| | - A Cariou
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France. .,Paris Sudden Death Expertise Center, Paris, France. .,Université de Paris, Paris, France. .,Medical Intensive Care Unit, AP-HP, Cochin Hospital, Paris Cedex 14, France.
| | - W Bougouin
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France.,Paris Sudden Death Expertise Center, Paris, France.,Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, Massy, France
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15
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Song H, Oh SH, Woo HR, on behalf of CROWN Investigators. Brain Death and Its Prediction in Out-of-Hospital Cardiac Arrest Patients Treated with Targeted Temperature Management. Diagnostics (Basel) 2022; 12:diagnostics12051190. [PMID: 35626345 PMCID: PMC9140750 DOI: 10.3390/diagnostics12051190] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 05/04/2022] [Accepted: 05/06/2022] [Indexed: 02/01/2023] Open
Abstract
Evolution toward brain death (BD) in out-of-hospital cardiac arrest patients with targeted temperature management (TTM) provides opportunities for organ donation. However, knowledge regarding BD in these patients is limited. We retrospectively analyzed the TTM registry of one hospital where life-sustaining therapy was not withdrawn. In-hospital death patients were categorized into BD and non-BD groups. We explored the process of evolution toward BD and its predictors by comparing the serial measurements of clinical variables and the results of various prognostic tests between the two groups. Of the 121 patients who died before hospital discharge, 19 patients (15.7%) developed BD at a median of 6 (interquartile range, 5.0–7.0) days after cardiac arrest. Four patients with pupillary light reflexes at 48 h eventually developed BD. The area under the curves of the gray-to-white matter ratio (GWR) on early brain computed tomography images and the level of S100 calcium-binding protein B (S100B) at 72 h were 0.67 (95% CI, 0.55–0.77) and 0.70 (95% CI, 0.55–0.83), respectively. In conclusion, approximately one-sixth of all in-hospital deaths were diagnosed with BD at a median of 6 days after cardiac arrest. The use of GWR and serial S100B measurements may help to screen potential BD.
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Affiliation(s)
- Hwan Song
- Department of Emergency Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
| | - Sang Hoon Oh
- Department of Emergency Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea
- Correspondence: ; Tel.: +82-2-2258-1988; Fax: +82-2-2258-1997
| | - Hye Rim Woo
- Department of Emergency Medicine, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
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16
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Echterdiek F, Kitterer D, Dippon J, Paul G, Schwenger V, Latus J. Impact of cardiopulmonary resuscitation on outcome of kidney transplantations from braindead donors aged ≥65 years. Clin Transplant 2021; 35:e14452. [PMID: 34390272 DOI: 10.1111/ctr.14452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 07/23/2021] [Accepted: 07/31/2021] [Indexed: 11/28/2022]
Abstract
Patients with a history of cardiopulmonary resuscitation (CPR) and subsequent brain death are frequently evaluated for organ donation. Whether kidneys from ≥65-year-old braindead donors with a history of CPR can be transplanted with satisfactory outcomes is unknown. All kidney transplants (KT) from ≥65-year-old donors performed at our centre from 1999 to 2018 (n = 185) were retrospectively analysed and outcome was compared for KTs from donors with and without a history of CPR (n = 27 and n = 158, respectively). No significant differences in the incidence of delayed graft function (DGF) as well as one- and three-year graft function were observed between the CPR and the no-CPR group (DGF: 26.0% vs 31.0%, P = 0.76; one-year serum creatinine: 150.4 μmol/l vs 177.0 μmol/l, P = 0.11; three-year serum creatinine: 150.4 μmol/l vs 168.2 μmol/l, P = 0.52, respectively). Death-censored graft survival was comparable after one and five years (CPR group: 81.5% and 76.7% vs no-CPR group: 86.6% and 75.7%, P = 0.70). Likewise, patient survival was not significantly different. Multivariable Cox regression analysis also did not identify CPR as a significant risk factor for graft loss or death. Our study suggests that, following stringent donor selection, the outcome of KTs from ≥65-year-old braindead donors with and without a history of CPR is comparable. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Fabian Echterdiek
- Department of Nephrology, Klinikum Stuttgart - Katharinenhospital, Stuttgart, Germany
| | - Daniel Kitterer
- Department of Nephrology, Klinikum Stuttgart - Katharinenhospital, Stuttgart, Germany
| | - Jürgen Dippon
- Institute for Stochastics and Applications, University of Stuttgart, Germany
| | - Gregor Paul
- Department of Gastroenterology, Hepatology, Pneumology and Infectious Diseases, Klinikum Stuttgart - Katharinenhospital, Stuttgart, Germany.,University of Cologne, Department I of Internal Medicine, Division of Infectious Diseases, Cologne, Germany
| | - Vedat Schwenger
- Department of Nephrology, Klinikum Stuttgart - Katharinenhospital, Stuttgart, Germany
| | - Joerg Latus
- Department of Nephrology, Klinikum Stuttgart - Katharinenhospital, Stuttgart, Germany
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17
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Madelaine T, Cour M, Roy P, Vivien B, Charpentier J, Dumas F, Deye N, Bonnefoy E, Gueugniaud PY, Coste J, Cariou A, Argaud L. Prediction of Brain Death After Out-of-Hospital Cardiac Arrest: Development and Validation of the Brain Death After Cardiac Arrest Score. Chest 2021; 160:139-147. [PMID: 34116828 DOI: 10.1016/j.chest.2021.01.056] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 12/09/2020] [Accepted: 01/03/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Among patients successfully resuscitated after an out-of-hospital cardiac arrest (OHCA), 10% to 15% evolve toward brain death (BD), thus becoming potential organ donors. RESEARCH QUESTION Is it possible to establish a score for early estimation of BD risk after OHCA? STUDY DESIGN AND METHODS The BD after cardiac arrest (BDCA) score was developed from data available within 24 hours after OHCA from two OHCA trials: Cyclosporine in Cardiac Arrest Resuscitation and Erythropoietin After OHCA. The BDCA score was then validated in another large prospective multicenter data set. The main outcome was the occurrence of BD. Independent prognostic covariates for BD were identified using a binomial two-stage adaptive least absolute shrinkage and selection operator procedure. RESULTS The development cohort included 569 patients alive 24 hours after OHCA, among whom 84 (14.8%) experienced BD. Independent predictors of BD used to build the BDCA score were being female (4 points), nonshockable rhythm (24 points), cardiac cause of OHCA (-6 points), neurological cause of OHCA (45 points), natremia at 24 hours (natremia in millimoles per liter minus 140 points), and vasoactive drug at admission (4 points) and at 24 hours (6 points). The area under the curve (AUC) of the BDCA score was 0.82 (95% CI, 0.77-0.86), and the discrimination value in the validation cohort (n = 487) was consistent (AUC, 0.81; 95% CI, 0.76-0.86). In the validation cohort, BD occurred in 4.0%, 20.4%, and 67.7% of patients with scores of < 20, 20 to 50, and > 50, respectively. INTERPRETATION The BDCA score allows early detection of patients with a high probability of experiencing BD, which may help increase organ donation after OHCA. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov; No.: NCT01595958, and ClinicalTrials.gov; No.: NCT00999583; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Thomas Madelaine
- Médecine Intensive-Réanimation, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Martin Cour
- Médecine Intensive-Réanimation, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France; INSERM UMR1060 (CarMeN), Université de Lyon, Lyon, France
| | - Pascal Roy
- Service de Biostatistique-Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France
| | - Benoît Vivien
- SAMU de Paris, Hôpital Necker-Enfants Malades, Assistance Publique des Hôpitaux de Paris Paris, France
| | - Julien Charpentier
- Service de réanimation médicale, Hôpital Cochin, Assistance Publique des Hôpitaux de Paris Paris, France
| | - Florence Dumas
- Service des Urgences, Assistance Publique des Hôpitaux de Paris Paris, France
| | - Nicolas Deye
- Réanimation Médicale et Toxicologique, Hôpital Lariboisière, Assistance Publique des Hôpitaux de Paris Paris, France
| | - Eric Bonnefoy
- Unité de Soins Intensifs Cardiologiques, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron, France
| | | | - Joël Coste
- Unité de Biostatistique et d'Epidémiologie, Hôtel-Dieu de Paris, Assistance Publique des Hôpitaux de Paris Paris, France
| | - Alain Cariou
- Service de réanimation médicale, Hôpital Cochin, Assistance Publique des Hôpitaux de Paris Paris, France
| | - Laurent Argaud
- Médecine Intensive-Réanimation, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France; INSERM UMR1060 (CarMeN), Université de Lyon, Lyon, France.
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18
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Berg KM, Cheng A, Panchal AR, Topjian AA, Aziz K, Bhanji F, Bigham BL, Hirsch KG, Hoover AV, Kurz MC, Levy A, Lin Y, Magid DJ, Mahgoub M, Peberdy MA, Rodriguez AJ, Sasson C, Lavonas EJ. Part 7: Systems of Care: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S580-S604. [PMID: 33081524 DOI: 10.1161/cir.0000000000000899] [Citation(s) in RCA: 109] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Survival after cardiac arrest requires an integrated system of people, training, equipment, and organizations working together to achieve a common goal. Part 7 of the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care focuses on systems of care, with an emphasis on elements that are relevant to a broad range of resuscitation situations. Previous systems of care guidelines have identified a Chain of Survival, beginning with prevention and early identification of cardiac arrest and proceeding through resuscitation to post-cardiac arrest care. This concept is reinforced by the addition of recovery as an important stage in cardiac arrest survival. Debriefing and other quality improvement strategies were previously mentioned and are now emphasized. Specific to out-of-hospital cardiac arrest, this Part contains recommendations about community initiatives to promote cardiac arrest recognition, cardiopulmonary resuscitation, public access defibrillation, mobile phone technologies to summon first responders, and an enhanced role for emergency telecommunicators. Germane to in-hospital cardiac arrest are recommendations about the recognition and stabilization of hospital patients at risk for developing cardiac arrest. This Part also includes recommendations about clinical debriefing, transport to specialized cardiac arrest centers, organ donation, and performance measurement across the continuum of resuscitation situations.
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19
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Messner F, Etra JW, Yu Y, Massie AB, Jackson KR, Brandacher G, Schneeberger S, Margreiter C, Segev DL. Outcomes of simultaneous pancreas and kidney transplantation based on donor resuscitation. Am J Transplant 2020; 20:1720-1728. [PMID: 32026618 DOI: 10.1111/ajt.15808] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 01/02/2020] [Accepted: 01/20/2020] [Indexed: 01/25/2023]
Abstract
It has been hypothesized that transplanting simultaneous pancreas kidney (SPK) grafts from donors with a history of cardiac arrest and cardiopulmonary resuscitation (CACPR) leads to inferior posttransplant outcomes due to organ hypoperfusion during cardiac arrest and mechanical trauma during resuscitation. Using Scientific Registry of Transplant Recipients data, we identified 13 095 SPK transplants from 2000-2018, of which 810 (6.2%) were from donors with a history of CACPR. After inverse probability of treatment weighting on donor and recipient characteristics, we found that 1-, 5-, and 10-year patient (CACPR: 96.4%, 89.9%, and 78.9%; non-CACPR: 96.3%, 88.9%, and 76.0%; P = .3), death-censored pancreas graft survival (CACPR: 89.3%, 82.7%, 75.0%; non-CACPR: 89.9%, 82.7%, 76.3%; P = .7), and death-censored kidney graft survival (CACPR: 97.0%, 89.5%, 78.2%; non-CACPR: 96.9.9%, 88.7%, 80.0%; P = .4) were comparable between the two groups. There were no differences in the risk of pancreatitis (CACPR: 2.9%, non-CACPR: 2.4%; weighted OR = 0.74 1.22 2.02 ; P = .4), anastomotic leak (CACPR: 1.6%, non-CACPR: 2.0%; weighted OR = 0.54 1.02 1.93 ; P > .9), or median length of hospital stay (CACPR: 8 days, non-CACPR: 9 days; P = .6) for recipients of CACPR vs non-CACPR donors. Our findings suggest that CACPR donors could be used to expand the SPK donor pool without compromising short- or long-term outcomes.
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Affiliation(s)
- Franka Messner
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria.,Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joanna W Etra
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yifan Yu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Allan B Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Kyle R Jackson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gerald Brandacher
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Christian Margreiter
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, USA.,Scientific Registry of Transplant Recipients, Minneapolis, Minnesota, USA
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Messner F, Yu Y, Etra JW, Krendl FJ, Berchtold V, Bösmüller C, Brandacher G, Oberhuber R, Scheidl S, Maglione M, Öfner D, Schneeberger S, Margreiter C. Donor cardiac arrest and cardiopulmonary resuscitation: impact on outcomes after simultaneous pancreas-kidney transplantation - a retrospective study. Transpl Int 2020; 33:657-666. [PMID: 32027055 PMCID: PMC7318239 DOI: 10.1111/tri.13591] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 12/12/2019] [Accepted: 02/03/2020] [Indexed: 01/16/2023]
Abstract
Donor cardiac arrest and cardiopulmonary resuscitation (CACPR) has been considered critically because of concerns over hypoperfusion and mechanical trauma to the donor organs. We retrospectively analyzed 371 first simultaneous pancreas–kidney transplants performed at the Medical University of Innsbruck between 1997 and 2017. We evaluated short‐ and long‐term outcomes from recipients of organs from donors with and without a history of CACPR. A total of 63 recipients received a pancreas and kidney graft from a CACPR donor. At 1, and 5‐years, patient survival was similar with 98.3%, and 96.5% in the CACPR and 97.0%, and 90.2% in the non‐CACPR group (log rank P = 0.652). Death‐censored pancreas graft survival was superior in the CACPR group with 98.3%, and 91.4% compared to 86.3%, and 77.4% (log rank P = 0.028) in the non‐CACPR group, which remained statistically significant even after adjustment [aHR 0.49 (95% CI 0.24–0.98), P = 0.044]. Similar relative risks for postoperative complications Clavien Dindo > 3a, pancreatitis, abscess, immunologic complications, delayed pancreas graft function, and relative length of stay were observed for both groups. Donors with a history of CACPR are, in the current practice, safe for transplantation. Stringent donor selection and short CPR durations may allow for outcomes surpassing those of donors without CACPR.
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Affiliation(s)
- Franka Messner
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Yifan Yu
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Joanna W Etra
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Felix J Krendl
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Valeria Berchtold
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Claudia Bösmüller
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Gerald Brandacher
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Rupert Oberhuber
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Scheidl
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Manuel Maglione
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Dietmar Öfner
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Christian Margreiter
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
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Organ donation after resuscitation from cardiac arrest. Resuscitation 2019; 145:63-69. [PMID: 31654724 DOI: 10.1016/j.resuscitation.2019.10.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/27/2019] [Accepted: 10/14/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND We compared the characteristics and outcomes of post-arrest donors to those of other donors, described the proportion of post-arrest decedents who donated, and compared their characteristics to post-arrest decedents who did not donate. METHODS We performed a retrospective cohort study including patients who died at a single academic medical center from January 1, 2010 to February 28, 2019. We linked our registry of consecutive post-arrest patients to donation-related data from the Center for Organ Procurement and Recovery (CORE). We used data from CORE to identify donor eligibility, first person designation, family approaches to seek consent for donation, and approach outcomes. We determined number of organs procured and number transplanted, stratified by donor type (brain death donors (BDD) vs donors after circulatory determination of death (DCD)). RESULTS There were 12,130 decedents; 1525 (13%) were resuscitated from cardiac arrest. CORE staff approached families of 836 (260 (31%) post-arrest, 576 (69%) not post-arrest) to request donation. Post-arrest patients and families were more likely to authorize donation (172/260 (66%) vs 331/576 (57%), P = 0.02), and more likely to be DCDs (50/146 (34%) vs 55/289 (19%), P < 0.001). Overall, 4.1 ± 1.5 organs were procured and 2.9 ± 1.9 transplanted per BDD, which did not differ by post-arrest status, 3.2 ± 1.2 organs were procured and 1.8 ± 1.1 transplanted per DCD. Number of organs transplanted per DCD did not differ by post-arrest status. Unfavorable arrest characteristics were more common among post-arrest organ donors compared to non-donors. CONCLUSION Patients resuscitated from cardiac arrest with irrecoverable brain injury have excellent potential to become organ donors.
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Combined Treatment with Hydrophilic and Lipophilic Statins Improves Neurological Outcomes Following Experimental Cardiac Arrest in Mice. Neurocrit Care 2019; 33:64-72. [DOI: 10.1007/s12028-019-00862-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Glibenclamide and Therapeutic Hypothermia Have Comparable Effect on Attenuating Global Cerebral Edema Following Experimental Cardiac Arrest. Neurocrit Care 2019; 29:119-127. [PMID: 29150777 DOI: 10.1007/s12028-017-0479-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Cerebral edema is one of the major causes of mortality following cardiac arrest (CA) and cardiopulmonary resuscitation (CPR). A subunit of the sulfonylurea receptor 1-transient receptor potential M4 (Sur1-TRPM4) channel has been implicated in the pathogenesis of ischemia-evoked cerebral edema. In this study, we examined whether glibenclamide (GBC), a Sur1-TRPM4 channel inhibitor, attenuates cerebral edema following CA/CPR and further examined the efficacy of GBC combined with therapeutic hypothermia. METHODS Isoflurane-anesthetized adult male wild-type C57Bl/6 mice subjected to 7-min CA/CPR were randomized into five groups: sham operation, control with normothermia, GBC with normothermia, control with hypothermia, and GBC with hypothermia. The primary outcome was to evaluate regional brain water content; the secondary outcome was to measure blood glucose level, Sur1-TRPM4 expression, and pro-inflammatory factor expression. RESULTS Compared with normothermia, GBC treatment or hypothermia significantly attenuated brain water content in mice subjected to CA/CPR. GBC combined with hypothermia had no additional effects on attenuating cerebral edema. Pro-inflammatory factor messenger RNA expression (TNF-α and IL-6), NFκβ activation, and SUR1-TRPM4 levels were upregulated after CA/CPR. Compared with normothermia, hypothermia, but not GBC, partly suppressed these factors' expression. CONCLUSIONS GBC attenuated cerebral edema following CA/CPR by blocking Sur1-TRPM4 channels upregulated by CA insult. The effect of GBC was comparable with that of therapeutic hypothermia alone. These results suggest that GBC is an alternative approach for treating CA-evoked cerebral edema.
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Geocadin RG, Callaway CW, Fink EL, Golan E, Greer DM, Ko NU, Lang E, Licht DJ, Marino BS, McNair ND, Peberdy MA, Perman SM, Sims DB, Soar J, Sandroni C. Standards for Studies of Neurological Prognostication in Comatose Survivors of Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e517-e542. [DOI: 10.1161/cir.0000000000000702] [Citation(s) in RCA: 153] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Significant improvements have been achieved in cardiac arrest resuscitation and postarrest resuscitation care, but mortality remains high. Most of the poor outcomes and deaths of cardiac arrest survivors have been attributed to widespread brain injury. This brain injury, commonly manifested as a comatose state, is a marker of poor outcome and a major basis for unfavorable neurological prognostication. Accurate prognostication is important to avoid pursuing futile treatments when poor outcome is inevitable but also to avoid an inappropriate withdrawal of life-sustaining treatment in patients who may otherwise have a chance of achieving meaningful neurological recovery. Inaccurate neurological prognostication leading to withdrawal of life-sustaining treatment and deaths may significantly bias clinical studies, leading to failure in detecting the true study outcomes. The American Heart Association Emergency Cardiovascular Care Science Subcommittee organized a writing group composed of adult and pediatric experts from neurology, cardiology, emergency medicine, intensive care medicine, and nursing to review existing neurological prognostication studies, the practice of neurological prognostication, and withdrawal of life-sustaining treatment. The writing group determined that the overall quality of existing neurological prognostication studies is low. As a consequence, the degree of confidence in the predictors and the subsequent outcomes is also low. Therefore, the writing group suggests that neurological prognostication parameters need to be approached as index tests based on relevant neurological functions that are directly related to the functional outcome and contribute to the quality of life of cardiac arrest survivors. Suggestions to improve the quality of adult and pediatric neurological prognostication studies are provided.
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Cour M, Turc J, Madelaine T, Argaud L. Risk factors for progression toward brain death after out-of-hospital cardiac arrest. Ann Intensive Care 2019; 9:45. [PMID: 30963296 PMCID: PMC6453982 DOI: 10.1186/s13613-019-0520-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 04/02/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Successfully resuscitated out-of-hospital cardiac arrest (OHCA) may lead to brain death (BD) and good-quality transplantable organs. We aimed to determine risk factors for evolution toward BD after OHCA. We analyzed adult patients admitted to an intensive care unit (ICU) who survived at least 24 h after an OHCA between 2005 and 2015. BD was defined according to international guidelines. Multivariate logistic regression was used to identify potential risk factors for BD available 24 h after OHCA. RESULTS A total of 214 patients were included (median age 68 years; sex ratio 1.25; non-shockable OHCA: 88%). Among these, 42 (19.6%) developed BD, while 22 (10.3%) were alive at 1 year with a good neurological outcome. Independent risk factors for BD were age (OR per year 0.95; 95% CI [0.92-0.98]), female gender (OR 2.34; 95% CI [1.02-5.35]), neurological cause of OHCA (OR 14.72; 95% CI [3.03-71.37]), duration of the low-flow period > 16 min (OR 2.94, 95% CI [1.21-7.16]) and need of vasoactive drugs at 24 h (OR 6.20, 95% CI [2.41-15.93]). CONCLUSIONS The study identified, in a population of OHCA with predominantly non-shockable initial rhythms, five simple risk factors independently associated with progression toward BD.
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Affiliation(s)
- Martin Cour
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Intensive-Réanimation, 5, Place d’Arsonval, 69437 Lyon Cedex 03, France
- Faculté de médecine Lyon-Est, Université Claude Bernard Lyon 1, Université de Lyon, 69373 Lyon, France
- U1060 CarMeN, INSERM, 69373 Lyon, France
| | - Jean Turc
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Intensive-Réanimation, 5, Place d’Arsonval, 69437 Lyon Cedex 03, France
| | - Thomas Madelaine
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Intensive-Réanimation, 5, Place d’Arsonval, 69437 Lyon Cedex 03, France
- Faculté de médecine Lyon-Est, Université Claude Bernard Lyon 1, Université de Lyon, 69373 Lyon, France
| | - Laurent Argaud
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Intensive-Réanimation, 5, Place d’Arsonval, 69437 Lyon Cedex 03, France
- Faculté de médecine Lyon-Est, Université Claude Bernard Lyon 1, Université de Lyon, 69373 Lyon, France
- U1060 CarMeN, INSERM, 69373 Lyon, France
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26
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Mangus RS, Schroering JR, Fridell JA, Kubal CA. Impact of Donor Pre-Procurement Cardiac Arrest (PPCA) on Clinical Outcomes in Liver Transplantation. Ann Transplant 2018; 23:808-814. [PMID: 30455411 PMCID: PMC6259573 DOI: 10.12659/aot.910387] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background Transplantation of liver grafts from deceased donors who experienced cardiac arrest prior to liver procurement is now common. This single-center study analyzed the impact of pre-donation arrest time on clinical outcomes in liver transplantation. Material/Methods Records of all orthotopic liver transplants performed at a single center over a 15-year period were reviewed. Donor records were reviewed and total arrest time was calculated as cumulative minutes. Post-transplant liver graft function was assessed using laboratory values. Graft survival was assessed with Cox regression analysis. Results Records for 1830 deceased donor transplants were reviewed, and 521 donors experienced pre-procurement cardiac arrest (28%). Median arrest time was 21 min (mean 25 min, range 1–120 min). After transplant, the peak alanine aminotransferase and bilirubin levels for liver grafts from donors with arrest were lower compared to those for donors without arrest (p<0.001). Early allograft dysfunction occurred in 25% (arrest) and 28% (no arrest) of patients (p=0.22). There were no differences in risk of early graft loss (3% vs. 3%, p=0.84), length of hospital stay (10 vs. 10 days, p=0.76), and 1-year graft survival (89% vs. 89%, p=0.94). Cox regression analysis comparing 4 groups (no arrest, <20 min, 20–40 min, and >40 min arrest) demonstrated no statistically significant difference in survival at 10 years. Subgroup analysis of 93 donation after cardiac death grafts showed no significant difference for these same outcomes. Conclusions These results support the use of select deceased liver donors who experience pre-donation cardiac arrest. Pre-donation arrest may be associated with less early allograft dysfunction, but had no impact on long-term clinical outcomes. The results for donation after cardiac death donors were similar.
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Affiliation(s)
- Richard S Mangus
- Transplant Division, Department of Surgery, Indiana University, School of Medicine, Indianapolis, IN, USA
| | - Joel R Schroering
- Transplant Division, Department of Surgery, Indiana University, School of Medicine, Indianapolis, IN, USA
| | - Jonathan A Fridell
- Transplant Division, Department of Surgery, Indiana University, School of Medicine, Indianapolis, IN, USA
| | - Chandrashekhar A Kubal
- Transplant Division, Department of Surgery, Indiana University, School of Medicine, Indianapolis, IN, USA
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Jafari A, Matthaei H, Branchi V, Bölke E, Tolba RH, Kalff JC, Manekeller S. Donor liver quality after hypovolemic shock and venous systemic oxygen persufflation in an experimental animal model. Eur J Med Res 2018; 23:51. [PMID: 30352629 PMCID: PMC6198357 DOI: 10.1186/s40001-018-0346-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 10/13/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The ever growing demand for liver transplantation inevitably necessitates an expansion of the donor pool. Utilization of "shock organs" is considered suboptimal to date while the associated outcome has hardly been investigated. MATERIALS AND METHODS Male Wistar rats underwent a period of 30 min of hypovolemic shock. After 24 h livers were explanted and prior to reperfusion underwent either 18 h of cold storage (CS; N = 6) or 17 h of CS followed by 60 min venous systemic oxygen persufflation (VSOP; N = 6). The outcome of "shock organs (SHBD)" was compared to heart-beating donor (HBD; N = 12) as positive control and non-heart-beating donor (NHBD; N = 12) as negative control animal groups. Liver function was assessed by measuring enzyme release (AST, ALT, LDH), bile production, portal vein pressure and hepatic oxygen uptake during reperfusion. For reperfusion, the isolated perfused rat liver system was used. RESULTS Liver function was severely limited in NHBD group compared to HBD organs after 18 h of CS (e.g., AST; HBD: 32.25 ± 7.25 U/l vs. NHBD: 790 ± 414.56 U/l; p < 0.005). VSOP improved liver function of NHBD organs significantly (AST; NHBD + VSOP: 333.6 ± 149.1 U/l; p < 0.005). SHBD organs showed a comparable outcome to HBD and clearly better results than NHBD organs after 18 h of CS (AST; SHBD: 76.4 ± 21.9 U/l). After 17 h of CS accompanied by 60 min VSOP, no improvement concerning liver function and integrity of SHBD organs was observed while the results were severely deteriorated by VSOP resulting in higher enzyme release (AST; SHBD + VSOP: 213 ± 61 U/l, p < 0.001), higher portal vein pressure (SHBD: 10.8 ± 1.92 mm Hg vs. SHBD + VSOP: 21.6 ± 8.8 mm Hg; p < 0.05) and lower hepatic oxygen uptake (SHBD: 321.75 ± 3.87 ml/glw/min vs. SHBD + VSOP: 395.8 ± 46.64 ml/glw/min, p < 0.05) at 24 h. CONCLUSIONS Our data suggest that the potential of "shock organs" within liver transplantation may be underestimated. If our findings are reproducable in humans, SHBD grafts should be considered as a valuable source for expanding the thus far limited donor pool.
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Affiliation(s)
- Azin Jafari
- Department of Surgery, Faculty of Medicine, Rheinische Friedrich-Wilhelms-Universität, Sigmund-Freudstr. 25, 53127 Bonn, Germany
| | - Hanno Matthaei
- Department of Surgery, Faculty of Medicine, Rheinische Friedrich-Wilhelms-Universität, Sigmund-Freudstr. 25, 53127 Bonn, Germany
| | - Vittorio Branchi
- Department of Surgery, Faculty of Medicine, Rheinische Friedrich-Wilhelms-Universität, Sigmund-Freudstr. 25, 53127 Bonn, Germany
| | - Edwin Bölke
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine, Heinrich-Heine-Universität, Düsseldorf, Germany
| | - Rene H. Tolba
- Institute for Laboratory Animal Science and Experimental Surgery, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Jörg C. Kalff
- Department of Surgery, Faculty of Medicine, Rheinische Friedrich-Wilhelms-Universität, Sigmund-Freudstr. 25, 53127 Bonn, Germany
| | - Steffen Manekeller
- Department of Surgery, Faculty of Medicine, Rheinische Friedrich-Wilhelms-Universität, Sigmund-Freudstr. 25, 53127 Bonn, Germany
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Zhu F, Zhong X, Zhou Y, Hou Z, Hu H, Liang L, Chen J, Chen Q, Ji X, Shang D. Protective effects of nicorandil against cerebral injury in a swine cardiac arrest model. Exp Ther Med 2018; 16:37-44. [PMID: 29977355 PMCID: PMC6030868 DOI: 10.3892/etm.2018.6136] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 10/25/2017] [Indexed: 01/28/2023] Open
Abstract
The present study investigated the effects of nicorandil on cerebral injury following cardiopulmonary resuscitation (CPR) in a swine model of cardiac arrest. CPR was performed on swine following 4 min induced ventricular fibrillation. Surviving animals were randomly divided into 3 groups: A nicorandil group (n=8), a control group (n=8) and a sham group (n=4). The sham group underwent the same surgical procedure to imitate cardiac arrest, but ventricular fibrillation was not induced. When the earliest observable return of spontaneous circulation (ROSC) was detected, the nicorandil and control groups received injections of nicorandil and saline, respectively. Swine serum was collected at baseline and 5 min, 0.5, 3 and 6 h following ROSC. Serum levels of neuron-specific enolase (NSE), S100β, tumor necrosis factor α (TNF-α) and interleukin 6 (IL-6) were measured using ELISA. Animals were euthanized and brain tissue samples were collected and assessed using light and electron microscopy 6 h following ROSC. The expression of aquaporin-4 (AQP-4) in the brain tissue was measured using western blotting. Malondialdehyde (MDA) and glutathione (GSH) levels in the brain tissue were determined using thiobarbituric acid and thiobenzoic acid colorimetric methods, respectively. Serum NSE and S100β were significantly higher in the nicorandil and control groups following CPR, compared with baseline (P<0.05). Additionally, NSE and S100β levels were significantly lower in the nicorandil group compared with the control (P<0.05). Pathological examinations and electron microscopy indicated that nicorandil reduced brain tissue damage. TNF-α and IL-6 levels were significantly decreased in the nicorandil group compared with the control group (P<0.05). Furthermore, AQP-4 expression in brain tissue 6 h following ROSC was significantly lower in the nicorandil group compared with the control group (P<0.05). MDA and GSH levels in swine brain tissue decreased and increased, respectively, in the nicorandil group compared with the control group (P<0.05). The results of the present study demonstrate that nicorandil exerts a protective effect against brain injury following cardiac arrest by reducing oxidative damage, inflammatory responses and brain edema post-ROSC.
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Affiliation(s)
- Fangfang Zhu
- Emergency Department, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China
| | - Xia Zhong
- Emergency Department, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China
| | - Yi Zhou
- Emergency Department, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China
| | - Zhiqiang Hou
- Emergency Department, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China
| | - Haoran Hu
- Emergency Department, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China
| | - Lining Liang
- Emergency Department, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China
| | - Jibin Chen
- Emergency Department, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China
| | - Qianqian Chen
- Emergency Department, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China
| | - Xianfei Ji
- Emergency Department, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China
| | - Deya Shang
- Emergency Department, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China
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Ching CK, Leong SHB, Chua SJT, Lim SH, Heng K, Pothiawala S, Anantharaman V. Advanced Cardiac Life Support: 2016 Singapore Guidelines. Singapore Med J 2018; 58:360-372. [PMID: 28740999 DOI: 10.11622/smedj.2017064] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The main areas of emphasis in the Advanced Cardiac Life Support (ACLS) guidelines are: early recognition of cardiac arrest and call for help; good-quality chest compressions; early defibrillation when applicable; early administration of drugs; appropriate airway management ensuring normoventilation; and delivery of appropriate post-resuscitation care to enhance survival. Of note, it is important to monitor the quality of the various care procedures. The resuscitation team needs to reduce unnecessary interruptions to chest compressions in order to maintain adequate coronary perfusion pressure during the ACLS drill. In addition, the team needs to continually look out for reversible causes of the cardiac arrest.
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Affiliation(s)
- Chi Keong Ching
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | | | | | - Swee Han Lim
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - Kenneth Heng
- Emergency Department, Tan Tock Seng Hospital, Singapore
| | - Sohil Pothiawala
- Department of Emergency Medicine, Singapore General Hospital, Singapore
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Scarpino M, Lanzo G, Lolli F, Moretti M, Carrai R, Migliaccio ML, Spalletti M, Bonizzoli M, Peris A, Amantini A, Grippo A. Is brain computed tomography combined with somatosensory evoked potentials useful in the prediction of brain death after cardiac arrest? Neurophysiol Clin 2017; 47:327-335. [DOI: 10.1016/j.neucli.2017.07.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 07/06/2017] [Accepted: 07/12/2017] [Indexed: 12/12/2022] Open
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31
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Postreanimationsbehandlung. Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0331-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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32
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Saving lives despite 'failed' extracorporeal resuscitation. Resuscitation 2017; 118:A5-A6. [PMID: 28728895 DOI: 10.1016/j.resuscitation.2017.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 07/10/2017] [Indexed: 11/23/2022]
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Osmotherapy With Hypertonic Saline Attenuates Global Cerebral Edema Following Experimental Cardiac Arrest via Perivascular Pool of Aquaporin-4. Crit Care Med 2017; 44:e702-10. [PMID: 27035238 DOI: 10.1097/ccm.0000000000001671] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES We tested the hypothesis that osmotherapy with hypertonic saline attenuates cerebral edema following experimental cardiac arrest and cardiopulmonary resuscitation by exerting its effect via the perivascular pool of aquaporin-4. We used mice with targeted disruption of the gene encoding α-syntrophin (α-Syn) that demonstrate diminished perivascular aquaporin-4 pool but retain the non-endfoot and ependymal pools. DESIGN Laboratory animal study. SETTING University animal research laboratory. INTERVENTIONS Isoflurane-anesthetized adult male wild-type C57B/6 or α-Syn mice were subjected to cardiac arrest/cardiopulmonary resuscitation and treated with either a continuous IV infusion of 0.9% saline or various concentrations of hypertonic saline. Serum osmolality, regional brain water content, blood-brain barrier disruption, and aquaporin-4 protein expression were determined at 24 hours after cardiac arrest/cardiopulmonary resuscitation. MEASUREMENTS AND MAIN RESULTS Hypertonic saline (7.5%) treatment significantly attenuated water content in the caudoputamen complex and cortex compared with 0.9% saline treatment in wild-type mice subjected to cardiac arrest/cardiopulmonary resuscitation. In contrast, in α-Syn mice subjected to cardiac arrest/cardiopulmonary resuscitation, 7.5% hypertonic saline treatment did not attenuate water content. Treatment with 7.5% hypertonic saline attenuated blood-brain barrier disruption at 24 hours following cardiac arrest/cardiopulmonary resuscitation in wild-type mice but not in α-Syn mice. Total aquaporin-4 protein expression was not different between 0.9% saline and hypertonic saline-treated wild-type mice. CONCLUSIONS Following experimental cardiac arrest/cardiopulmonary resuscitation: 1) continuous hypertonic saline therapy maintained to achieve serum osmolality of ≈ 350 mOsm/L is beneficial for the treatment of cerebral edema; 2) perivascular pool of aquaporin-4 plays a critical role in water egress from brain; and 3) hypertonic saline attenuates blood-brain barrier disruption via perivascular aquaporin-4 pool.
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Neurologic Recovery After Cardiac Arrest: a Multifaceted Puzzle Requiring Comprehensive Coordinated Care. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:52. [PMID: 28536893 DOI: 10.1007/s11936-017-0548-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OPINION STATEMENT Surviving cardiac arrest (CA) requires a longitudinal approach with multiple levels of responsibility, including fostering a culture of action by increasing public awareness and training, optimization of resuscitation measures including frequent updates of guidelines and their timely implementation into practice, and optimization of post-CA care. This clearly goes beyond resuscitation and targeted temperature management. Brain-directed physiologic goals should dictate the post-CA management, as accumulating evidence suggests that the degree of hypoxic brain injury is the main determinant of survival, regardless of the etiology of arrest. Early assessment of the need for further hemodynamic and electrophysiologic cardiac interventions, adjusting ventilator settings to avoid hyperoxia/hypoxia while targeting high-normal to mildly elevated PaCO2, maintaining mean arterial blood pressures >65 mmHg, evaluating for and treating seizures, maintaining euglycemia, and aggressively pursuing normothermia are key steps in reducing the bioenergetic failure that underlies secondary brain injury. Accurate neuroprognostication requires a multimodal approach with standardized assessments accounting for confounders while recognizing the importance of a delayed prognostication when there is any uncertainty regarding outcome. The concept of a highly specialized post-CA team with expertise in the management of post-CA syndrome (mindful of the brain-directed physiologic goals during the early post-resuscitation phase), TTM, and neuroprognostication, guiding the comprehensive care to the CA survivor, is likely cost-effective and should be explored by institutions that frequently care for these patients. Finally, providing tailored rehabilitation care with systematic reassessment of the needs and overall goals is key for increasing independence and improving quality-of-life in survivors, thereby also alleviating the burden on families. Emerging evidence from multicenter collaborations advances the field of resuscitation at an incredible pace, challenging previously well-established paradigms. There is no more room for "conventional wisdom" in saving the survivors of cardiac arrest.
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Conivaptan, a Selective Arginine Vasopressin V1a and V2 Receptor Antagonist Attenuates Global Cerebral Edema Following Experimental Cardiac Arrest via Perivascular Pool of Aquaporin-4. Neurocrit Care 2017; 24:273-82. [PMID: 26732270 DOI: 10.1007/s12028-015-0236-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Cerebral edema is a major cause of mortality following cardiac arrest (CA) and cardiopulmonary resuscitation (CPR). Arginine vasopressin (AVP) and water channel aquaporin-4 (AQP4) have been implicated in the pathogenesis of CA-evoked cerebral edema. In this study, we examined if conivaptan, a V1a and V2 antagonist, attenuates cerebral edema following CA/CPR in wild type (WT) mice as well as mice with targeted disruption of the gene encoding α-syntrophin (α-syn(-/-)) that demonstrate diminished perivascular AQP4 pool. METHODS Isoflurane-anesthetized adult male WT C57Bl/6 and α-syn(-/-) mice were subjected to 8 min CA/CPR and treated with either bolus IV injection (0.15 or 0.3 mg/kg) followed by continuous infusion of conivaptan (0.15 mg/kg/day or 0.3 mg/kg/day), or vehicle infusion for 48 h. Serum osmolality, regional brain water content, and blood-brain barrier (BBB) disruption were determined at the end of the experiment. Sham-operated mice in both strains served as controls. RESULTS Treatment with conivaptan elevated serum osmolality in a dose-dependent manner. In WT mice, conivaptan at 0.3 mg dose significantly attenuated regional water content in the caudoputamen (81.0 ± 0.5 vs. 82.5 ± 0.4% in controls; mean ± SEM) and cortex (78.8 ± 0.2 vs. 79.4 ± 0.2% in controls), while conivaptan at 0.15 mg was not effective. In α-syn(-/-) mice, conivaptan at 0.3 mg dose did not attenuate water content compared with controls. Conivaptan (0.3 mg/kg/day) attenuated post-CA BBB disruption at 48 h in WT mice but not in α-syn(-/-) mice. CONCLUSIONS Continuous IV infusion of conivaptan attenuates cerebral edema and BBB disruption following CA. These effects of conivaptan that are dependent on the presence of perivascular pool of AQP4 appear be mediated via its dual effect on V1 and V2 receptors.
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Kramer AH, Baht R, Doig CJ. Time trends in organ donation after neurologic determination of death: a cohort study. CMAJ Open 2017; 5:E19-E27. [PMID: 28401114 PMCID: PMC5378522 DOI: 10.9778/cmajo.20160093] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The cause of brain injury may influence the number of organs that can be procured and transplanted with donation following neurologic determination of death. We investigated whether the distribution of causes responsible for neurologic death has changed over time and, if so, whether this has had an impact on organ quality, transplantation rates and recipient outcomes. METHODS We performed a cohort study involving consecutive brain-dead organ donors in southern Alberta between 2003 and 2014. For each donor, we determined last available measures of organ injury and number of organs transplanted, and compared these variables for various causes of neurologic death. We compared trends to national Canadian data for 2000-2013 (2000-2011 for Quebec). RESULTS There were 226 brain-dead organ donors over the study period, of whom 100 (44.2%) had anoxic brain injury, 63 (27.9%) had stroke, and 51 (22.6%) had traumatic brain injury. The relative proportion of donors with traumatic brain injury decreased over time (> 30% in 2003-2005 v. 6%-23% in 2012-2014) (p = 0.004), whereas that with anoxic brain injury increased (14%-37% v. 46%-80%, respectively) (p < 0.001). Nationally, the annual number of brain-dead donors with traumatic brain injury decreased from 4.4 to less than 3 per million population between 2000 and 2013, and that with anoxic brain injury increased from 1.1 to 3.1 per million. Donors with anoxic brain injury had higher concentrations of creatinine, alanine aminotransferase and troponin T, and lower PaO2/FIO2 and urine output than donors with other diagnoses. The average number of organs transplanted per donor was 3.6 with anoxic brain injury versus 4.5 with traumatic brain injury or stroke (p = 0.002). INTERPRETATION Anoxic brain injury has become a leading cause of organ donation after neurologic determination of death in Canada. Organs from donors with anoxic brain injury have a greater degree of injury, and fewer are transplanted. These findings have implications for availability of organs for transplantation in patients with end-stage organ failure.
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Affiliation(s)
- Andreas H Kramer
- Departments of Critical Care Medicine (Kramer, Doig) and Clinical Neurosciences (Kramer), University of Calgary; Southern Alberta Organ and Tissue Donation Program (Kramer, Baht); Department of Community Health Sciences (Doig), University of Calgary, Calgary, Alta
| | - Ryan Baht
- Departments of Critical Care Medicine (Kramer, Doig) and Clinical Neurosciences (Kramer), University of Calgary; Southern Alberta Organ and Tissue Donation Program (Kramer, Baht); Department of Community Health Sciences (Doig), University of Calgary, Calgary, Alta
| | - Christopher J Doig
- Departments of Critical Care Medicine (Kramer, Doig) and Clinical Neurosciences (Kramer), University of Calgary; Southern Alberta Organ and Tissue Donation Program (Kramer, Baht); Department of Community Health Sciences (Doig), University of Calgary, Calgary, Alta
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Sandroni C, D'Arrigo S, Callaway CW, Cariou A, Dragancea I, Taccone FS, Antonelli M. The rate of brain death and organ donation in patients resuscitated from cardiac arrest: a systematic review and meta-analysis. Intensive Care Med 2016; 42:1661-1671. [PMID: 27699457 PMCID: PMC5069310 DOI: 10.1007/s00134-016-4549-3] [Citation(s) in RCA: 127] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 09/11/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND The occurrence of brain death in patients with hypoxic-ischaemic brain injury after resuscitation from cardiac arrest creates opportunities for organ donation. However, its prevalence is currently unknown. METHODS Systematic review. MEDLINE via PubMed, ISI Web of Science and the Cochrane Database of Systematic Reviews were searched for eligible studies (2002-2016). The prevalence of brain death in adult patients resuscitated from cardiac arrest and the rate of organ donation among brain dead patients were summarised using a random effect model with double-arcsine transformation. The quality of evidence (QOE) was evaluated according to the GRADE guidelines. RESULTS 26 studies [16 on conventional cardiopulmonary resuscitation (c-CPR), 10 on extracorporeal CPR (e-CPR)] included a total of 23,388 patients, 1830 of whom developed brain death at a mean time of 3.2 ± 0.4 days after recovery of circulation. The overall prevalence of brain death among patients who died before hospital discharge was 12.6 [10.2-15.2] %. Prevalence was significantly higher in e-CPR vs. c-CPR patients (27.9 [19.7-36.6] vs. 8.3 [6.5-10.4] %; p < 0.0001). The overall rate of organ donation among brain dead patients was 41.8 [20.2-51.0] % (9/26 studies, 1264 patients; range 0-100 %). The QOE was very low for both outcomes. CONCLUSIONS In patients with hypoxic-ischaemic brain injury following CPR, more than 10 % of deaths were due to brain death. More than 40 % of brain-dead patients could donate organs. Patients who are unconscious after resuscitation from cardiac arrest, especially when resuscitated using e-CPR, should be carefully screened for signs of brain death.
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Affiliation(s)
- Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Largo Agostino Gemelli 8, 00168, Rome, Italy.
| | - Sonia D'Arrigo
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alain Cariou
- Medical ICU, Cochin Hospital (AP-HP) Paris Descartes University, Paris, France
| | - Irina Dragancea
- Department of Clinical Sciences, Division of Neurology, Lund University, Lund, Sweden
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Massimo Antonelli
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Largo Agostino Gemelli 8, 00168, Rome, Italy
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Sharma RP, Stub D. Controversies in Out of Hospital Cardiac Arrest? Interv Cardiol Clin 2016; 5:551-559. [PMID: 28582003 DOI: 10.1016/j.iccl.2016.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Cardiac arrest is a major cause of morbidity and mortality and accounts for nearly 500,000 deaths annually in the United States. In patients suffering out-of-hospital cardiac arrest, survival is less than 15%, with considerable regional variation. Although most deaths occur during the initial resuscitation, an increasing proportion occur in patients hospitalized after initially successful resuscitation. In these patients, the significant subsequent morbidity and mortality is due to "post cardiac arrest syndrome." Until recently, most single interventions have yielded little improvement in rates of survival; however, there is growing recognition that optimal treatment strategies during the postresuscitation phase may improve outcomes.
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Affiliation(s)
- Rahul P Sharma
- Cedars-Sinai Heart Institute, Beverly Boulevard, Los Angeles, CA 90048, USA.
| | - Dion Stub
- Alfred and Western Hospital, Monash University, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
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West S, Soar J, Callaway CW. The viability of transplanting organs from donors who underwent cardiopulmonary resuscitation: A systematic review. Resuscitation 2016; 108:27-33. [PMID: 27568108 DOI: 10.1016/j.resuscitation.2016.07.229] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 07/02/2016] [Accepted: 07/24/2016] [Indexed: 01/08/2023]
Abstract
AIMS To identify reports of patients who underwent cardiopulmonary resuscitation (CPR) prior to solid organ donation and compare recipient and organ function outcomes to those that did not undergo CPR. Donation after restoration of circulation then progressing to death and those donating with on-going CPR who would have otherwise have termination of efforts were both included. METHODS Systematic review. Clinical studies comparing the outcome of patients and organs retrieved from donors who underwent CPR with those that did not require CPR. Full-text articles were searched on EmBASE, MEDLINE, Cochrane Database of Systematic Reviews and the Cochrane Register of Controlled Trials. RESULTS Twenty-two observational studies were included. There were 12,206 adult and 2552 paediatric organ transplantation identified. Comparing donation after restoration of circulation there was no difference in immediate, one year, and five-year graft function. Donation with on-going CPR was associated with reduced immediate graft function for both renal and hepatic transplantation, however long term function was not different. CONCLUSIONS CPR does not appear to adversely affect graft function. Patients who have restored circulation after resuscitation and subsequently progress to death should be evaluated for organ donation. Those with on-going CPR should be considered for hepatic and renal transplantation but there may be worse initial graft function.
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Affiliation(s)
- Stephen West
- Department of Anaesthesia Intensive Care, Southmead Hospital, Bristol BS10 5NB, UK.
| | - Jasmeet Soar
- Department of Anaesthesia Intensive Care, Southmead Hospital, Bristol BS10 5NB, UK
| | - Clifton W Callaway
- Department of Emergency Medicine and Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, PA 15260, USA
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Nolan JP, Soar J, Cariou A, Cronberg T, Moulaert VRM, Deakin CD, Bottiger BW, Friberg H, Sunde K, Sandroni C. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines for Post-resuscitation Care 2015: Section 5 of the European Resuscitation Council Guidelines for Resuscitation 2015. Resuscitation 2016; 95:202-22. [PMID: 26477702 DOI: 10.1016/j.resuscitation.2015.07.018] [Citation(s) in RCA: 756] [Impact Index Per Article: 84.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jerry P Nolan
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, UK.
| | - Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK
| | - Alain Cariou
- Cochin University Hospital (APHP) and Paris Descartes University, Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Division of Neurology, Lund University, Lund, Sweden
| | - Véronique R M Moulaert
- Adelante, Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands
| | - Charles D Deakin
- Cardiac Anaesthesia and Cardiac Intensive Care and NIHR Southampton Respiratory Biomedical Research Unit, University Hospital, Southampton, UK
| | - Bernd W Bottiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Hans Friberg
- Department of Clinical Sciences, Division of Anesthesia and Intensive Care Medicine, Lund University, Lund, Sweden
| | - Kjetil Sunde
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
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Geri G, Cariou A. Syndrome post-arrêt cardiaque. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-016-1191-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Cour M, Bresson D, Hernu R, Argaud L. SOFA score to assess the severity of the post-cardiac arrest syndrome. Resuscitation 2016; 102:110-5. [PMID: 26965206 DOI: 10.1016/j.resuscitation.2016.03.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 02/17/2016] [Accepted: 03/01/2016] [Indexed: 01/31/2023]
Abstract
AIM OF THE STUDY The aim of the study was to assess the prognostic impact of organ failures at ICU admission after out-of-hospital cardiac arrest (CA) according to the SOFA score. METHODS We performed a retrospective analysis of a prospective cohort of all adult patients admitted to a 15-bed medical ICU in a university-affiliated hospital after an out-of-hospital CA. In addition to demographic and clinical data, initial illness severity was measured using the SOFA score. Outcomes (mortality and neurological prognosis) were also collected at day 28 and one year. RESULTS A total of 304 patients (age: 66±16 years, male: 55%) were admitted for post-CA management. An initial nonshockable cardiac rhythm was recorded in 274 (90%) cases. At admission, SOFA score averaged 9.8±3.1 for the entire cohort (8.1±3.3 for day 28 survivors versus 10.1±3.1 for non-survivors, p<0.001). At day 1, SOFA remained significantly (p<0.001) higher in nonsurvivors (9.8±3.8) when compared to survivors (6.5±4.1). Death occurred in 269 (88%) and 275 (90%) patients within the 28-day and one-year period, respectively. Neurological outcome at one year was favorable (CPC score 1-2) in 23patients (8%). Multivariate analysis identified the SOFA score at admission as independently associated with mortality at day28 (OR per point of SOFA score 1.17; 95% CI 1.01-1.35; p=0.03). CONCLUSIONS In the present study, early organ failures, as assessed by the SOFA score at ICU admission, were independently associated with day 28 mortality. SOFA score may help clinicians objectively evaluate the severity of the post-CA syndrome.
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Affiliation(s)
- Martin Cour
- Hospices Civils de Lyon, Groupement Hospitalier Edouard Herriot, Service de Réanimation Médicale, F-69437 Lyon, France; Université de Lyon, Université Claude Bernard Lyon 1, Faculté de médecine Lyon-Est, F-69373 Lyon, France; INSERM, U1060 CarMeN, F-69373 Lyon, France.
| | - Didier Bresson
- Hospices Civils de Lyon, Groupement Hospitalier Edouard Herriot, Service de Réanimation Médicale, F-69437 Lyon, France; Université de Lyon, Université Claude Bernard Lyon 1, Faculté de médecine Lyon-Est, F-69373 Lyon, France.
| | - Romain Hernu
- Hospices Civils de Lyon, Groupement Hospitalier Edouard Herriot, Service de Réanimation Médicale, F-69437 Lyon, France; Université de Lyon, Université Claude Bernard Lyon 1, Faculté de médecine Lyon-Est, F-69373 Lyon, France.
| | - Laurent Argaud
- Hospices Civils de Lyon, Groupement Hospitalier Edouard Herriot, Service de Réanimation Médicale, F-69437 Lyon, France; Université de Lyon, Université Claude Bernard Lyon 1, Faculté de médecine Lyon-Est, F-69373 Lyon, France; INSERM, U1060 CarMeN, F-69373 Lyon, France.
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Callaway CW, Soar J, Aibiki M, Böttiger BW, Brooks SC, Deakin CD, Donnino MW, Drajer S, Kloeck W, Morley PT, Morrison LJ, Neumar RW, Nicholson TC, Nolan JP, Okada K, O'Neil BJ, Paiva EF, Parr MJ, Wang TL, Witt J. Part 4: Advanced Life Support: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2016; 132:S84-145. [PMID: 26472860 DOI: 10.1161/cir.0000000000000273] [Citation(s) in RCA: 237] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Patroniti N, Sangalli F, Avalli L. Post-cardiac arrest extracorporeal life support. Best Pract Res Clin Anaesthesiol 2015; 29:497-508. [DOI: 10.1016/j.bpa.2015.09.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 09/17/2015] [Accepted: 09/22/2015] [Indexed: 01/19/2023]
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Callaway CW, Donnino MW, Fink EL, Geocadin RG, Golan E, Kern KB, Leary M, Meurer WJ, Peberdy MA, Thompson TM, Zimmerman JL. Part 8: Post-Cardiac Arrest Care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132:S465-82. [PMID: 26472996 PMCID: PMC4959439 DOI: 10.1161/cir.0000000000000262] [Citation(s) in RCA: 1032] [Impact Index Per Article: 103.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Lu Q, Tucker D, Dong Y, Zhao N, Zhang Q. Neuroprotective and Functional Improvement Effects of Methylene Blue in Global Cerebral Ischemia. Mol Neurobiol 2015; 53:5344-55. [PMID: 26433378 DOI: 10.1007/s12035-015-9455-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 09/25/2015] [Indexed: 11/25/2022]
Abstract
Transient global cerebral ischemia (GCI) causes delayed neuronal cell death in the vulnerable hippocampus CA1 subfield, as well as behavioral deficits. Ischemia reperfusion (I/R) produces excessive reactive oxygen species and plays a key role in brain injury. The mitochondrial electron respiratory chain is the main cellular source of free radical generation, and dysfunction of mitochondria has a significant impact on the neuronal cell death in ischemic brain. The aim of the present study is to investigate the potential beneficial effects of methylene blue (MB) in a four-vessel occlusion (4VO) GCI model on adult male rats. MB was delivered at a dose of 0.5 mg/kg/day for 7 days, through a mini-pump implanted subcutaneously after GCI. We first found that MB significantly improved ischemic neuronal survival in the hippocampal CA1 region as measured by cresyl violet staining as well as NeuN staining. We also found that MB has the ability to rescue ischemia-induced decreases of cytochrome c oxidase activity and ATP generation in the CA1 region following I/R. Further analysis with labeling of MitoTracker® Red revealed that the depolarization of mitochondrial membrane potential (MMP) was markedly attenuated following MB treatment. In addition, the induction of caspase-3, caspase-8, and caspase-9 activities and the increased numbers of TUNEL-positive cells of the CA1 region were significantly reduced by MB application. Correspondingly, Barnes maze tests showed that the deterioration of spatial learning and memory performance following GCI was significantly improved in the MB-treatment group compared to the ischemic control group. In summary, our study suggests that MB may be a promising therapeutic agent targeting neuronal cell death and cognitive deficits following transient global cerebral ischemia.
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Affiliation(s)
- Qing Lu
- Department of Neuroscience and Regenerative Medicine, Medical College of Georgia, Georgia Regent University, 1120 15th Street, CA3050, Augusta, GA, 30912, USA
| | - Donovan Tucker
- Department of Neuroscience and Regenerative Medicine, Medical College of Georgia, Georgia Regent University, 1120 15th Street, CA3050, Augusta, GA, 30912, USA
| | - Yan Dong
- Department of Neuroscience and Regenerative Medicine, Medical College of Georgia, Georgia Regent University, 1120 15th Street, CA3050, Augusta, GA, 30912, USA
| | - Ningjun Zhao
- Department of Neuroscience and Regenerative Medicine, Medical College of Georgia, Georgia Regent University, 1120 15th Street, CA3050, Augusta, GA, 30912, USA
| | - Quanguang Zhang
- Department of Neuroscience and Regenerative Medicine, Medical College of Georgia, Georgia Regent University, 1120 15th Street, CA3050, Augusta, GA, 30912, USA.
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Soar J, Callaway CW, Aibiki M, Böttiger BW, Brooks SC, Deakin CD, Donnino MW, Drajer S, Kloeck W, Morley PT, Morrison LJ, Neumar RW, Nicholson TC, Nolan JP, Okada K, O’Neil BJ, Paiva EF, Parr MJ, Wang TL, Witt J, Andersen LW, Berg KM, Sandroni C, Lin S, Lavonas EJ, Golan E, Alhelail MA, Chopra A, Cocchi MN, Cronberg T, Dainty KN, Drennan IR, Fries M, Geocadin RG, Gräsner JT, Granfeldt A, Heikal S, Kudenchuk PJ, Lagina AT, Løfgren B, Mhyre J, Monsieurs KG, Mottram AR, Pellis T, Reynolds JC, Ristagno G, Severyn FA, Skrifvars M, Stacey WC, Sullivan J, Todhunter SL, Vissers G, West S, Wetsch WA, Wong N, Xanthos T, Zelop CM, Zimmerman J. Part 4: Advanced life support. Resuscitation 2015; 95:e71-120. [DOI: 10.1016/j.resuscitation.2015.07.042] [Citation(s) in RCA: 214] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Dragancea I, Horn J, Kuiper M, Friberg H, Ullén S, Wetterslev J, Cranshaw J, Hassager C, Nielsen N, Cronberg T. Neurological prognostication after cardiac arrest and targeted temperature management 33°C versus 36°C: Results from a randomised controlled clinical trial. Resuscitation 2015; 93:164-70. [DOI: 10.1016/j.resuscitation.2015.04.013] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 03/28/2015] [Accepted: 04/07/2015] [Indexed: 12/29/2022]
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Hoyer DP, Paul A, Saner F, Gallinat A, Mathé Z, Treckmann JW, Schulze M, Kaiser GM, Canbay A, Molmenti E, Sotiropoulos GC. Safely expanding the donor pool: brain dead donors with history of temporary cardiac arrest. Liver Int 2015; 35:1756-63. [PMID: 25522767 DOI: 10.1111/liv.12766] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 12/09/2014] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Cardiac arrest (CA) in deceased organ donors can potentially be associated with ischaemic organ injury, resulting in allograft dysfunction after liver transplantation (LT). The aim of this study was to analyse the influence of cardiac arrest in liver donors. METHODS We evaluated 884 consecutive adult patients undergoing LT at our Institution from September 2003 to December 2011. Uni- and multivariable analyses was performed to identify predictive factors of outcome and survival for organs from donors with (CA donor) and without (no CA donor) a history of cardiac arrest. RESULTS We identified 77 (8.7%) CA donors. Median resuscitation time was 16.5 (1-150) minutes. Allografts from CA donors had prolonged CIT (p = 0.016), were obtained from younger individuals (p < 0.001), and had higher terminal preprocurement AST and ALT (p < 0.001) than those of no CA donors. 3-month, 1-year and 5-year survival for recipients of CA donor grafts was 79%, 76% and 57% and 72.1%, 65.1% and 53% for no CA donor grafts (log rank p = 0.435). Peak AST after LT was significantly lower in CA donor organs than in no CA donor ones (886U/l vs 1321U/l; p = 0.031). Multivariable analysis identified CIT as a risk factor for both patient and graft survival in CA donors. CONCLUSION This analysis represents the largest cohort of liver donors with a history of cardiac arrest. Reasonable selection of these donors constitutes a safe approach to the expansion of the donor pool. Rapid allocation and implantation with diminution of CIT may further improve the outcomes of livers from CA donors.
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Affiliation(s)
- Dieter P Hoyer
- General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany
| | - Andreas Paul
- General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany
| | - Fuat Saner
- General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany
| | - Anja Gallinat
- General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany
| | - Zoltan Mathé
- General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany
| | - Juergen W Treckmann
- General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany
| | - Maren Schulze
- General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany
| | - Gernot M Kaiser
- General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany
| | - Ali Canbay
- Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
| | - Ernesto Molmenti
- Department of Surgery, North Shore University Hospital, Manhasset, NY, USA
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