52: Brain Freeze- Selective Retrograde Cerebral Perfusion for Intra-Arrest Neuroprotection

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We've all heard of therapeutic hypothermia.  Some of us have heard of deep hypothermia for traumatic arrest.  But what about deep regional hypothermia of brain for cardiac arrest!  Zack interviewed Rob Schultz, a CT surgeon resident from Calgary who is doing research on deep hypothermia of the brain using some of the tactics that are utilized in operating room.  His stuff is mind blowing!

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Milewski RK, Pacini D, Moser GW, et al. Retrograde and Antegrade Cerebral Perfusion: Results in Short Elective Arch Reconstructive Times. The Annals of Thoracic Surgery. 2010;89(5):1448-1457. doi:10.1016/j.athoracsur.2010.01.056
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Keeling WB, Leshnower BG, Hunting JC, Binongo J, Chen EP. Hypothermia and Selective Antegrade Cerebral Perfusion Is Safe for Arch Repair in Type A Dissection. The Annals of Thoracic Surgery. 2017;104(3):767-772. doi:10.1016/j.athoracsur.2017.02.066
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Papadopoulos N, Risteski P, Hack T, et al. Is More than One Hour of Selective Antegrade Cerebral Perfusion in Moderate-to-Mild Systemic Hypothermic Circulatory Arrest for Surgery of Acute Type A Aortic Dissection Safe? Thorac cardiovasc Surg. 2017;66(03):215-221. doi:10.1055/s-0037-1604451
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Perreas K, Samanidis G, Thanopoulos A, et al. Antegrade or Retrograde Cerebral Perfusion in Ascending Aorta and Hemiarch Surgery? A Propensity-Matched Analysis. The Annals of Thoracic Surgery. 2016;101(1):146-152. doi:10.1016/j.athoracsur.2015.06.029
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McCullough J, Zhang N, Reich D, et al. Cerebral metabolic suppression during hypothermic circulatory arrest in humans. Ann Thorac Surg. 1999;67(6):1895-1899; discussion 1919-21. [PubMed]
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Yan T, Bannon P, Bavaria J, et al. Consensus on hypothermia in aortic arch surgery. Ann Cardiothorac Surg. 2013;2(2):163-168. [PubMed]

EDECMO 29 – ECMO in Hypothermic Cardiac Arrest – with Torvind Naesheim of Norway

Torvind Næsheim

 

 

University of North Norway, Tromso

University of North Norway, Tromso

University Hospital of North Norway:

  • located at 69 degrees North latitude – likely the northernmost ECMO center in the world.
  • The warmest month is July with a mean air temperature of 11.8C and mean sea temperature of 10.8 C.
  • The coldest month is January with a mean air temperature of -4.4 C and mean sea temperature of 5.1 C.
  • ECMO program since 1988
  • Yearly ECMO volume is approx 20 per year – including postcardiotomy support, ECPR, cardiogenic shock and respiratory failure
  • ECMO Retrieval Ambulance service: Since 12/2015: 5 ECMO transports
  • Cases are reported through the ELSO registry

Accidental Hypothermia – some definitions:
mild : 32-35 C – preserved capability to maintain core temperature through compensating thermoregulatory mechanisms
Moderate: 28-32 – loss of ability to sustain temperature via either voluntary or autonomic means
Severe: 20-28 – high risk of malignant arrhythmias
Profound: <20 Asystole

The Paper: Hilmo, J et al. Prolonged resuscitation is warranted in arrested hypothermic victims also in remote areas – A retrospective study from northern Norway. Resuscitation , Volume 85 , Issue 9 , 1204 – 1211

  • “Nobody is dead until warm and dead”
  • retrospective study looking at accidental hypothermia victims with cardiac arrest admitted to UNN between 1985-2013
  • no survivors prior to 1999
  • 1999-2013: 9/24 (37.5%) survival, defined as alive at 1 year – most with a ‘favorable' neurologic outcome
  • PRIOR studies suggested that asphyxiation, either via snow burial (avalance) or water submersion had a lower chance of survival, but this study suggests that hypothermic arrest during submersion injury may be very different. It is hypothesized that very cold temps create faster cooling rates and aspiration of cold water may induce rapid protective cerebral hypothermia. So drowning victims (asphyxia by submersion in cold water may have a higher survival)
  • Hyperkalemia is bad (>8 is bad; >12 is dead)
  • Bottom Line: “No patient is dead until they are warm and dead” – current neuroprognostication can't identify OHCA patients who may be salvageable.  So assume they are!

Key ECMO Points:

  1. Profoundly hypothermic patients cannot generate high flow rates – possibly due to increase blood viscosity.  Consider larger cannulae. Torvinde uses 29F venous and 21F arterial as a starting point.
  2. Rewarm with a veno-arterial temperature gradient of no more than 10 degrees C. Faster rewarming may result in bubble formation. Torvinde does this via the water bath heater/cooler.
  3. Therapeutic hypothermia is still in play. Torvinde holds the core temp at 36 for 24-28 hours.
  4. “You're not dead unless you're warm and dead” – consider transporting potentially salvageable patients with a reliable history.

Torvind and AnnaThe Story of Anna Bågenholm was told in this article in the Lancet:

Torvinde