Abstract
BackgroundIn current guidelines, prolonged cardiopulmonary resuscitation (CPR) mandates administration of repeated intravenous epinephrine (EPI) doses. This porcine study simulating a prolonged CPR-situation in the coronary catheterisation laboratory, explores the effect of EPI-administrations on coronary perfusion pressure (CPP), continuous coronary artery flow average peak velocity (APV) and amplitude spectrum area (AMSA).MethodsThirty-six pigs were randomized 1:1:1 to EPI 0.02 mg/kg/dose, EPI 0.03 mg/kg/dose or saline (control) in an experimental cardiac arrest (CA) model. During 15 minutes of mechanical chest compressions, four EPI/saline-injections were administered, and the effect on CPP, APV and AMSA were recorded. Comparisons were performed between the control and the two EPI-groups and a combination of the two EPI-groups, EPI-all.ResultCompared to the control group, maximum peak of CPP (Pmax) after injection 1 and 2 was significantly increased in the EPI-all group (p = 0.022, p = 0.016), in EPI 0.02-group after injection 2 and 3 (p = 0.023, p = 0.027) and in EPI 0.03-group after injection 1 (p = 0.013). At Pmax, APV increased only after first injection in both the EPI-all and the EPI 0.03-group compared with the control group (p = 0.011, p = 0.018). There was no statistical difference of AMSA at any Pmax. Seven out of 12 animals (58%) in each EPI-group versus 10 out of 12 (83%) achieved spontaneous circulation after CA.ConclusionIn an experimental CA-CPR pig model repeated doses of intravenous EPI results in a significant increase in APV only after the first injection despite increments in CPP also during the following 2 injections indicating inappropriate changes in coronary vascular resistance during subsequent EPI administration.
Highlights
In current guidelines, prolonged cardiopulmonary resuscitation (CPR) mandates administration of repeated intravenous epinephrine (EPI) doses
The increased frequency of return of spontaneous circulation (ROSC) does not convey improvements in discharge from hospital in good neurological condition or long term survival [4,7,8]. Both experimental and clinical studies have shown a higher frequency of ROSC when the coronary perfusion pressure (CPP) can be brought to a level > 15 mmHg before defibrillation during CPR-treatment [9,10,11,12,13]. Both increments in CPP and myocardial creatine phosphate are associated with altered ventricular fibrillation (VF) wavelets that in turn increase the possibility of a successful CPR
Amplitude spectrum area (AMSA) represents a quantitative combined measure of the electrical activity of VF wavelets, that seems to be a predictor of defibrillation success [15] and other experimental studies have shown a correlation between CPP, amplitude spectrum area (AMSA), and defibrillation success [13,16]
Summary
In current guidelines, prolonged cardiopulmonary resuscitation (CPR) mandates administration of repeated intravenous epinephrine (EPI) doses This porcine study simulating a prolonged CPR-situation in the coronary catheterisation laboratory, explores the effect of EPI-administrations on coronary perfusion pressure (CPP), continuous coronary artery flow average peak velocity (APV) and amplitude spectrum area (AMSA). Several clinical studies and randomized trials have reported an increased frequency of return of spontaneous circulation (ROSC) in Both experimental and clinical studies have shown a higher frequency of ROSC when the coronary perfusion pressure (CPP) can be brought to a level > 15 mmHg before defibrillation during CPR-treatment [9,10,11,12,13]. A Doppler flow wire can be used to measure coronary blood flow in patients with a stable circulation [17,18,19], and experimentally a good correlation has been demonstrated between CPP and the average blood flow (APV) in a coronary vessel assessed by a Doppler flow wire during mechanical chest compressions (MCC) [20]
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