emerging therapies after cardiac arrest · emerging therapies after cardiac arrest cccf october...

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