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Therapeutic Hypothermia Reduces Lactate for Post-Resuscitation Syndrome
- 1. THERAPEUTIC HYPOTHERMIA FOR POSTRESUSCITATION SYNDROME AND LACTATE LEVELS Sule AKIN, Assoc.Prof, MD Baskent University School of Medicine Anesthesiology and Critical Care Department Adana - TURKEY 2nd World Congress on BIOMARKERS & CLINICAL RESEARCH Baltimore, Maryland , USA. – 13 September 2011
- 7. Cardiac arrest ROSC (+) 25% ROSC (-) 75 % Recovery 7% PRS 18% Alive 3% Dead 15% ROSC: Return Of Spontaneous Circulation Estimated ratios of cardiac arrest patients (< 4 min)
- 8. Resuscitation after cardiac arrest : a 3-phase time-sensitive model Weisfeldt ML. JAMA 2002 No Flow Low Flow Post-CPR ROSCCardiac Arrest CPR Electrical phase 0 – 4 min Circıulatory phase 4 – 10 min Metabolic phase > 10 min
- 9. Severe Global Ischemia Reperfusion Multiple Organ Failure SYSTEMIC INFLAMMATORY RESPONSE SYNDROME (SIRS) PRS
- 11. Ischemia Mitochondrian Oxidative phosphorylation Extracellular Ca+2 Injurious agent Mitochondrion Endolasmic reticulum Injcreased cytosolic Ca+2 ATPase Phospholipase Protease Endonuclease Decreased ATP Decreased phospholipids Disruption of membrane and cytoskeletal proteins Nucleus chromatin damage Membrane damage Ca+2 Ca+2 Ca+2Ca+2
- 12. Necrosis Apoptosis Cell Death Inflammation REPERFUSION Clot Dissolution Flow Restoration Oxidative Stress Mitochondrial Resp. Chain NAD(P)H Oxidases Nitric Oxide Synthesas O2- , H2O2-, OH-, NO, ONO O- O2
- 13. • Ischemia and reperfusion syndrome • Inflammatory response • Coagulopathy • Circulatory failure • Adrenal dysfunction Current Opinion in Crit Care. 2004 u t
- 15. 61% 23% 10% 3% 3% Proceedings of the ATS 2007;4:A792
- 16. BRAIN INJURY DUE TO PRS Causes: - Limited tolerence to ischemia - Specific response to reperfusion OUT -OF- HOSPITAL CPR 23% IN- HOSPITAL CPR 68%
- 18. WHAT WILL WE DO AFTER THE CRISIS (CPR) ENDS? POST CPR INTENSIVE CARE
- 19. Common intensive care protocols Sedation and neuromuscular blockade Monitorisation Seizıre control and propylaxis Early hemodynamic optimisation GLUCOSE control Oxygenation Neuroprotection by drugs Ventilation Adrenal dysfunction treatment Circulatory support Renal failure management Acute Coronary Syndrome management Infection control PRS- TREATMENT STRATEGIES
- 20. Common intensive care protocols Sedation and neuromuscular blockade Monitorisation Seizıre control and prophylaxis Early hemodynamic optimisation GLUCOSE control Oxygenation Neuroprotection by drugs Ventilation Adrenal dysfunction treatment Circulatory support Renal failure management Acute Coronary Syndrome management Infection control PRS- TREATMENT STRATEGIES
- 21. THERAPEUTIC HYPOTHERMIA Common intensive care protocols Sedation and neuromuscular blockade Monitorisation Seizıre control and propylaxis Early hemodynamic optimisation GLUCOSE control Oxygenation Neuroprotection by drugs Ventilation Adrenal dysfunction treatment Circulatory support Renal failure management Acute Coronary Syndrome management Infection control PRS- TREATMENT STRATEGIES
- 24. HYPOTHERMIA • Body Temperature < 35 C (95 F) MILD HYPOTHERMIA 32-35 C 90 -95 F MODERATE HYPOTHERMIA 28-32 C 82-90 F SEVERE HYPOTHERMIA 20-28 C 68-82 F PROFOUND HYPOTHERMIA < 20 C < 68 F
- 25. THERAPEUTIC HYPOTHERMIA (TH) Low Blood Flow Tissue Ischemia THERAPEUTIC HYPOTHERMIA
- 27. TH INDICATIONS IN CLINICS • Cardiopulmonary Resuscitation • Traumatic Brain Injury • Cerebral Infarct • Encephalitis / Bacterial Menengitis • Hepatic Encephalopathy • Heart Failure • Postoperative tachicardia • ARDS
- 30. Anesthesia and Analgesia 1959 38(6);423- 428
- 31. TH - MECHANISMS HYPOTHERMIA Metabolic rate 1 C CMRO2 6 % Oxygen consumption reperfusion ischemia Glutamate release Calcium shifts Mitocondrial disfunction Free oxygen radicals Exotoxicity Inflammation cascade CELL DEATH BBB Impairment Brain Edema Neurol Clin 2008;22:487-506
- 32. THE CHAIN OF SURVIVAL Resuscitation 2005: 67S1;3-6 Circulation 2005: 112; 206-211
- 33. Out-of-hospital CPR, VF First 6 hours, 32-34 C For 12-24 hours
- 34. European Resuscitation Council Guidelines for Resuscitation 2010 Section 1. Executive summary Jerry P. Nolana, Jasmeet Soarb, David A. Zidemanc, Dominique Biarentd, Leo L. Bossaerte, Charles Deakinf, Rudolph W. Kosterg, Jonathan Wyllieh, Bernd Böttigeri, on behalf of the ERC Guidelines Writing Group1 Therapeutic Hypothermia There is good evidence supporting the use of induced hypothermia in comatose survivors of out-of- hospital cardiac arrest caused by VF. One randomised trial and a pseudorandomised trial669 demonstrated improved neurological outcome at hospital discharge or at 6 months in comatose patients after out-of-hospital VF cardiac arrest. Cooling was initiated within minutes to hours after ROSC and a temperature range of 32–34 ◦C was maintained for 12–24 h. Two studies with historical control groups showed improvement in neurological outcome after therapeutic hypothermia for comatose survivors of VF cardiac arrest. Extrapolation of these data to other cardiac arrests (e.g., other initial rhythms, in- hospital arrests, paediatric patients) seems reasonable but is supported by only lower level data. Out-of-hospital CPR, In –hospital CPR VF, PVT, Asistoly, PEA First 6 hours, 32-34 C For 12-24 hours
- 37. GLUCOSE Pyruvate Oxygen (-) (anaerobic) Oxygen (-) (anaerobic) Acetyl CoA CO2 + H2O Oxygen (+) (aerobic) PPK LDHPDH 2 Lactate2 Ethanol + H2O KREB’S Cycle 2 ATP 36 ATP GLYCOLYSIS
- 38. GLUCOSE Pyruvate Oxygen (-) (anaerobic) Oxygen (-) (anaerobic) Acetyl CoA CO2 + H2O Oxygen (+) (aerobic) PFK LDHPDH 2 Lactate2 Ethanol + H2O 2 ATP 36 ATP
- 39. PRS Ischemia Low blood flow Low oxygen supply Less removal of lactic acid /CO2/protons Reperfusion Rapidly removal of extracellular protons and CO2 BLOOD LACTATE LEVELS
- 42. MY CLINIC’S EXPERIENCE • Lactate ; • Retrospective investigation • 63 resuscitated patient • Group I (n=33) ; TH administered patients for 24 hours (32-35 C) • Grouıp II (n=30) ; No TH A predictor of neurologic outcome?
- 44. MY CLINIC’S EXPERIENCE • Initial cardiac arres t rhythms • ICU admission times • Initial and after 24 hours Glasgow Coma Scales (GCS) and Cerebral Performance Categories (CPC) • Lactate • AST, ALT • BUN, Creatinine Levels at 1st, 3rd, 6th, 12th, 18th, 24th hours
- 45. Cerebral Performance Categories (CPC) Scale CPC 1 Good cerebral performance: conscious, alert, able to work, might have mild neurologic or psychologic deficit. CPC 2 Moderate cerebral disability: conscious, sufficient cerebral function for independent activities of daily life. Able to work in sheltered environment. CPC 3 Severe cerebral disability: conscious, dependent on others for daily support because of impaired brain function. Ranges from ambulatory state to severe dementia or paralysis. CPC 4 Coma or vegetative state: any degree of coma without the presence of all brain death criteria. Unawareness, even if appears awake (vegetative state) without interaction with environment; may have spontaneous eye opening and sleep/awake cycles. Cerebral unresponsiveness. CPC 5 Brain death: apnea, areflexia, EEG silence, etc. Safar P. Brain Failure and Resuscitation Churchill Livingstone, New York, 1981; 155-184
- 46. MY CLINIC’S EXPERIENCE Demographical findings Comparable Initial rhythms Comparable Renal and hepatic functions Insignificant differences (p>0.05) Neurologic outcomes (GCS CPC) Better in Group I (p<0.05)
- 47. MY CLINIC’S EXPERIENCE DURATION AFTER CPR GROUP I (n=33) GROUP II (n=30) 1st hour 4.8 1.2 4.7 1.2 3rd hour 4.8 1.0 4.8 1.1 6th hour 3.9 0.9 4.3 0.9 12th hour 3.2 0.9 3.6 0.8 18th hour 2.6 1.0 3.0 1.1 24th hour 2.1 0.7 2.7 1.1 Blood Lactate Levels
- 48. MY CLINIC’S EXPERIENCE DURATION AFTER CPR GROUP I (n=33) GROUP II (n=30) 1st hour 4.8 1.2 4.7 1.2 3rd hour 4.8 1.0 4.8 1.1 6th hour 3.9 0.9 4.3 0.9 12th hour 3.2 0.9 3.6 0.8 18th hour 2.6 1.0 3.0 1.1 24th hour 2.1 0.7 2.7 1.1 Blood Lactate Levels MY CLINIC’S EXPERIENCE
- 50. MY CLINIC’S EXPERIENCE • Significant decrease s in lactate levels on targeted temperature times (6th hours) were associated with good outcomes of neurological status (CPC 1 and CPC 2)
- 51. SUMMARY POST RESUSCITATION SYNDROME is a problem caused by ishemia-reperfusion injury after CPR Besides “Intensive Care” protocols, THERAEPEUTIC HYPOTHERMIA is one of the best strategy for PRS TH does not only improve neurologic outcome but also helps to cure other organ functions LACTATE is recommended to follow up as a biomarker of good neurologic outcome during TH for PRS
- 52. AT THE END OF THE WORDS… THE TEAM OF CPR AND PRS GETS UP ON STAGE…
- 53. “I’m afraid you’ll have to go back down. You’ve been resuscitated….”