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Signa Vitae

Journal of Intensive Care and Emergency Medicine

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Terlipressin/adrenaline is better than adrenaline alone in a porcine model of prolonged ventricular fibrillation A randomized controlled study

Abstract

Objectives. Vasopressors have been routinely used in cardiopulmonary resuscitation. Recent data show that terlipressin may restore blood pressure in asphyxial and prolonged arrests but its potential role in ventricular fibrillation (VF) remains unknown. The aim of this study was to compare coronary (CorPP) and cerebral (CPP) perfusion pressures achieved by terlipressin/adrenaline versus placebo/adrenaline in VF.

Methods. Fourteen domestic pigs were randomly assigned into group A and B. After 5 min of untreated VF, compression-only resuscitation was applied for 10 min, followed by advanced life support. Terlipressin in a single-dose of 30 µg·kg-1 was added to the first dose of adrenaline in group A, while placebo was given in group B. CorPP and CPP were calculated from right atrial, aortic and intracerebral pressures. Data were analyzed using repeated measurements ANOVA and a Fisher´s protected LSD post hoc test.

Results. Terlipressin/adrenaline maintained CorPP above 10 mmHg for 17.7 min longer than adrenaline alone (P=0.003) unable to prevent refractory hypotension. CorPP (mean±SD) measured at 35, 45, and 55 min after the onset of VF was 12 ± 4, 11 ± 6, and 10 ± 5 mmHg in the terlipressin group A; and 6 ± 4, 1 ± 5, and -1 ± 5 mmHg in placebo group B (P=0.03, <0.001, and <0.001). CPP measured at the same times was 23 ± 7, 20 ± 7, and 23 ± 7 mmHg in group A; and 13 ± 7, 6 ± 5, and 6 ± 7 mmHg in group B (P=0.01, <0.001, and <0.001).

Conclusion. The study showed that a single dose of terlipressin, when added to adrenaline, was effective for achievement of higher vital organ perfusion pressures compared to adrenaline alone.

Key words: cardiopulmonary resuscitation (CPR), cardiac arrest, terlipressin, vasopressor therapy, cerebral perfusion pressure, coronary perfusion pressure, ventricular fibrillation

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High frequency oscillatory ventilation as the most appropriate treatment for life threatening thoracic trauma

Abstract

Acute respiratory failure is common in trauma patients and can be a threat to life in severe thoracic injury. We represent a case of severe respiratory failure after blunt thoracic injury with uncontrollable bleeding and massive air leak which was successfully managed with high frequency oscillatory ventilation. In our opinion high frequency oscillatory ventilation represent a safe and effective treatment of life threatening acute respiratory failure in trauma patients.

Key words: traumatic lung injury, hypoxemic respiratory failure, air leak, cardiac arrest

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From Science to Guidelines: The Future for Resuscitation

Abstract

The periodic development and publication of treatment guidelines is integral to the field of cardiopulmonary resuscitation and emergency cardiovascular care. The methods for guideline development have evolved over the past few decades, and the process itself has become the subject of increasing scientific investigation. An internationally validated tool for assessing the quality of clinical practice guidelines is The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument. Applying this tool to the ILCOR 2010 International Consensus on CPR (cardiopulmonary resuscitation) and ECC (emergency cardiac care) Science with Treatment Recommendations (CoSTR) and the resulting member council guidelines will be a valuable initial step in evaluating both the process and the product. By doing so, important strengths can be recognized as well as opportunities for improvement moving forward. Beyond validated tools to assess and improve the quality of the traditional guidelines process, a critical reassessment of the overall strategy for improving cardiac arrest outcomes is indicated. From the lay-provider perspective, innovative approaches to facilitate performance of bystander CPR are needed. This is likely to entail more individualized instructional methods that are titrated to the provider’s capabilities for learning and performance. What the future might hold for professional providers is a more individualized treatment strategy titrated to real-time physiologic monitoring with mechanized delivery of therapies guided by real-time computer-aided medical decision-making. These individualized instructional and treatment strategies could revolutionize our approach to cardiac arrest resuscitation, and dramatically change how guidelines are developed, implemented and evaluated.

Keywords: cardiac arrest, cardiopulmonary resuscitation, CPR, guidelines

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Hypothermia during percutaneous coronary intervention in comatose survivors of cardiac arrest

Abstract

Urgent invasive coronary strategy including coronary angiography and percutaneous coronary intervention (PCI) is feasible and safe in combination with mild induced hypothermia and may significantly improve survival with good neurological outcome in comatose patients after reestablishment of spontaneous circulation (ROSC). The starting hypothermia already in the prehospital setting or immediately after arrival to the catheterization laboratory to complement urgent coronary angiography and PCI seems to be a logical strategy.

Keywords: cardiac arrest, urgent coronary angiography, percutaneous coronary intervention PCI , mild induced hypothermia, outcome

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Targeting the Endothelium

Abstract

The endothelium is an active organ with paracrine-endocrine capabilities that directs a multitude of physiological actions both locally and remotely. Cardiac arrest and resuscitation is a model of whole body ischemia reperfusion injury, interventions that have their basis in cytoprotection, reduction of the inflammatory cascade, fibrinolysis and improvement of microvasculature blood flow target the endothelium. This presentation will review pharmacologic, cell targeted therapies and periodic acceleration (pGz) interventions that have the endothelium in part as the target organ. The clinical potential of such interventions as preconditioning, conditioning and postconditioning strategies associated with cardiac arrest will be defined.

Keywords: endothelium, periodic acceleration (pGz), cardiac arrest, cardiopulmonary resuscitation, ischemia reperfusion, nitric oxide, shear stress

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