emerging therapies after cardiac arrest · emerging therapies after cardiac arrest cccf october...
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Emerging therapies after cardiac arrest
CCCFOctober 4th, 2017
Myp Sekhon MD FRCPCClinical Assistant ProfessorDivision of Critical Care MedicineUniversity of British Columbia
“Beyond temperature control”
Disclosures
Disclosures Evidence Based Medicine
Disclosures Evidence Based Medicine
Disclosures Evidence Based Medicine
Cardiac arrest
Cardiac arrest
Cardiac Arrest is NOT a heart problem
Cardiac arrest
Cardiac Arrest is a brain problem
Cardiac arrest
Hypoxic ischemic brain injury
Secondary Injury Occurs after return of spontaneous circulation
Hallmark – neuron hypoxia / ischemia
No inherent energy stores in neural tissue
Cell energy supply / utilization mismatch
Cell death (necrosis, apoptosis etc)
CORNERSTONE of HIBI Critical Care Management
Secondary Injury
Secondary Injury
Management Approach to HIBI management?
Management
Cerebral oxygen delivery
Cerebral oxygen utilization
HIBI Management ParadigmPrevention of Secondary Injury
Cerebral oxygen delivery
Cerebral oxygen utilization
HIBI Management ParadigmPrevention of Secondary Injury
Management
CDO2 = CBF x O2 content
Cerebral Perfusion Pressure Hemoglobin concentration
Mean arterial pressure
Carbon dioxide
Cerebral Oxygen DeliveryPrevention of Secondary Injury
Management
CDO2 = CBF x O2 content
Cerebral Perfusion Pressure Hemoglobin concentration
Cerebral Oxygen DeliveryPrevention of Secondary Injury
Mean arterial pressure
Carbon dioxide
Management
Managementa) Blood Pressureb) Carbon Dioxidec) Hemoglobin
What is the optimal mean arterial pressure to
perfuse the brain in hypoxic ischemic brain injury?
1
Managementa) Blood Pressureb) Carbon Dioxidec) Hemoglobin
Managementa) Blood Pressureb) Carbon Dioxidec) Hemoglobin
Evidence Based MedicineManagement
a) Blood Pressureb) Carbon Dioxidec) Hemoglobin
Managementa) Blood Pressureb) Carbon Dioxidec) Hemoglobin
Managementa) Blood Pressureb) Carbon Dioxidec) Hemoglobin
Managementa) Blood Pressureb) Carbon Dioxidec) Hemoglobin
Managementa) Blood Pressureb) Carbon Dioxidec) Hemoglobin
Managementa) Blood Pressureb) Carbon Dioxidec) Hemoglobin
EvidenceBasedMedicine
Managementa) Blood Pressureb) Carbon Dioxidec) Hemoglobin
Primary Injury
Secondary Injury
a) Blood Pressure
b) Carbon Dioxide
c) Hemoglobin
Mean arterial pressure and parenchymal brain oxygenation
MAP
PbO2
90
20
Primary Injury
Secondary Injury
a) Blood Pressure
b) Carbon Dioxide
c) Hemoglobin
Mean arterial pressure and parenchymal brain oxygenation
MAP
PbO2
ICP
100
40
20
CPP
PbO2
90
60
20
Primary Injury
Secondary Injury
a) Blood Pressure
b) Carbon Dioxide
c) Hemoglobin
Primary Injury
Secondary Injury
a) Blood Pressure
b) Carbon Dioxide
c) Hemoglobin
Primary Injury
Secondary Injury
a) Blood Pressure
b) Carbon Dioxide
c) Hemoglobin
Mean arterial pressure and jugular bulb oximetry
MAP
SjO2
80
50
70
60
MAP
SjO2
80
50
70
60
Decreasing MAP Decreasing CDO2 Increased O2 uptake
Managementa) Blood Pressureb) Carbon Dioxidec) Hemoglobin
What is the optimal carbon dioxide in hypoxic
ischemic brain injury?
2
Managementa) Blood Pressureb) Carbon Dioxidec) Hemoglobin
Managementa) Blood Pressureb) Carbon Dioxidec) Hemoglobin
Managementa) Blood Pressureb) Carbon Dioxidec) Hemoglobin
Managementa) Blood Pressureb) Carbon Dioxidec) Hemoglobin
35 - 45 < 35> 45
PaCO2 (mmHg)
Managementa) Blood Pressureb) Carbon Dioxidec) Hemoglobin
EvidenceBasedMedicine
Managementa) Blood Pressureb) Carbon Dioxidec) Hemoglobin
Hypocapnia Vasoconstriction Decreased ICP
Managementa) Blood Pressureb) Carbon Dioxidec) Hemoglobin
Brain hypoxia Hypocapnia Vasoconstriction
Managementa) Blood Pressureb) Carbon Dioxidec) Hemoglobin
Hypercapnia Vasodilation Increased ICP
Managementa) Blood Pressureb) Carbon Dioxidec) Hemoglobin
What is the optimal hemoglobin in hypoxic
ischemic brain injury?
3
Managementa) Blood Pressureb) Carbon Dioxidec) Hemoglobin
Managementa) Blood Pressureb) Carbon Dioxidec) Hemoglobin
Managementa) Blood Pressureb) Carbon Dioxidec) Hemoglobin
Managementa) Blood Pressureb) Carbon Dioxidec) Hemoglobin
Managementa) Blood Pressureb) Carbon Dioxidec) Hemoglobin
EvidenceBasedMedicine
Managementa) Blood Pressureb) Carbon Dioxidec) Hemoglobin
PbO2 Increases post transfusion(Hb – 87 g/L)
RBC Transfusion (Hb = 75 g/L)
Managementa) Blood Pressureb) Carbon Dioxidec) Hemoglobin
MAP
ICP
PRx
PbO2
100
20
20
Hypoxic ischemic brain injury is the major determinant of outcome after cardiac arrest
Pathophysiology Primary injury
Secondary injury
Cornerstone of management
Management of HIBI Mean arterial pressure
Carbon dioxide
Hemoglobin
Summary
Summary
Acknowledgements
Dr. Donald Griesdale
Vancouver General Hospital ICU / Neurocritical Care Program
University of Cambridge Neurosciences Group Professors David Menon / Arun Gupta
Dr. Chiara Robba
CBF
MAP
25 50 75 100 125 150 175
25
50
75
100
HIBI
1. Stroke 2001; 32: 128–322. Acta Anaesthesiol Scand 1996;40:1149
Zone of autoregulation
Primary Injury
Secondary Injury
a) Blood Pressure
b) Carbon Dioxide
c) Hemoglobin
Individualized perfusion targets - autoregulation
CBF
MAP
25 50 75 100 125 150 175
25
50
75
100
HIBI
rSO2 (%)
50
60
70
80
1. Neurocrit Care 2009;10:1222. Stroke 2010;41:93. Stroke 2009;40:1820
Cerebral Oximetry
(rSO2)
Primary Injury
Secondary Injury
a) Blood Pressure
b) Carbon Dioxide
c) Hemoglobin
CBF
MAP
25 50 75 100 125 150 175
25
50
75
100
1. Stroke 2007;38:2818
rSO2 (%)
50
60
70
80COx
Cerebral Oximetry
(rSO2)
Primary Injury
Secondary Injury
a) Blood Pressure
b) Carbon Dioxide
c) Hemoglobin
MAP
25 50 75 100 125 150 175
-0.5
0
0.5
1.0
rSO2 (%)
50
60
70
80
COx
MAPOPT
Autoregulation monitor –Indirect Measure of CBF
Primary Injury
Secondary Injury
a) Blood Pressure
b) Carbon Dioxide
c) Hemoglobin
INVOS Cerebral oximter
ICM+ Software (Cambridge)
rSO2
MAP
COx
Primary Injury
Secondary Injury
a) Blood Pressure
b) Carbon Dioxide
c) Hemoglobin
Primary Injury
Secondary Injury
a) Blood Pressure
b) Carbon Dioxide
c) Hemoglobin
Primary Injury
Secondary Injury
a) Blood Pressure
b) Carbon Dioxide
c) Hemoglobin
Primary Injury
Secondary Injury
a) Blood Pressure
b) Carbon Dioxide
c) Hemoglobin
Primary Injury
Secondary Injury
a) Blood Pressure
b) Carbon Dioxide
c) Hemoglobin