Effect of neuromonitor-guided titrated care on brain tissue hypoxia after opioid overdose cardiac arrest. (August 2018)

• Record Type: Journal Article
• Authors: Elmer, Jonathan; Flickinger, Katharyn L.; Anderson, Maighdlin W.; Koller, Allison C.; Sundermann, Matthew L.; Dezfulian, Cameron; Okonkwo, David O.; Shutter, Lori A.; Salcido, David D.; Callaway, Clifton W.; Menegazzi, James J.
• Is Part Of: Resuscitation. Volume 129(2018)
• Page Start: 121
• Page End: 126
• Publication Date: 2018-08
• Subjects: Cardiac arrest -- Resuscitation -- Critical care -- Neuromonitoring -- Precision medicine; Resuscitation -- Periodicals; Resuscitation -- Periodicals; Réanimation -- Périodiques; Electronic journals; 616.025
• DOI: 10.1016/j.resuscitation.2018.04.013
• Languages: English
• ISSNs: 0300-9572

Abstract

Abstract: Introduction: Brain tissue hypoxia may contribute to preventable secondary brain injury after cardiac arrest. We developed a porcine model of opioid overdose cardiac arrest and post-arrest care including invasive, multimodal neurological monitoring of regional brain physiology. We hypothesized brain tissue hypoxia is common with usual post-arrest care and can be prevented by modifying mean arterial pressure (MAP) and arterial oxygen concentration (PaO2 ). Methods: We induced opioid overdose and cardiac arrest in sixteen swine, attempted resuscitation after 9 min of apnea, and randomized resuscitated animals to three alternating 6-h blocks of standard or titrated care. We invasively monitored physiological parameters including brain tissue oxygen (PbtO2 ). During standard care blocks, we maintained MAP > 65 mmHg and oxygen saturation 94–98%. During titrated care, we targeted PbtO2 > 20 mmHg. Results: Overall, 10 animals (63%) achieved ROSC after a median of 12.4 min (range 10.8–21.5 min). PbtO2 was higher during titrated care than standard care blocks (unadjusted β = 0.60, 95% confidence interval (CI) 0.42–0.78, P < 0.001). In an adjusted model controlling for MAP, vasopressors, sedation, and block sequence, PbtO2 remained higher during titrated care (adjusted β = 0.75, 95%CI 0.43–1.06, P < 0.001). At three predetermined thresholds, brain tissue hypoxia was significantly less common during titrated care blocks (44 vs 2% of the block duration spent below 20 mmHg, P < 0.001; 21 vs 0% below 15 mmHg, P < 0.001; and, 7 vs 0% below 10 mmHg, P = .01). Conclusions: In this model of opioid overdose cardiac arrest, brain tissue hypoxia is common and treatable. Further work will elucidate best strategies and impact of titrated care on functional outcomes.