Ken Arima

Cardiopulmonary cerebral resuscitation using emergency cardiopulmonary bypass, coronary reperfusion therapy and mild hypothermia in patients with cardiac arrest outside the hospital

OBJECTIVESnThe purpose of this study was to evaluate the efficacy of an alternative cardiopulmonary cerebral resuscitation (CPCR) using emergency cardiopulmonary bypass (CPB), coronary reperfusion therapy and mild hypothermia.nnnBACKGROUNDnGood recovery of patients with out-of-hospital cardiac arrest is still inadequate. An alternative therapeutic method for patients who do not respond to conventional CPCR is required.nnnMETHODSnA prospective preliminary study was performed in 50 patients with out-of-hospital cardiac arrest meeting the inclusion criteria. Patients were treated with standard CPCR and, if there was no response, by emergency CPB plus intra-aortic balloon pumping. Immediate coronary angiography for coronary reperfusion therapy was performed in patients with suspected acute coronary syndrome. Subsequently, in patients with systolic blood pressure above 90 mm Hg and Glasgow coma scale score of 3 to 5, mild hypothermia (34 C for at least two days) was induced by coil cooling. Neurologic outcome was assessed by cerebral performance categories at hospital discharge.nnnRESULTSnThirty-six of the 50 patients were treated with emergency CPB, and 30 of 39 patients who underwent angiography suffered acute coronary artery occlusion. Return of spontaneous circulation and successful coronary reperfusion were achieved in 92% and 87%, respectively. Mild hypothermia could be induced in 23 patients, and 12 (52%) of them showed good recovery. Factors related to a good recovery were cardiac index in hypothermia and the presence of serious complications with hypothermia or CPB.nnnCONCLUSIONSnThe alternative CPCR demonstrated an improvement in the incidence of good recovery. Based upon these findings, randomized studies of this hypothermia are needed.

New Hypothermia Method Using Blood Cooling System: MONAN and KANEM Method

The main method for brain hypothermia today is surface cooling using cooling blankets. However, surface cooling has posed a problem that requires a complicated technique and manpower for controlling the core temperature of hypothermia. We have devised a blood circuit for continuous hemodiafiltration and produced and used clinically two new blood cooling systems (MONAN and KANEM methods). Compared with surface cooling, these blood cooling systems have made it easy to control the core temperature during the periods of induction, cooling, and rewarming without being influenced by the patient’s body form. Moreover, postural drainage for preventing pulmonary infections, which were severe complications of hypothermia, is possible without use of a particular kinetic bed. Furthermore, it is possible improve the abnormal electrolytes seen with hypothermia, particularly hyperkalemia, at rewarming, by removing the humoral mediator that increases and courses the systemic inflammatory response syndrome. Based on our results, it is suggested that a blood cooling system using the MONAN and KANEM method is a useful technique for instituting brain hypothermia.

Mild Hypothermia for Cerebral Resuscitation in Survivors of Out-of­ Hospital Ventricular Fibrillation

As emergency and intensive care medicine progresses, brain hypothermia is attracting attention as a therapeutic method that overcomes the hmitations of cerebral protection and resuscitation. We conducted a preliminary study by preparing a protocol of mild hypothermia by coil cooling at 34°C in patients who returned to spontaneous circulation via standard advanced cardiac life support and had experienced out-of-hospital ventricular fibrillation (VF) due to suspected cardiac arrest. Primary endpoints were survival at hospital discharge and good recovery using the Glasgow Outcome Scale. This study was performed in 15 patients meeting the inclusion criteria of mild hypothermia. The average core temperature during mild hypothermia at the cooling stage was 34.4°C, and the average duration was 83.9h. Survival rate at hospital discharge was 80%, and the good recovery rate was 67%. Multivariate analysis revealed that systemic oxygen delivery at the cooling stage was an indepedent predictor of good recovery. In conclusion, brain hypothermia (at a temperature of 34°C for 3 days and by coil cooling) in comatose survivors with out-of-hospital VF may have improved the outcome.