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  • 1.
    Basu, Samar
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Mutschler, Diana K.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Larsson, Anders O.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences.
    Kiiski, Ritva
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Nordgren, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Eriksson, Mats
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Propofol (Diprivan-EDTA) counteracts oxidative injury and deterioration of the arterial oxygen tension during experimental septic shock2001In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 50, no 3, p. 341-348Article in journal (Refereed)
    Abstract [en]

    PURPOSE: Human septic shock can be replicated in the endotoxaemic pig. Endotoxaemia causes a multitude of events, including reduced PaO(2) and increased lipid peroxidation. This study was designed to evaluate the possible effects of a commonly used anaesthetic drug with known antioxidant properties (propofol) during porcine endotoxaemia.

    METHODS: Ten pigs were anaesthetised and given a 6 h E. coli endotoxin infusion. The animals received, randomly, a supplementary continuous infusion of propofol emulsion (containing 0.005% EDTA) or the corresponding volume of vehicle (controls). Pathophysiologic responses were determined. Non-enzymatic (by measuring plasma 8-iso-PGF(2 alpha) and enzymatic (by measuring plasma 15-keto-dihydro-PGF(2 alpha)) lipid peroxidations were evaluated. Plasma levels of the endogenous antioxidants alpha- and gamma-tocopherols, were also analysed.

    RESULTS: Endotoxaemia increased plasma levels of 8-iso-PGF(2 alpha) (1st-4th h) and 15-keto-dihydro-PGF(2 alpha) (1st-4th h) significantly more in controls than in the propofol+endotoxin group. PaO(2) was significantly less affected by endotoxin in the propofol treated animals (2nd-4th h). Mean arterial pressure (4th-6th h) and systemic vascular resistance (6th h) were reduced significantly more by endotoxin among the propofol-treated animals. Vitamin E (alpha-tocopherol) increased in all animals, significantly more in the propofol+endotoxin group (1/2-6th h) than in the control group.

    CONCLUSIONS: Propofol reduced endotoxin-induced free radical mediated and cyclooxygenase catalysed lipid peroxidation significantly. The implication is that propofol counteracts endotoxin-induced deterioration of PaO(2).

  • 2.
    Blomberg, Hans
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Gedeborg, Rolf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm , UCR-Uppsala Clinical Research Center.
    Berglund, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm , UCR-Uppsala Clinical Research Center.
    Karlsten, Rolf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Johansson, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Poor chest compression quality with mechanical compressions in simulated cardiopulmonary resuscitation: A randomized, cross-over manikin study2011In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 82, no 10, p. 1332-1337Article in journal (Refereed)
    Abstract [en]

    Introduction: Mechanical chest compression devices are being implemented as an aid in cardiopulmonary resuscitation (CPR), despite lack of evidence of improved outcome. This manikin study evaluates the CPR-performance of ambulance crews, who had a mechanical chest compression device implemented in their routine clinical practice 8 months previously. The objectives were to evaluate time to first defibrillation, no-flow time, and estimate the quality of compressions. Methods: The performance of 21 ambulance crews (ambulance nurse and emergency medical technician) with the authorization to perform advanced life support was studied in an experimental, randomized cross-over study in a manikin setup. Each crew performed two identical CPR scenarios, with and without the aid of the mechanical compression device LUCAS. A computerized manikin was used for data sampling. Results: There were no substantial differences in time to first defibrillation or no-flow time until first defibrillation. However, the fraction of adequate compressions in relation to total compressions was remarkably low in LUCAS-CPR (58%) compared to manual CPR (88%) (95% confidence interval for the difference: 13-50%). Only 12 out of the 21 ambulance crews (57%) applied the mandatory stabilization strap on the LUCAS device. Conclusions: The use of a mechanical compression aid was not associated with substantial differences in time to first defibrillation or no-flow time in the early phase of CPR. However, constant but poor chest compressions due to failure in recognizing and correcting a malposition of the device may counteract a potential benefit of mechanical chest compressions. 

  • 3.
    Blomberg, Hans
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Johansson, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Reply to Letter: Technical factors weaken the clinical relevance of manikin measurements of mechanical chest compression depth2012In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 83, no 4, p. E99-E99Article in journal (Refereed)
  • 4. Castren, M.
    et al.
    Bohm, K.
    Kvam, A. M.
    Bovim, E.
    Christensene, E. F.
    Steen-Hansen, J. -E
    Karlsten, Rolf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Reporting of data from out-of-hospital cardiac arrest has to involve emergency medical dispatching: Taking the recommendations on reporting OHCA the Utstein style a step further2011In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 82, no 12, p. 1496-1500Article in journal (Refereed)
    Abstract [en]

    Objectives: As a part of the chain of survival, the emergency medical communication centre (EMCC) and the emergency medical dispatcher (EMD) has an important role in early identification of out-of-hospital cardiac arrests (OHCA). The EMD may provide instructions to the caller and thereby initiate cardiopulmonary resuscitation in a substantial number of subjects and thus contribute to increased survival. The EMCC provides a response with first responders, ambulances, physician manned units and potentially other health care providers. EMCC in many cases initiates the communication with experts in the referral hospital and provide added value to the post resuscitation care by providing advanced transport, logistics and follow up. In research there is a growing focus on the EMCC/EMDs impact on survival in OHCA. The lack of standards in reporting results from medical dispatching is an obstacle for thorough evaluation of results in this area and comparison of data. The objective for this paper is to introduce a framework for uniform reporting of the dispatching process for quality improvement, collecting and reporting data and exchanging information regarding OHCA.

  • 5. Castrén, M.
    et al.
    Karlsten, Rolf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Lippert, F.
    Christensen, E. F.
    Bovim, E.
    Kvam, A. M.
    Robertson-Steel, I.
    Overton, J.
    Kraft, T.
    Engerström, L.
    Garcia-Castrill Riego, L.
    Recommended guidelines for reporting on emergency medical dispatch when conducting research in emergency medicine: The Utstein style2008In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 79, no 2, p. 193-197Article in journal (Refereed)
    Abstract [en]

    Objectives: To establish a uniform framework describing the system and organisation of emergency medical response centres and the process of emergency medical dispatching (EMD) when reporting results from studies in emergency medicine and prehospital care. Design and results: In September 2005 a task force of 22 experts from 12 countries met in Stavanger; Norway at the Utstein Abbey to review data and establish a common terminology for medical dispatch centres including core and optional data to be used for health monitoring, benchmarking and future research.

  • 6.
    Covaciu, Lucian
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Allers, M.
    Enblad, Per
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurosurgery.
    Lunderquist, A.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Wieloch, T.
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Intranasal selective brain cooling in pigs2008In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 78, no 1, p. 83-88Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Special clinical situations where general hypothermia cannot be recommended but can be a useful treatment demand a new approach, selective brain cooling. The purpose of this study was to selectively cool the brain with cold saline circulating in balloon catheters introduced into the nasal cavity in pigs. MATERIAL AND METHODS: Twelve anaesthetised pigs were subjected to selective cerebral cooling for a period of 6 h. Cerebral temperature was lowered by means of bilaterally introduced nasal balloon catheters perfused with saline cooled by a heat exchanger to 8-10 degrees C. Brain temperature was measured in both cerebral hemispheres. Body temperature was measured in rectum, oesophagus and the right atrium. The pigs were normoventilated and haemodynamic variables were measured continuously. Acid-base and electrolyte status was measured hourly. RESULTS: Cerebral hypothermia was induced rapidly and within the first 20 min of cooling cerebral temperature was lowered from 38.1+/-0.6 degrees C by a mean of 2.8+/-0.6 to 35.3+/-0.6 degrees C. Cooling was maintained for 6 h and the final brain temperature was 34.7+/-0.9 degrees C. Concomitantly, the body temperature, as reflected by oesophageal temperature was decreased from 38.3+/-0.5 to 36.6+/-0.9 degrees C. No circulatory or metabolic disturbances were noted. CONCLUSIONS: Inducing selective brain hypothermia with cold saline via nasal balloon catheters can effectively be accomplished in pigs, with no major disturbances in systemic circulation or physiological variables. The temperature gradients between brain and body can be maintained for at least 6 h.

  • 7. Cronberg, Tobias
    et al.
    Brizzi, Marco
    Liedholm, Lars Johan
    Rosén, Ingmar
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Rylander, Christian
    Friberg, Hans
    Neurological prognostication after cardiac arrest: Recommendations from the Swedish Resuscitation Council2013In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 84, no 7, p. 867-872Article in journal (Refereed)
    Abstract [en]

    Cardiopulmonary resuscitation is started in 5000 victims of out-of-hospital cardiac arrest in Sweden each year and the survival rate is approximately 10%. The subsequent development of a global ischaemic brain injury is the major determinant of the neurological prognosis for those patients who reach the hospital alive. Induced hypothermia is a recommended treatment after cardiac arrest and has been implemented in most Swedish hospitals.

    Recent studies indicate that induced hypothermia may affect neurological prognostication and previous international recommendations are therefore no longer valid when hypothermia is applied. An expert group from the Swedish Resuscitation Council has reviewed the literature and made recommendations taking into account the effects of induced hypothermia and concomitant sedation.

    A delayed neurological evaluation at 72h after rewarming is recommended for hypothermia treated patients. This evaluation should be based on several independent methods and the possibility of lingering pharmacological effects should be considered.

  • 8. Esibov, Alexander
    et al.
    Banville, Isabelle
    Chapman, Fred W.
    Boomars, Rene
    Box, Martyn
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Mechanical chest compressions improved aspects of CPR in the LINC trial2015In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 91, p. 116-121Article in journal (Refereed)
    Abstract [en]

    Aim: We studied resuscitation process metrics in patients with out-of-hospital cardiac arrest enrolled in a randomized trial comparing one protocol designed to best use a mechanical CPR device, with another based on the 2005 European Resuscitation Council guidelines for manual CPR. Methods: We analyzed clinical data, ECG signals, and transthoracic impedance signals for a subset of the patients in the LUCAS in Cardiac Arrest (LINC) trial, including 124 patients randomized to mechanical and 82 to manual CPR. Chest compression fraction (CCF) was defined as the fraction of time during cardiac arrest that chest compressions were administered. Results: Patients in the mechanical CPR group had a higher CCF than those in the manual CPR group [0.84 (0.78, 0.91) vs. 0.79 (0.70, 0.86), p < 0.001]. The median duration of their pauses for defibrillation was also shorter [0 s (0, 6.0) vs. 10.0 s (7.0, 14.3), p < 0.001]. Compressions were interrupted for a median of 36.0 s to apply the compression device. There was no difference between groups in duration of the longest pause in compressions [32.5 s vs. 26.0 s, p = 0.24], number of compressions received per minute [86.5 vs. 88.3, p = 0.47], defibrillation success rate [73.2% vs. 81.0%, p = 0.15], or refibrillation rate [74% vs. 77%, p = 0.79]. Conclusions: A protocol using mechanical chest compression devices reduced interruptions in chest compressions, and enabled defibrillation during ongoing compressions, without adversely affecting other resuscitation process metrics. Future emphasis on optimizing device deployment may be beneficial.

  • 9. Faxén, Jonas
    et al.
    Hall, Marlous
    Gale, Chris P
    Sundström, Johan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology.
    Lindahl, Bertil
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, UCR-Uppsala Clinical Research Center.
    Jernberg, Tomas
    Szummer, Karolina
    A user-friendly risk-score for predicting in-hospital cardiac arrest among patients admitted with suspected non ST-elevation acute coronary syndrome - The SAFER-score2017In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 121, p. 41-48Article in journal (Refereed)
    Abstract [en]

    AIM: To develop a simple risk-score model for predicting in-hospital cardiac arrest (CA) among patients hospitalized with suspected non-ST elevation acute coronary syndrome (NSTE-ACS).

    METHODS: Using the Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART), we identified patients (n=242 303) admitted with suspected NSTE-ACS between 2008 and 2014. Logistic regression was used to assess the association between 26 candidate variables and in-hospital CA. A risk-score model was developed and validated using a temporal cohort (n=126 073) comprising patients from SWEDEHEART between 2005 and 2007 and an external cohort (n=276 109) comprising patients from the Myocardial Ischaemia National Audit Project (MINAP) between 2008 and 2013.

    RESULTS: The incidence of in-hospital CA for NSTE-ACS and non-ACS was lower in the SWEDEHEART-derivation cohort than in MINAP (1.3% and 0.5% vs. 2.3% and 2.3%). A seven point, five variable risk score (age ≥60 years (1 point), ST-T abnormalities (2 points), Killip Class >1 (1 point), heart rate <50 or ≥100bpm (1 point), and systolic blood pressure <100mmHg (2 points) was developed. Model discrimination was good in the derivation cohort (c-statistic 0.72) and temporal validation cohort (c-statistic 0.74), and calibration was reasonable with a tendency towards overestimation of risk with a higher sum of score points. External validation showed moderate discrimination (c-statistic 0.65) and calibration showed a general underestimation of predicted risk.

    CONCLUSIONS: A simple points score containing five variables readily available on admission predicts in-hospital CA for patients with suspected NSTE-ACS.

  • 10.
    Gagnon, David J.
    et al.
    Maine Med Ctr, Dept Pharm, Portland, ME, USA.
    Nielsen, Niklas
    Helsingborg Hosp, Dept Anesthesia & Intens Care, Helsingborg, Sweden.
    Fraser, Gilles L.
    Maine Med Ctr, Dept Pharm, Portland, ME 04102 USA.;Maine Med Ctr, Dept Crit Care Serv, Portland, ME 04102 USA..
    Riker, Richard R.
    Maine Med Ctr, Dept Crit Care Serv, Portland, ME 04102 USA.;Maine Med Ctr, Neurosci Inst, Portland, ME 04102 USA.;Maine Med Ctr, Div Pulm Med, Portland, ME 04102 USA..
    Dziodzio, John
    Maine Med Ctr, Dept Crit Care Serv, Portland, ME 04102 USA..
    Sunde, Kjetil
    Oslo Univ Hosp Ulleval, Dept Anesthesiol, Div Emergencies & Crit Care, Oslo, Norway..
    Hovdenes, Jan
    Natl Hosp Norway, Oslo Univ Hosp, Dept Anesthesiol, Div Emergencies & Crit Care, Oslo, Norway..
    Stammet, Pascal
    Ctr Hosp Luxembourg, Dept Anesthesia & Intens Care, Luxembourg, Luxembourg..
    Friberg, Hans
    Lund Univ, Dept Clin Sci, Lund, Sweden..
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Wanscher, Michael
    Rigshosp, Copenhagen Univ Hosp, Dept Cardiothorac Anesthesia, DK-2100 Copenhagen, Denmark..
    Seder, David B.
    Maine Med Ctr, Dept Crit Care Serv, Portland, ME 04102 USA.;Maine Med Ctr, Neurosci Inst, Portland, ME 04102 USA.;Maine Med Ctr, Div Pulm Med, Portland, ME 04102 USA..
    Prophylactic antibiotics are associated with a lower incidence of pneumonia in cardiac arrest survivors treated with targeted temperature management2015In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 92, p. 154-159Article in journal (Refereed)
    Abstract [en]

    Introduction: Prophylactic antibiotics (PRO) reduce the incidence of early-onset pneumonia in comatose patients with structural brain injury, but have not been examined in cardiac arrest survivors undergoing targeted temperature management (TTM). We investigated the effect of PRO on the development of pneumonia in that population. Methods: We conducted a retrospective cohort study comparing patients treated with PRO to those not receiving PRO (no-PRO) using Northern Hypothermia Network registry data. Cardiac arrest survivors >= 18 years of age with a GCS < 8 at hospital admission and treated with TTM at 32-34 degrees C were enrolled in the registry. Differences were analyzed in univariate analyses and with logistic regression models to evaluate independent associations of clinical factors with incidence of pneumonia and good functional outcome. Results: 416 of 1240 patients (33.5%) received PRO. Groups were similar in age, gender, arrest location, initial rhythm, and time from collapse to return of spontaneous circulation. PRO patients had less pneumonia (12.6% vs. 54.9%, p < 0.001) and less sepsis (1.2 vs. 5.7%, p < 0.001) compared to no-PRO patients. ICU length of stay (98 vs. 100 h, p = 0.2) and incidence of a good functional outcome (41.1 vs. 36.6%, p = 0.19) were similar between groups. Backwards stepwise logistic regression demonstrated PRO were independently associated with a lower incidence of pneumonia (OR 0.09, 95% 0.06-0.14, p < 0.001) and a similar incidence of good functional outcome. Conclusions: Prophylactic antibiotics were associated with a reduced incidence of pneumonia but a similar rate of good functional outcome.

  • 11.
    Gedeborg, Rolf
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, UCR-Uppsala Clinical Research Center.
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Wiklund, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Improved haemodynamics and restoration of spontaneous circulation with constant aortic occlusion during experimental cardiopulmonary resuscitation.1999In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 40, no 3, p. 171-180Article in journal (Refereed)
    Abstract [en]

    Continuous balloon occlusion of the descending aorta is an experimental method that may improve blood flow to the myocardium and the brain during cardiopulmonary resuscitation (CPR). The aim of the present investigation was to evaluate the effects of this intervention on haemodynamics and the frequency of restoration of spontaneous circulation. Ventricular fibrillation was induced in 39 anaesthetised piglets, followed by an 8-min non-intervention interval. In a haemodynamic study (n = 10), closed chest CPR was performed for 7 min before the intra-aortic balloon was inflated. This intervention increased mean arterial blood pressure by 20%, reduced cardiac output by 33%, increased coronary artery blood flow by 86%, and increased common carotid artery blood flow by 62%. All these changes were statistically significant. Administration of epinephrine further increased mean arterial blood pressure and coronary artery blood flow, while cardiac output and common carotid artery blood flow decreased. In a study of short-term survival, nine out of 13 animals (69%) in the balloon group and in three out of 13 animals (23%) in the control group had spontaneous circulation restored. The difference between these two proportions was 0.46, which was statistically significant with a 95% confidence interval from 0.12 to 0.80. In conclusion, balloon occlusion of the descending aorta increased coronary and common carotid artery blood flow and the frequency of restoration of spontaneous circulation. It was also noted that epinephrine appears to augment the redistribution of blood flow caused by the aortic occlusion.

  • 12.
    Gedeborg, Rolf
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, UCR-Uppsala Clinical Research Center.
    Silander, H C
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Wiklund, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Cerebral ischaemia in experimental cardiopulmonary resuscitation--comparison of epinephrine and aortic occlusion.2001In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 50, no 3, p. 319-29Article in journal (Refereed)
    Abstract [en]

    The apparent inability of epinephrine to improve outcome after cardiopulmonary resuscitation (CPR) could be caused by direct negative effects on the cerebral circulation. Constant aortic occlusion with a balloon catheter could be an alternative way to improve coronary and cerebral perfusion during CPR. The objective of the present study was to compare the effects of standard-dose epinephrine with balloon occlusion of the descending aorta on cortical cerebral blood flow augmentation during CPR. Ventricular fibrillation was induced in 24 anaesthetised piglets. A non-intervention interval of 9 min was followed by open-chest CPR. The animals were randomised to receive repeated intravenous bolus doses of epinephrine 20 microg/kg or balloon occlusion of the descending aorta. Focal cortical cerebral blood flow was measured continuously using laser-Doppler flowmetry. Balloon occlusion of the aorta resulted in a significantly higher mean cortical cerebral blood flow and a lower cerebral oxygen extraction ratio than epinephrine during CPR. After restoration of spontaneous circulation the cerebral perfusion appeared compromised to the same extent in both groups, with lower blood flow compared to baseline, high cerebral oxygen extraction and cerebral tissue acidosis. No difference in cerebral cortical vascular resistance between the two groups could be detected. It is concluded that aortic balloon occlusion was superior to epinephrine in cerebral blood flow augmentation during resuscitation and did not generate adverse effects on cerebral blood flow, oxygenation or tissue pH after restoration of spontaneous circulation. No evidence of cerebral vasoconstriction induced by standard-dose epinephrine was found.

  • 13.
    Hardig, Bjarne Madsen
    et al.
    Physio Control, Lund, Sweden..
    Lindgren, Erik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Östlund, Ollie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, UCR-Uppsala Clinical Research Center.
    Herlitz, Johan
    Univ Boras, Prehosp Res Ctr Western Sweden, Res Ctr PreHospen, Sch Hlth Sci, Boras, Sweden..
    Karlsten, Rolf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Outcome among VF/VT patients in the LINC (LUCAS IN cardiac arrest) trial-A randomised, controlled trial2017In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 115, p. 155-162Article in journal (Refereed)
    Abstract [en]

    Introduction: The LINC trial evaluated two ALS-CPR algorithms for OHCA patients, consisting of 3 min' mechanical chest compression (LUCAS) cycles with defibrillation attempt through compressions vs. 2 min' manual compressions with compression pause for defibrillation. The PARAMEDIC trial, using 2 min' algorithm found worse outcome for patients with initial VF/VT in the LUCAS group and they received more adrenalin compared to the manual group. We wanted to evaluate if these algorithms had any outcome effect for patients still in VF/VT after the initial defibrillation and how adrenalin timing impacted it. Method: Both groups received manual chest compressions first. Based on non-electronic CPR process documentation, outcome, neurologic status and its relation to CPR duration prior to the first detected return of spontaneous circulation (ROSC), time to defibrillation and adrenalin given were analysed in the subgroup of VF/VT patients. Results: Seven hundred and fifty-seven patients had still VF/VT after initial chest compressions combined with a defibrillation attempt (374 received mechanical CPR) or not (383 received manual CPR). No differences were found for ROSC (mechanical CPR 58.3% vs. manual CPR 58.6%, p = 0.94), or 6-month survival with good neurologic outcome (mechanical CPR 25.1% vs. manual CPR 23.0%, p = 0.50). A significant difference was found regarding the time from start of manual chest compression to the first defibrillation (mechanical CPR: 4 (2-5) min vs manual CPR 3 (2-4) min, P < 0.001). The time from the start of manual chest compressions to ROSC was longer in the mechanical CPR group. Conclusions: No difference in short-or long-term outcomes was found between the 2 algorithms for patients still in VF/VT after the initial defibrillation. The time to the 1st defibrillation and the interval between defibrillations were longer in the mechanical CPR group without impacting the overall outcome. The number of defibrillations required to achieve ROSC or adrenalin doses did not differ between the groups.

  • 14. Hellevuo, Heidi
    et al.
    Sainio, Marko
    Nevalainen, Riikka
    Huhtala, Heini
    Olkkola, Klaus T.
    Tenhunen, Jyrki
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Hoppu, Sanna
    Deeper chest compression - More complications for cardiac arrest patients?2013In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 84, no 6, p. 760-765Article in journal (Refereed)
    Abstract [en]

    Aim of the study: Sternal and rib fractures are frequent complications caused by chest compressions during cardiopulmonary resuscitation (CPR). This study aimed to investigate the potential association of CPR-related thoracic and abdominal injuries and compression depth measured with an accelerometer. Methods: We analysed the autopsy records, CT scans or chest radiographs of 170 adult patients, suffering in-hospital cardiac arrest at the Tampere University Hospital during the period 2009-2011 to investigate possible association of chest compressions and iatrogenic injuries. The quality of manual compressions during CPR was recorded on a Philips, HeartStart MRx Q-CPR (TM)-defibrillator. Results: Patients were 110 males and 60 females. Injuries were found in 36% of male and 23% of female patients. Among male patients CPR-related injuries were associated with deeper mean - and peak compression depths (p < 0.05). No such association was observed in women. The frequency of injuries in mean compression depth categories <5, 5-6 and >6 cm, was 28%, 27% and 49% (p = 0.06). Of all patients 27% sustained rib fractures, 11% sternal fracture and eight patients had haematomas/ruptures in the myocardium. In addition, we observed one laceration of the stomach without bleeding, one ruptured spleen, one mediastinal haemorrhage and two pneumothoraxes. Conclusion: The number of iatrogenic injuries in male patients was associated with chest compressions during cardiopulmonary resuscitation increased as the measured compression depth exceeded 6 cm. While there is an increased risk of complications with deeper compressions it is important to realize that the injuries were by and large not fatal. 

  • 15. Heradstveit, Bård E
    et al.
    Larsson, Elna-Marie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Radiology, Oncology and Radiation Science, Radiology.
    Skeidsvoll, Håvard
    Hammersborg, Stig-Morten
    Wentzel-Larsen, Tore
    Guttormsen, Anne Berit
    Heltne, Jon-Kenneth
    Repeated magnetic resonance imaging and cerebral performance after cardiac arrest: a pilot study2011In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 82, no 5, p. 549-555Article in journal (Refereed)
    Abstract [en]

    AIM OF THE STUDY:

    Prognostication may be difficult in comatose cardiac arrest survivors. Magnetic resonance imaging (MRI) is potentially useful in the prediction of neurological outcome, and it may detect acute ischemia at an early stage. In a pilot setting we determined the prevalence and development of cerebral ischemia using serial MRI examinations and neurological assessment.

    METHODS:

    Ten witnessed out-of-hospital cardiac arrest patients were included. MRI was carried out approximately 2h after admission to the hospital, repeated after 24h of therapeutic hypothermia and 96 h after the arrest. The images were assessed for development of acute ischemic lesions. Neurophysiological and cognitive tests as well as a self-reported quality-of-life questionnaire, Short Form-36 (SF-36), were administered minimum 12 months after discharge.

    RESULTS:

    None of the patients had acute cerebral ischemia on MRI at admission. Three patients developed ischemic lesions after therapeutic hypothermia. There was a change in the apparent diffusion coefficient, which significantly correlated with the temperature (p < 0.001). The neurophysiological tests appeared normal. The patients scored significantly better on SF 36 than the controls as regards both bodily pain (p = 0.023) and mental health (p = 0.016).

    CONCLUSIONS:

    MRI performed in an early phase after cardiac arrest has limitations, as MRI performed after 24 and 96 h revealed ischemic lesions not detectable on admission. ADC was related to the core temperature, and not to the volume distributed intravenously. Follow-up neurophysiologic tests and self-reported quality of life were good.

  • 16.
    Israelsson, Johan
    et al.
    Kalmar Cty Hosp, Div Cardiol, Dept Internal Med, S-39185 Kalmar, Sweden.;Linnaeus Univ, Kalmar Maritime Acad, Kalmar, Sweden.;Linkoping Univ, Div Nursing Sci, Dept Med & Hlth Sci, Linkoping, Sweden..
    Bremer, Anders
    Univ Boras, Ctr Prehosp Res, Dept Acute & Prehosp Care & Med Technol & PreHosp, Boras, Sweden.;Kalmar Cty Hosp, Div Emergency Med Serv, Kalmar, Sweden..
    Herlitz, Johan
    Univ Boras, Ctr Prehosp Res, Dept Acute & Prehosp Care & Med Technol & PreHosp, Boras, Sweden..
    Axelsson, Asa B.
    Univ Gothenburg, Sahlgrenska Acad, Inst Hlth & Care Sci, Gothenburg, Sweden..
    Cronberg, Tobias
    Lund Univ, Skane Univ Hosp, Dept Clin Sci Lund, Neurol, Lund, Sweden..
    Djarv, Therese
    Karolinska Inst, Dept Med Solna, Stockholm, Sweden.;Karolinska Univ Hosp, Stockholm, Sweden..
    Kristofferzon, Marja-Leena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences. Univ Gavle, Fac Hlth & Occupat Studies, Dept Hlth & Caring Sci, Gavle, Sweden..
    Larsson, Ing-Marie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Lilja, Gisela
    Lund Univ, Skane Univ Hosp, Dept Clin Sci Lund, Neurol, Lund, Sweden..
    Sunnerhagen, Katharina S.
    Univ Gothenburg, Inst Neurosci & Physiol, Sect Clin Neurosci & Rehabil, Gothenburg, Sweden..
    Wallin, Ewa
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Agren, Susanna
    Linkoping Univ, Dept Med & Hlth Sci, Linkoping, Sweden.;Cty Council Ostergotland, Dept Cardiothorac Surg, Linkoping, Sweden..
    Akerman, Eva
    Skane Univ Hosp, Dept Perioperat Med & Intens Care, Malmo, Sweden.;Karolinska Inst, Dept Neurobiol Care Sci & Soc, Stockholm, Sweden..
    Arestedt, Kristofer
    Linnaeus Univ, Fac Hlth & Life Sci, Kalmar, Sweden.;Ersta Skondal Univ Coll, Dept Hlth Care Sci, Stockholm, Sweden.;Kalmar Cty Hosp, Dept Res, Kalmar, Sweden..
    Health status and psychological distress among in-hospital cardiac arrest survivors in relation to gender2017In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 114, p. 27-33Article in journal (Refereed)
    Abstract [en]

    Aim: To describe health status and psychological distress among in -hospital cardiac arrest (IHCA) survivors in relation to gender. Methods: This national register study consists of data from follow-up registration of IHCA survivors 3-6 months post cardiac arrest (CA) in Sweden. A questionnaire was sent to the survivors, including measurements of health status (EQ-5D-5L) and psychological distress (HADS). Results: Between 2013 and 2015, 594 IHCA survivors were included in the study. The median values for EQ-5D-5L index and EQVAS among survivors were 0.78 (ql-q3 = 0.67-0.86) and 70 (ql -q3 = 50-80) respectively. The values were significantly lower (p < 0.001) in women compared to men. In addition, women reported more problems than men in all dimensions of EQ-5D-5L, except self -care. A majority of the respondents reported no problems with anxiety (85.4%) and/or symptoms of depression (87.0%). Women reported significantly more problems with anxiety (p < 0.001) and symptoms of depression (p < 0.001) compared to men. Gender was significantly associated with poorer health status and more psychological distress. No interaction effects for gender and age were found. Conclusions: Although the majority of survivors reported acceptable health status and no psychological distress, a substantial proportion reported severe problems. Women reported worse health status and more psychological distress compared to men. Therefore, a higher proportion of women may be in need of support. Health care professionals should make efforts to identify health problems among survivors and offer individualised support when needed. (C) 2017 Elsevier B.V. All rights reserved.

  • 17. Jalkanen, Ville
    et al.
    Vaahersalo, Jukka
    Pettila, Ville
    Kurola, Jouni
    Varpula, Tero
    Tiainen, Marjaana
    Huhtala, Heini
    Alaspaa, Ari
    Hovilehto, Seppo
    Kiviniemi, Outi
    Kuitunen, Anne
    Tenhunen, Jyrki
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    The predictive value of soluble urokinase plasminogen activator receptor (SuPAR) regarding 90-day mortality and 12-month neurological outcome in critically ill patients after out-of-hospital cardiac arrest. Data from the prospective FINNRESUSCI study2014In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 85, no 11, p. 1562-1567Article in journal (Refereed)
    Abstract [en]

    Aim: The whole body ischaemia-reperfusion after cardiac arrest (CA) induces a systemic inflammation-reperfusion response. The expression of urokinase plasminogen activator receptor (uPAR) is known to be induced after hypoxia and increased levels of soluble form suPAR have been measured after hypoxia and ischaemia. Our aim was to evaluate, whether ischaemia/reperfusion injury after out-of-hospital cardiac arrest (OHCA) increases suPAR concentrations in serum and to evaluate the prognostic value of suPAR regarding 90-day mortality and 12-month neurological outcome. Methods: This is a pre-determined substudy of prospective FINNRESUSCI study. Total of 287 patients treated in the intensive care units after OHCA and with consent from the next-of-kin and serum samples between baseline and day 4 were included. Outcome and neurological outcome were evaluated according the Pittsburgh Cerebral Performance Categories (CPC). Kaplan-Meier survival curves, areas under receiver operational characteristics curves and positive likelihood ratios for mortality and poor neurological outcome were calculated. Results: Non-survivors had higher levels of suPAR after OHCA. Kaplan-Meier survival curves indicated high 90-day mortality in the highest concentration quintiles. LR+ for 1-year CPC 3-5 was 1.8-2.7 for the whole patient cohort and in shockable rhythms 2.0-2.4. In therapeutic hypothermia prognostic value remained. Conclusions: We found that high SuPAR concentrations were associated with poor outcome in patients with OHCA admitted to critical care. However, suPAR alone had inadequate predictive value for poor outcome and did not associate with 12-month neurological outcome.  

  • 18.
    Johansson, Jakob
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Blomberg, Hans
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Svennblad, Bodil
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, UCR-Uppsala Clinical Research Center.
    Wernroth, Lisa
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, UCR-Uppsala Clinical Research Center.
    Melhus, Håkan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Clinical pharmacogenomics and osteoporosis.
    Byberg, Liisa
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, UCR-Uppsala Clinical Research Center. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Michaëlsson, Karl
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, UCR-Uppsala Clinical Research Center.
    Karlsten, Rolf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Gedeborg, Rolf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, UCR-Uppsala Clinical Research Center.
    Prehospital Trauma Life Support (PHTLS) training of ambulance caregivers and impact on survival of trauma victims2012In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 83, no 10, p. 1259-1264Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    The Prehospital Trauma Life Support (PHTLS) course has been widely implemented and approximately half a million prehospital caregivers in over 50 countries have taken this course. Still, the effect on injury outcome remains to be established. The objective of this study was to investigate the association between PHTLS training of ambulance crew members and the mortality in trauma patients.

    METHODS:

    A population-based observational study of 2830 injured patients, who either died or were hospitalized for more than 24h, was performed during gradual implementation of PHTLS in Uppsala County in Sweden between 1998 and 2004. Prehospital patient records were linked to hospital-discharge records, cause-of-death records, and information on PHTLS training and the educational level of ambulance crews. The main outcome measure was death, on scene or in hospital.

    RESULTS:

    Adjusting for multiple potential confounders, PHTLS training appeared to be associated with a reduction in mortality, but the precision of this estimate was poor (odds ratio, 0.71; 95% confidence interval, 0.42-1.19). The mortality risk was 4.7% (36/763) without PHTLS training and 4.5% (94/2067) with PHTLS training. The predicted absolute risk reduction is estimated to correspond to 0.5 lives saved annually per 100,000 population with PHTLS fully implemented.

    CONCLUSIONS:

    PHTLS training of ambulance crew members may be associated with reduced mortality in trauma patients, but the precision in this estimate was low due to the overall low mortality. While there may be a relative risk reduction, the predicted absolute risk reduction in this population was low.

  • 19.
    Johansson, Jakob
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Gedeborg, Rolf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, UCR-Uppsala Clinical Research Center.
    Basu, Samar
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Increased cortical cerebral blood flow by continuous infusion of epinephrine during experimental cardiopulmonary resuscitation2003In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 57, no 3, p. 299-307Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To study the effects of continuously administered adrenaline (epinephrine), compared to bolus doses, on the dynamics of cortical cerebral blood flow during experimental cardiopulmonary resuscitation (CPR), and after restoration of spontaneous circulation (ROSC).

    METHODS: Ventricular fibrillation was induced in 24 anaesthetised pigs. After a 5-min non-intervention interval, closed-chest CPR was started. The animals were randomised into two groups. One group received three boluses of adrenaline (20 microg/kg) at 3-min intervals. The other group received an initial bolus of adrenaline (20 microg/kg) followed by an infusion of adrenaline (10 microg/kg x min). After 9 min of CPR, defibrillation was attempted, and if spontaneous circulation was achieved the adrenaline infusion was stopped. Cortical cerebral blood flow was measured continuously using Laser-Doppler flowmetry. Jugular bulb oxygen saturation was measured to reflect global cerebral oxygenation. Repeated measurements of 8-iso-prostaglandin F(2alpha) (8-iso-PGF(2alpha)) in jugular bulb plasma were performed to evaluate cerebral oxidative injury.

    RESULTS: During CPR mean cortical cerebral blood flow was significantly higher (P=0.009) with a continuous adrenaline infusion than with repeated bolus doses. Following ROSC there was no significant difference in cortical cerebral blood flow between the two study groups. No differences in coronary perfusion pressure, rate of ROSC, jugular bulb oxygen saturation or 8-iso-PGF(2alpha) were seen between the study groups.

    CONCLUSIONS: Continuous infusion of adrenaline (10 microg/kg x min) generated a more sustained increase in cortical cerebral blood flow during CPR as compared to intermittent bolus doses (20 microg/kg every third minute). Thus, continuous infusion might be a more appropriate way to administer adrenaline as compared to bolus doses during CPR.

  • 20.
    Johansson, Jakob
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Gedeborg, Rolf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Vasopressin versus continuous adrenaline during experimental cardiopulmonary resuscitation2004In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 62, no 1, p. 61-69Article in journal (Refereed)
    Abstract [en]

    Objective: To evaluate the effects of a bolus dose of vasopressin compared to continuous adrenaline (epinephrine) infusion on vital organ blood flow during cardiopulmonary resuscitation (CPR). Methods: Ventricular fibrillation was induced in 24 anaesthetised pigs. After a 5-min non-intervention interval, CPR was started. After 2 min of CPR the animals were randomly assigned to receive either vasopressin (0.4 U/kg) or adrenaline (bolus of 20 μg/kg followed by continuous infusion of 10 μg/(kg min)). Defibrillation was attempted after 9 min of CPR. Results: Vasopressin generated higher cortical cerebral blood flow (P<0.001) and lower cerebral oxygen extraction (P<0.001) during CPR compared to continuous adrenaline. Coronary perfusion pressure during CPR was higher in vasopressin-treated pigs (P<0.001) and successful resuscitation was achieved in 12/12 in the vasopressin group versus 5/12 in the adrenaline group (P=0.005). Conclusions: In this experimental model, vasopressin caused a greater increase in cortical cerebral blood flow and lower cerebral oxygen extraction during CPR compared to continuous adrenaline. Furthermore, vasopressin generated higher coronary perfusion pressure and increased the likelihood of restoring spontaneous circulation.

  • 21.
    Johansson, Jakob
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Ridefelt, Peter
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences.
    Basu, Samar
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Antithrombin administration during experimental cardiopulmonary resuscitation2004In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 62, no 1, p. 71-78Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To determine whether antithrombin (AT) administration during cardiopulmonary resuscitation (CPR) increased cerebral circulation and reduced reperfusion injury.

    METHODS: Ventricular fibrillation was induced in 24 anaesthetised pigs. After a 5-min non-intervention interval, CPR was started. The animals were randomised into two groups. The treatment group received AT (250 U/kg) and the control group received placebo, after 7 min of CPR. Defibrillation was attempted after 9 min of CPR. If restoration of spontaneous circulation (ROSC) was achieved, the animals were observed for 4 h. Cortical cerebral blood flow was measured using laser-Doppler flowmetry. Cerebral oxygen extraction was calculated to reflect the relation between global cerebral circulation and oxygen demand. Measurements of eicosanoids (8-iso-PGF(2alpha) and 15-keto-dihydro-PGF(2alpha)), AT, thrombin-antithrombin complex (TAT) and soluble fibrin in jugular bulb plasma were performed to detect any signs of cerebral oxidative injury, inflammation and coagulation.

    RESULTS: There was no difference between the groups in cortical cerebral blood flow, cerebral oxygen extraction, or levels of eicosanoids, TAT or soluble fibrin in jugular bulb plasma after ROSC. In the control group reduction of AT began 15 min after ROSC and continued throughout the entire observation period (P < 0.05). Eicosanoids and TAT were increased compared to baseline in all animals (P < 0.01).

    CONCLUSIONS: In this experimental model of CPR, AT administration did not increase cerebral circulation or reduce reperfusion injury after ROSC.

  • 22.
    Johansson, Jakob
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Ridefelt, Peter
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences.
    Basu, Samar
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Antithrombin reduction after experimental cardiopulmonary resuscitation2003In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 59, no 2, p. 229-236Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To determine whether activation of coagulation and inflammation during cardiac arrest results in a reduction of antithrombin (AT) and an increase in thrombin-antithrombin (TAT) complex during reperfusion.

    METHODS: Ventricular fibrillation (VF) was induced in ten anaesthetized pigs. After a 5-min non-intervention interval, closed-chest cardiopulmonary resuscitation (CPR) was performed for 9 min before defibrillation was attempted. If restoration of spontaneous circulation (ROSC) was achieved, the animals were observed for 4 h and repeated blood samples were taken for assay of AT, TAT and eicosanoids (8-iso-PGF(2alpha) and 15-keto-dihydro-PGF(2alpha)).

    RESULTS: AT began to decrease 15 min after ROSC and the reduction continued throughout the observation period (P<0.05). The lowest mean value (79%) occurred 60 min after ROSC. The TAT level was increased during the first 3 h after ROSC (P<0.05), indicating thrombin generation. The eicosanoids were increased throughout the observation period (P<0.05).

    CONCLUSIONS: AT is reduced and TAT and eicosanoids are increased after cardiac arrest, indicating activation of coagulation and inflammation.

  • 23.
    Kawati, Rafael
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Covaciu, Lucian
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Hypothermia after drowning in paediatric patients2009In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 80, no 11, p. 1325-1326Article in journal (Refereed)
  • 24. Kämäräinen, Antti
    et al.
    Sainio, Marko
    Olkkola, Klaus T
    Huhtala, Heini
    Tenhunen, Jyrki
    Critical Care Medicine Research Group, Department of Critical Care Medicine, Tampere University Hospital and University of Tampere, Tampere, Finland.
    Hoppu, Sanna
    Quality controlled manual chest compressions and cerebral oxygenation during in-hospital cardiac arrest2012In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 83, no 1, p. 138-142Article in journal (Refereed)
    Abstract [en]

    AIM:

    The quality of cardiopulmonary resuscitation (CPR) is associated with the rate of return of spontaneous circulation (ROSC) during human cardiac arrest. Current advances in defibrillator technology enable measurement of CPR quality during resuscitation, but it is not known whether this is directly reflected in cerebral oxygenation. In this descriptive study we aimed to evaluate whether the quality of feedback-monitored CPR during in-hospital cardiac arrest is reflected in near infrared frontal cerebral spectroscopy (NIRS).

    METHODS:

    Nine patients suffering an in-hospital cardiac arrest in a university hospital were included. All patients underwent quality-controlled CPR performed by a dedicated medical emergency team using a Philips HeartStart MRx defibrillator (Philips, Eindhoven, Netherlands) with a CPR quality (Q-CPR, Laerdal Medical, Stavanger, Norway) analysis feature. Simultaneously, bilateral frontal cerebral oximetry was measured using INVOS 5100c (Somanetics, Troy, MI, USA) NIRS.

    RESULTS:

    During quality controlled resuscitation, regional cerebral oxygenation (rSO2) as measured with NIRS was low but it improved during CPR (p = 0.043) and 8 min after ROSC (p = 0.022). After the onset of NIRS recording, there were four episodes exceeding 30 s, during which the quality of CPR was substandard. When CPR technique was corrected and maintained for 2 min, a minor non-significant increase in rSO2 was observed in two cases.

    CONCLUSIONS:

    High quality CPR was not significantly reflected in cerebral oxygenation as quantified using NIRS. Even after ROSC and subsequent significant increase in cerebral oxygenation, rSO2 readings were below previously suggested threshold of cerebral ischaemia. Improving CPR technique after an episode of low quality CPR did not significantly increase rSO2.

  • 25.
    Larsson, Ing-Marie
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Education in Nursing.
    Wallin, Ewa
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Education in Nursing.
    Kristofferzon, Marja-Leena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Niessner, Maron
    Zetterberg, Henrik
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Post-cardiac arrest serum levels of glial fibrillary acidic protein for predicting neurological outcome2014In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 85, no 12, p. 1654-1661Article in journal (Refereed)
    Abstract [en]

    AIM OF THE STUDY: To investigate serum levels of glial fibrillary acidic protein (GFAP) for evaluation of neurological outcome in cardiac arrest (CA) patients and compare GFAP sensitivity and specificity to that of more studied biomarkers neuron-specific enolas (NSE) and S100B.METHOD: A prospective observational study was performed in three hospitals in Sweden during 2008-2012. The participants were 125 CA patients treated with therapeutic hypothermia (TH) to 32-34°C for 24hours. Samples were collected from peripheral blood (n=125) and the jugular bulb (n=47) up to 108hours post-CA. GFAP serum levels were quantified using a novel, fully automated immunochemical method. Other biomarkers investigated were NSE and S100B. Neurological outcome was assessed using the Cerebral Performance Categories scale (CPC) and dichotomized into good and poor outcome.RESULTS: GFAP predicted poor neurological outcome with 100% specificity and 14-23% sensitivity at 24, 48 and 72hours post-CA. The corresponding values for NSE were 27-50% sensitivity and for S100B 21-30% sensitivity when specificity was set to 100%. A logistic regression with stepwise combination of the investigated biomarkers, GFAP, did not increase the ability to predict neurological outcome. No differences were found in GFAP, NSE and S100B levels when peripheral and jugular bulb blood samples were compared.CONCLUSION: Serum GFAP increase in patients with poor outcome but did not show sufficient sensitivity to predict neurological outcome after CA. Both NSE and S100B were shown to be better predictors. The ability to predict neurological outcome did not increased when combining the three biomarkers.

  • 26.
    Larsson, Ing-Marie
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Wallin, Ewa
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Cold saline infusion and ice packs alone are effective in inducing and maintaining therapeutic hypothermia after cardiac arrest2010In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 81, no 1, p. 15-19Article in journal (Refereed)
    Abstract [en]

    AIM OF THE STUDY: Hypothermia treatment with cold intravenous infusion and ice packs after cardiac arrest has been described and used in clinical practice. We hypothesised that with this method a target temperature of 32-34 degrees C could be achieved and maintained during treatment and that rewarming could be controlled. MATERIALS AND METHODS: Thirty-eight patients treated with hypothermia after cardiac arrest were included in this prospective observational study. The patients were cooled with 4 degrees C intravenous saline infusion combined with ice packs applied in the groins, axillae, and along the neck. Hypothermia treatment was maintained for 26h after cardiac arrest. It was estimated that passive rewarming would occur over a period of 8h. Body temperature was monitored continuously and recorded every 15min up to 44h after cardiac arrest. RESULTS: All patients reached the target temperature interval of 32-34 degrees C within 279+/-185min from cardiac arrest and 216+/-177min from induction of cooling. In nine patients the temperature dropped to below 32 degrees C during a period of 15min up to 2.5h, with the lowest (nadir) temperature of 31.3 degrees C in one of the patients. The target temperature was maintained by periodically applying ice packs on the patients. Passive rewarming started 26h after cardiac arrest and continued for 8+/-3h. Rebound hyperthermia (>38 degrees C) occurred in eight patients 44h after cardiac arrest. CONCLUSIONS: Intravenous cold saline infusion combined with ice packs is effective in inducing and maintaining therapeutic hypothermia, with good temperature control even during rewarming.

  • 27.
    Larsson, Ing-Marie
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Education in Nursing.
    Wallin, Ewa
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Education in Nursing.
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Kristofferzon, Marja-Leena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Health-related quality of life improves during the first six months after cardiac arrest and hypothermia treatment2014In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 85, no 2, p. 215-220Article in journal (Refereed)
    Abstract [en]

    Aim of the study: To investigate whether there were any changes in and correlations between anxiety, depression and health-related quality of life (HRQoL) over time, between hospital discharge and one and six months after cardiac arrest (CA), in patients treated with therapeutic hypothermia (TH).

    Method: During a 4-year period at three hospitals in Sweden, 26 patients were prospectively included after CA treated with TH. All patients completed the questionnaires Hospital Anxiety and Depression Scale (HADS), Euroqol (EQ5D), Euroqol visual analogue scale (EQ-VAS) and Short Form 12 (SF12) at three occasions, at hospital discharge, and at one and 6 months after CA.

    Result: There was improvement over time in HRQoL, the EQ5D index (p = 0.002) and the SF12 physical component score (PCS) (p = 0.005). Changes over time in anxiety and depression were not found. Seventy-three percent of patients had an EQ-VAS score below 70 (scale 0-100) on overall health status at discharge from hospital; at 6 months the corresponding figure was 41%. Physical problems were the most common complaint affecting HRQoL. A correlation was found between depression and HRQoL, and this was strongest at six months (rs = -0.44 to -0.71, p = 0.001).

    Conclusion: HRQoL improves over the first 6 months after a CA. Patients reported lower levels of HRQoL on the physical as compared to mental component. The results indicate that the less anxiety and depression patients perceive, the better HRQoL they have and that time can be an important factor in recovery after CA.

  • 28. Liu, Xiaoli
    et al.
    Nozari, Ala
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Wiklund, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Buffer administration during CPR promotes cerebral reperfusion after return of spontaneous circulation and mitigates post-resuscitation cerebral acidosis.2002In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 55, no 1, p. 45-55Article in journal (Refereed)
    Abstract [en]

    To explore the effects of alkaline buffers on cerebral perfusion and cerebral acidosis during and after cardiopulmonary resuscitation (CPR), 45 anaesthetized piglets were studied. The animals were subjected to 5 min non-interventional circulatory arrest followed by 7 min closed chest CPR and received either 1 mmol/kg of sodium bicarbonate, 1 mmol/kg of tris buffer mixture, or the same volume of saline (n=15 in all groups), adrenaline (epinephrine) boluses and finally external defibrillatory shocks. Systemic haemodynamic variables, cerebral cortical blood flow, arterial, mixed venous, and internal jugular bulb blood acid-base status and blood gases as well as cerebral tissue pH and PCO(2) were monitored. Cerebral tissue acidosis was recorded much earlier than arterial acidaemia. After restoration of spontaneous circulation, during and after temporary arterial hypotension, pH in internal jugular bulb blood and in cerebral tissue as well as cerebral cortical blood flow was lower after saline than in animals receiving alkaline buffer. Buffer administration during CPR promoted cerebral cortical reperfusion and mitigated subsequent post-resuscitation cerebral acidosis during lower blood pressure and flow in the reperfusion phase. The arterial alkalosis often noticed during CPR after the administration of alkaline buffers was caused by low systemic blood flow, which also results in poor outcome.

  • 29.
    Miclescu, Adriana
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Basu, Samar
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism.
    Wiklund, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Cardio-cerebral and metabolic effects of methylene blue in hypertonic sodium lactate during experimental cardiopulmonary resuscitation2007In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 75, no 1, p. 88-97Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Methylene blue (MB) administered with a hypertonic-hyperoncotic solution reduces the myocardial and cerebral damage due to ischaemia and reperfusion injury after experimental cardiac arrest and also increases short-term survival. As MB precipitates in hypertonic sodium chloride, an alternative mixture of methylene blue in hypertonic sodium lactate (MBL) was developed and investigated during and after cardiopulmonary resuscitation (CPR). METHODS: Using an experimental pig model of cardiac arrest (12 min cardiac arrest and 8 min CPR) the cardio-cerebral and metabolic effects of MBL (n=10), MB in normal saline (MBS; n=10) or in hypertonic saline dextran (MBHSD; n=10) were compared. Haemodynamic variables and cerebral cortical blood flow (CCBF) were recorded. Biochemical markers of cerebral oxidative injury (8-iso-PGF2alpha), inflammation (15-keto-dihydro-PGF2alpha), and neuronal damage (protein S-100beta) were measured in blood from the sagittal sinus, whereas markers of myocardial injury, electrolytes, and lactate were measured in arterial plasma. RESULTS: There were no differences between groups in survival, or in biochemical markers of cerebral injury. In contrast, the MBS group exhibited not only increased CKMB (P<0.001) and troponin I in comparison with MBHSD (P=0.019) and MBL (P=0.037), but also greater pulmonary capillary wedge pressure 120 min after return of spontaneous circulation (ROSC). Lactate administration had an alkalinizing effect started 120 min after ROSC. CONCLUSIONS: Methylene blue in hypertonic sodium lactate may be used against reperfusion injury during experimental cardiac arrest, having similar effects as MB with hypertonic saline-dextran, but in addition better myocardial protection than MB with normal saline. The neuroprotective effects did not differ.

  • 30.
    Miclescu, Adriana
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Sharma, Hari Shanker
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Wiklund, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Crystalloid vs. hypertonic crystalloid-colloid solutions for induction of mild therapeutic hypothermia after experimental cardiac arrest2013In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 84, no 2, p. 256-262Article in journal (Refereed)
    Abstract [en]

    PURPOSE:

    To compare cerebral and hemodynamic consequences of different volumes of cold acetated Ringer's solution or cold hypertonic saline dextran administered in order to achieve mild hypothermia after cardiac arrest (CA) in a pig model of experimental cardiopulmonary resuscitation (CPR).

    METHODS:

    Using an experimental pig model of 12min CA (followed by 8min CPR or no resuscitation) we compared four groups of piglets: a control group, a normothermic group and two groups with different solutions administered for induction of hypothermia. The control group of 5 piglets underwent 12min CA without subsequent CPR, after which the brain of the animals was removed immediately. After restoration of spontaneous circulation (ROSC) the resuscitated piglets were randomized into a normothermic group (NT group=10), and two hypothermic groups that received cold infusions of either 30mL/kg acetated Ringer's solution (Much fluid group, M, n=10) or 3mL/kg hypertonic saline dextran solution (Less fluid group, L, n=10), respectively, administered during 30min. Additional external cooling with ice packs was used in hypothermic groups. Sixty or 180min after ROSC the experiment was terminated. Immediately after arrest the brain was removed for histological analyses.

    RESULTS:

    The median time to reach the target core temperature of 34°C after ROSC was 51.5±7.8min in L group and 48.8±8.6min in M group. Less cerebral tissue content of water (p<0.001), sodium (p<0.0001), potassium (p<0.0001) and less central venous pressure (CVP) at 5 and 15min after ROSC were demonstrated in L group. Increased brain damage was demonstrated over time in NT group (p<0.001). Less neurologic damage and BBB disruptions (albumin leakage) was observed at 180min in M group in comparison with both NT and L groups (p<0.001).

    CONCLUSION:

    No statistical differences were observed between the hypothermic groups in the time to achieve mild hypothermia. Although inclusion of cold hypertonic crystalloid-colloidal solutions in the early resuscitation after ROSC may be more effective than cold crystalloids in reducing brain edema, this study demonstrates that mild hypothermia induced with small volumes of cold hypertonic crystalloid-colloids is less as effective as crystalloid's induced hypothermia in mitigating brain injury after cardiac arrest.

  • 31.
    Mörtberg, Erik
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Cumming, Paul
    Wiklund, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Cerebral metabolic rate of oxygen (CMRO2) in pig brain determined by PET after resuscitation from cardiac arrest2009In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 80, no 6, p. 701-706Article in journal (Refereed)
    Abstract [en]

    AIM: To assess the regional vulnerability to ischemic damage and perfusion/metabolism mismatch of reperfused brain following restoration of spontaneous circulation (ROSC) after cardiac arrest. METHOD: We used positron emission tomography (PET) to map cerebral metabolic rate of oxygen (CMRO(2)), cerebral blood flow (CBF) and oxygen extraction fraction (OEF) in brain of young pigs at intervals after resuscitation from cardiac arrest. After obtaining baseline PET recordings, ventricular fibrillation of 10 min duration was induced, followed by mechanical closed-chest cardiopulmonary resuscitation (CPR) in conjunction with i.v. administration of 0.4 U/kg of vasopressin. After CPR, external defibrillatory shocks were applied to achieve restoration of spontaneous circulation (ROSC). CBF and CMRO(2) were mapped and voxelwise maps of OEF were calculated at times of 60, 180, and 300 min after ROSC. RESULTS: There was hypoperfusion throughout the telencephalon at 60 min, with a return towards baseline values at 300 min. In contrast, there was progressively increasing CBF in cerebellum throughout the observation period. The magnitude of CMRO(2) decreased globally after ROSC, especially in cerebral cortex. The magnitude of OEF in cerebral cortex was 60% at baseline, tended to increase at 60 min after ROSC, and declined to 50% thereafter, thus suggesting transition to an ischemic state. CONCLUSION: The cortical regions tended most vulnerable to the ischemic insult with an oligaemic pattern and a low CMRO(2) whereas the cerebellum instead showed a pattern of luxury perfusion.

  • 32.
    Mörtberg, Erik
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Cumming, Paul
    Wiklund, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Wall, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Radiology, Oncology and Radiation Science, Section of Nuclear Medicine and PET.
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    A PET study of regional cerebral blood flow after experimental cardiopulmonary resuscitation2007In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 75, no 1, p. 98-104Article in journal (Refereed)
    Abstract [en]

    Cerebral blood flow (CBF) during cardiopulmonary resuscitation and after restoration of spontaneous circulation (ROSC) from cardiac arrest has previously been measured with the microspheres and laser Doppler techniques. We used positron emission tomography (PET) with [15O]--water to map the haemodynamic changes after ROSC in nine young pigs. After the baseline PET recording, ventricular fibrillation of 5 min duration was induced, followed by closed-chest cardiopulmonary resuscitation (CPR) in conjunction with IV administration of three bolus doses of adrenaline (epinephrine). After CPR, external defibrillatory shocks were applied to achieve ROSC. CBF was measured at intervals during 4h after ROSC. Relative to the mean global CBF at baseline (32+/-5 ml hg(-1)min(-1)), there was a substantial global increase in CBF at 10 min, especially in the diencephalon. This was followed by an interval of cortical hypoperfusion and a subsequent gradual return to baseline values.

  • 33.
    Mörtberg, Erik
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Zetterberg, Henrik
    Psykiatri och neurokemi, Sahlgrenska akademin.
    Nordmark, Johanna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Blennow, Kaj
    Psykiatri och neurokemi, Sahlgrenska akademin.
    Rosengren, Lars
    Neurologi, Sahlgrenska akademin.
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    S-100B is superior to NSE, BDNF and GFAP in predicting outcome of resuscitation from cardiac arrest with hypothermia treatment2011In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 82, no 1, p. 26-31Article in journal (Refereed)
    Abstract [en]

    Objective: To conduct a pilot study to evaluate the blood levels of brain derived neurotrophic factor (BDNF), glial fibrillary acidic protein (GFAP), neuron specific enolase (NSE) and S-100B as prognostic markers for neurological outcome 6 months after hypothermia treatment following resuscitation from cardiac arrest. Design: Prospective observational study. Setting: One intensive care unit at Uppsala University Hospital. Patients: Thirty-one unconscious patients resuscitated after cardiac arrest. Interventions: None. Measurements and main results: Unconscious patients after cardiac arrest with restoration of spontaneous circulation (ROSC) were treated with mild hypothermia to 32-34 °C for 26. h. Time from cardiac arrest to target temperature was measured. Blood samples were collected at intervals of 1-108. h after ROSC. Neurological outcome was assessed with Glasgow-Pittsburgh cerebral performance category (CPC) scale at discharge from intensive care and again 6 months later, when 15/31 patients were alive, of whom 14 had a good outcome (CPC 1-2). Among the predictive biomarkers, S-100B at 24. h after ROSC was the best, predicting poor outcome (CPC 3-5) with a sensitivity of 87% and a specificity of 100%. NSE at 96. h after ROSC predicted poor outcome, with sensitivity of 57% and specificity of 93%. BDNF and GFAP levels did not predict outcome. The time from cardiac arrest to target temperature was shorter for those with poor outcome. Conclusions: The blood concentration of S-100B at 24. h after ROSC is highly predictive of outcome in patients treated with mild hypothermia after cardiac arrest.

  • 34.
    Nordmark, Johanna
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Enblad, Per
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience.
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Cerebral energy failure following experimental cardiac arrest: Hypothermia treatment reduces secondary lactate/pyruvate-ratio increase2009In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 80, no 5, p. 573-579Article in journal (Refereed)
    Abstract [en]

    AIM: This was an experimental study performed to investigate cerebral metabolism during hypothermia treatment and rewarming after resuscitation from cardiac arrest (CA). MATERIALS AND METHODS: Sixteen pigs underwent CA followed by cardiopulmonary resuscitation (CPR). After randomisation into one hypothermic (n=8) and one normothermic group (n=8) the animals received infusion of 4 or 38 degrees C saline, respectively. Following restoration of spontaneous circulation (ROSC) both groups were observed for 360min. The hypothermic group was cooled for 180 min and then rewarmed. Temperature was not modulated in the normothermic group. Cerebral microdialysis was conducted and lactate/pyruvate (L/P)-ratio and glutamate were analysed. Intracranial pressure probe was inserted. Oxygen saturation in venous jugular bulb blood (SjO2) was analysed. RESULTS: All animals initially had increased L/P-ratio (>30). A total of nine animals developed secondary increase. In the hypothermic group this was observed in 2/7 animals and in the normothermic group in 7/8 (p=0.04). Glutamate increased initially in all animals with secondary increases in two animals in each group. No differences in L/P-ratio or glutamate were detected during the rewarming phase compared to the hypothermic phase. The hypothermic group had higher SjO(2) (p=0.04). In both groups intracranial pressure increased after ROSC. CONCLUSION: After resuscitation from CA there was a risk of cerebral secondary energy failure (reflected as an increased L/P-ratio) but hypothermia treatment seemed to counteract this effect. Cerebral oxygen extraction, measured by SjO(2,) was increased in the hypothermic group probably due to reduced metabolism. Rewarming did not reveal any obvious harmful events.

  • 35.
    Nordmark, Johanna
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Johansson, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Sandberg, Dan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences.
    Granstam, Sven-Olof
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences.
    Huzevka, Tibor
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Covaciu, Lucian
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Mörtberg, Erik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Assessment of intravascular volume by transthoracic echocardiography during therapeutic hypothermia and rewarming in cardiac arrest survivors2009In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 80, no 11, p. 1234-1239Article in journal (Refereed)
    Abstract [en]

    AIM: To study haemodynamic effects and changes in intravascular volume during hypothermia treatment, induced by ice-cold fluids and maintained by ice-packs followed by rewarming in patients after resuscitation from cardiac arrest. MATERIALS AND METHODS: In 24 patients following successful restoration of spontaneous circulation (ROSC), hypothermia was induced with infusion of 4 degrees C normal saline and maintained with ice-packs for 26 h after ROSC. This was followed by passive rewarming. Transthoracic echocardiography was performed at 12, 24 and 48 h after ROSC to evaluate ejection fraction and intravascular volume status. Central venous pressure (CVP), central venous oxygen saturation (ScvO(2)) and serum lactate were measured. Fluid balance was calculated. RESULTS: Twelve hours after ROSC, two separate raters independently estimated that 10 and 13 out of 23 patients had a decreased intravascular volume using transthoracic echocardiography. After 24 and 48 h this number had increased further to 14 and 13 out of 19 patients and 13 and 12 out of 21 patients. Calculated fluid balance was positive (4000 ml the day 1 and 2500 ml day 2). There was no difference in ejection fraction between the recording time points. Serum lactate and ScvO(2) were in the normal range when echocardiography exams were performed. CVP did not alter over time. CONCLUSIONS: Our results support the hypothesis that inducing hypothermia following cardiac arrest, using cold intravenous fluid infusion does not cause serious haemodynamic side effects. Serial transthoracic echocardiographic estimation of intravascular volume suggests that many patients are hypovolaemic during therapeutic hypothermia and rewarming in spite of a positive fluid balance.

  • 36.
    Nordmark, Johanna
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Induction of mild hypothermia with infusion of cold (4°C)fluid during ongoing CPR2005In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 66, no 3, p. 357-365Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Therapeutic hypothermia after resuscitation has been shown to improve the outcome regarding neurological state and to reduce mortality. The earlier hypothermia therapy is induced probably the better. We studied the induction of hypothermia with a large volume of intravenous ice-cold fluid after cardiac arrest during ongoing cardiopulmonary resuscitation (CPR). METHODS: Twenty anaesthetised piglets were subjected to 8 min of ventricular fibrillation, followed by CPR. They were randomized into two groups. The hypothermic group was given an infusion of 4 degrees C acetated Ringer's solution 30 ml/kg at an infusion rate of 1.33 ml/kg/min, starting after 1 min of CPR. The control group received the same infusion at room temperature. All pigs received a bolus dose of vasopressin after 3 min of CPR. After 9 min, defibrillatory shocks were applied to achieve restoration of spontaneous circulation (ROSC). Core temperature and haemodynamic variables were measured at baseline and repeatedly until 180 min after ROSC. Cortical cerebral blood flow was measured, using Laser-Doppler flowmetry. RESULTS: All pigs had ROSC, except one animal in the hypothermic group. Only one animal in the hypothermic group died during the observation period. The calculated mean temperature reduction was 1.6+/-0.35 degrees C (S.D.) in the hypothermic group and 1.1+/-0.37 degrees C in the control group (p=0.009). There was no difference in cortical cerebral blood flow and haemodynamic variables. CONCLUSION: Inducing hypothermia with a cold infusion seems to be an effective method that can be started even during ongoing CPR. This method might warrant consideration for induction of early therapeutic hypothermia in cardiac arrest victims.

  • 37. Nozari, A
    et al.
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Differences in the pharmacodynamics of epinephrine and vasopressin during and after experimental cardiopulmonary resuscitation.2001In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 49, no 1, p. 59-72Article in journal (Refereed)
    Abstract [en]

    Vasopressin has been investigated as a possible alternative to epinephrine during cardiopulmonary resuscitation (CPR). We tested the hypothesis that vasopressin, in comparison with epinephrine, would improve cerebral blood flow and metabolism during CPR as well as after restoration of spontaneous circulation (ROSC). A total of 22 anaesthetised piglets were subjected to 5 min of ventricular fibrillation followed by 8 min of closed-chest CPR. The piglets were randomly allocated to receive repeated boluses of either 45 microg/kg epinephrine or 0.4 U/kg vasopressin IV. Haemodynamic parameters, cerebral cortical blood flow and cerebral tissue pH and PCO(2) were continuously monitored during CPR and up to 4 h after ROSC. Cerebral oxygen extraction ratio was calculated. Cerebral cortical blood flow increased transiently after each bolus of epinephrine, while only the first bolus of vasopressin resulted in a sustained increase. The peak in cerebral cortical blood flow was reached approximately 30 s later with vasopressin. During the initial 5 min following ROSC, cerebral cortical blood flow was greater in the vasopressin group. In conclusion, there is a difference between epinephrine and vasopressin in the time from injection to maximal clinical response and the duration of their effect, but their overall effects on blood pressures and cerebral perfusion do not differ significantly during CPR. In contrast, vasopressin results in a greater cerebral cortical blood flow during a transient period after ROSC.

  • 38. Ornato, J P
    et al.
    Paradis, N
    Bircher, N
    Brown, C
    DeLooz, H
    Dick, W
    Kaye, W
    Levine, R
    Martens, P
    Neumar, R
    Patel, R
    Pepe, P
    Ramanathan, S
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Traystman, R
    von Planta, M
    Vostrikov, V
    Weil, M H
    Future directions for resuscitation research. III. External cardiopulmonary resuscitation advanced life support.1996In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 32, no 2, p. 139-58Article in journal (Refereed)
    Abstract [en]

    This discussion about advanced cardiac life support (ACLS) reflects disappointment with the over 50% of out-of-hospital cardiopulmonary resuscitation (CPR) attempts that fail to achieve restoration of spontaneous circulation (ROSC). Hospital discharge rates are equally poor for in-hospital CPR attempts outside special care units. Early bystander CPR and early defibrillation (manual, semi-automatic or automatic) are the most effective methods for achieving ROSC from ventricular fibrillation (VF). Automated external defibrillation (AED), which is effective in the hands of first responders in the out-of-hospital setting, should also be used and evaluated in hospitals, inside and outside of special care units. The first countershock is most important. Biphasic waveforms seem to have advantages over monophasic ones. Tracheal intubation has obvious efficacy when the airway is threatened. Scientific documentation of specific types, doses, and timing of drug treatments (epinephrine, bicarbonate, lidocaine, bretylium) are weak. Clinical trials have failed so far to document anything statistically but a breakthrough effect. Interactions between catecholamines and buffers need further exploration. A major cause of unsuccessful attempts at ROSC is the underlying disease, which present ACLS guidelines do not consider adequately. Early thrombolysis and early coronary revascularization procedures should also be considered for selected victims of sudden cardiac death. Emergency cardiopulmonary bypass (CPB) could be a breakthrough measure, but cannot be initiated rapidly enough in the field due to technical limitations. Open-chest CPR by ambulance physicians deserves further trials. In searches for causes of VF, neurocardiology gives clues for new directions. Fibrillation and defibrillation thresholds are influenced by the peripheral sympathetic and parasympathetic nervous systems and impulses from the frontal cerebral cortex. CPR for cardiac arrest of the mother in advanced pregnancy requires modifications and outcome data. Until more recognizable critical factors for ROSC are identified, titrated sequencing of ACLS measures, based on physiologic rationale and sound judgement, rather than rigid standards, gives the best chance for achieving survival with good cerebral function.

  • 39. Randall, Jeffrey
    et al.
    Mortberg, Erik
    Provuncher, Gail K.
    Fournier, David R.
    Duffy, David C.
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Blennow, Kaj
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Zetterberg, Henrik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Wilson, David H.
    Tau proteins in serum predict neurological outcome after hypoxic brain injury from cardiac arrest: Results of a pilot study2013In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 84, no 3, p. 351-356Article in journal (Refereed)
    Abstract [en]

    Objective: To conduct a pilot study to evaluate the prognostic potential of serum tau protein measurements to predict neurological outcome 6 months following resuscitation from cardiac arrest. Methods: In this retrospective observational study, we employed a new ultra sensitive digital immunoassay technology to examine serial serum samples from 25 cardiac arrest patients to examine tau release into serum as a result of brain hypoxia, and probe for its significance predicting six-month neurological outcome. Serial blood samples were obtained from resuscitated cardiac arrest survivors during their first five days in an intensive care unit, and serum total tau was measured. Cerebral function assessments were made using Cerebral Performance Categorization (CPC) at discharge from the ICU and six months later. Tau data were analyzed in the context of 6-month CPC scores. Results: Tau elevations ranged from modest (< 10 pg/mL) to very high (hundreds of pg/mL), and exhibited unexpected bi-modal kinetics in some patients. Early tau elevations appeared within 24 h of cardiac arrest, and delayed elevations appeared after 24-48 h. In patients with delayed elevations, areas under the curves of tau concentration vs. hours since cardiac arrest were highly predictive of 6-month outcome (P < 0.0005). Conclusion: High-sensitivity serum tau measurements combined with an understanding of tau release kinetics could have utility for hypoxic brain injury assessment and prediction of cerebral function outcome.

  • 40.
    Rubertsson, Sten
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Karlsten, Rolf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Increased cortical cerebral blood flow with LUCAS; a new device for mechanical chest compressions compared to standard external compressions during experimental cardiopulmonary resuscitation2005In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 65, no 3, p. 357-63Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: LUCAS is a new device for mechanical compression and decompression of the chest during cardiopulmonary resuscitation (CPR). The aim of this study was to compare the efficacy of this new device with standard manual external chest compressions using cerebral cortical blood flow, cerebral oxygen extraction, and end-tidal CO2 for indirect measurement of cardiac output. Drug therapy, with adrenaline (epinephrine) was eliminated in order to evaluate the effects of chest compressions alone. METHODS: Ventricular fibrillation (VF) was induced in 14 anaesthetized pigs. After 8 min non-intervention interval, the animals were randomized into two groups. One group received external chest compressions using a new mechanical device, LUCAS. The other group received standard manual external chest compressions. The compression rate was 100 min(-1) and mechanical ventilation was resumed with 100% oxygen during CPR in both groups. No adrenaline was given. After 15 min of CPR, external defibrillatory shocks were applied to achieve restoration of spontaneous circulation (ROSC). Cortical cerebral blood flow was measured continuously using Laser-Doppler flowmetry. End-tidal CO2 was measured using mainstream capnography. RESULTS: During CPR, the cortical cerebral blood flow was significantly higher in the group treated with LUCAS (p = 0.041). There was no difference in oxygen extraction between the groups. End-tidal CO2, an indirect measurement of the achieved cardiac output during CPR, was significantly higher in the group treated with the LUCAS device (p = 0.009). Restoration of spontaneous circulation was achieved in two animals, one from each group. CONCLUSIONS: Chest compressions with the LUCAS device during experimental cardiopulmonary resuscitation resulted in higher cerebral blood flow and cardiac output than standard manual external chest compressions. These results strongly support prospective randomised studies in patients to evaluate this new device.

  • 41.
    Rubertsson, Sten
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Lindgren, Erik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Smekal, David
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Östlund, Ollie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, UCR-Uppsala Clinical Research Center.
    Silfverstolpe, Johan
    Lichtveld, Robert A
    Boomars, Rene
    Bruins, Wendy
    Ahlstedt, Björn
    Skoog, Gunnar
    Kastberg, Robert
    Halliwell, David
    Box, Martyn
    Herlitz, Johan
    Karlsten, Rolf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Per-Protocol and Pre-Defined population analysis of the LINC study2015In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 96, p. 92-99Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To perform two predefined sub-group analyses within the LINC study and evaluate if the results were supportive of the previous reported intention to treat (ITT) analysis.

    METHODS: Predefined subgroup analyses from the previously published LINC study were performed. The Per-Protocol population (PPP) included the randomized patients included in the ITT-population but excluding those with violated inclusion or exclusion criteria and those that did not get the actual treatment to which the patient was randomized. In the Pre-Defined population (PDP) analyses patients were also excluded if the dispatch time to ambulance arrival at the address exceeded 12min, there was a non-witnessed cardiac arrest, or if it was not possible to determine whether the arrest was witnessed or not, and those cases where LUCAS was not brought to the scene at the first instance.

    RESULTS: After exclusion from the 2589 patients within the ITT-population, the Per-Protocol analysis was performed in 2370 patients and the Pre-Defined analysis within 1133 patients. There was no significant difference in 4-h survival of patients between the mechanical-CPR group and the manual-CPR group in the Per-Protocol population; 279 of 1172 patients (23.8%) versus 281 of 1198 patients (23.5%) (risk difference -0.35%, 95% C.I. -3.1 to 3.8, p=0.85) or in the Pre-Defined population; 176 of 567 patients (31.0%) versus 192 of 566 patients (33.9%) (risk difference -2.88%, 95% C.I. -8.3 to 2.6, p=0.31). There was no difference in any of the second outcome variables analyzed in the Pre-Protocol or Pre-Defined populations.

    CONCLUSIONS: The results from these predefined sub-group analyses of the LINC study population did not show any difference in 4h survival or in secondary outcome variables between patients treated with mechanical-CPR or manual-CPR. This is consistent with the previously published ITT analysis.

  • 42.
    Rubertsson, Sten
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Smekal, David
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Reply to Letter: Human studies may overestimate injuries related to mechanical chest compression cardiopulmonary resuscitation2010In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 81, no 6, p. 775-776Article in journal (Refereed)
  • 43. Sainio, Marko
    et al.
    Hellevuo, Heidi
    Huhtala, Heini
    Hoppu, Sanna
    Eilevstjonn, Joar
    Tenhunen, Jyrki
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Olkkola, Klaus T.
    Effect of mattress and bed frame deflection on real chest compression depth measured with two CPR sensors2014In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 85, no 6, p. 840-843Article in journal (Refereed)
    Abstract [en]

    Aim: Implementation of chest compression (CC) feedback devices with a single force and deflection sensor (FDS) may improve the quality of CPR. However, CC depth may be overestimated if the patient is on a compliant surface. We have measured the true CC depth during in-hospital CPR using two FDSs on different bed and mattress types. Methods: This prospective observational study was conducted at Tampere University Hospital between August 2011 and September 2012. During in-hospital CPR one FDS was placed between the rescuer's hand and the patient's chest, with the second attached to the backboard between the patient's back and the mattress. The real CC depth was calculated as the difference between the total depth from upper FDS to lower FDS. Results: Ten cardiac arrests on three different bed and mattress types yielded 10,868 CCs for data analyses. The mean (SD) mattress/bed frame effect was 12.8 (4) mm on a standard hospital bed with a gel mattress, 12.4 (4) mm on an emergency room stretcher with a thin gel mattress and 14.1 (3) mm on an ICU bed with an emptied air mattress. The proportion of CCs with an adequate depth (>= 50 mm) decreased on all mattress types after compensating for the mattress/bed frame effect from 94 to 64%, 98 to 76% and 91 to 17%, in standard hospital bed, emergency room stretcher and ICU bed, respectively (p < 0.001). Conclusion: The use of FDS without real-time correction for deflection may result in CC depth not reaching the recommended depth of 50 mm.

  • 44.
    Sainio, Marko
    et al.
    Tampere Univ Hosp, Dept Intens Care Med, Crit Care Med Res Grp, FI-33521 Tampere, Finland.;Turku Univ Hosp, Dept Emergency Med, Emergency Med Serv, FI-20521 Turku, Finland..
    Hoppu, Sanna
    Tampere Univ Hosp, Dept Intens Care Med, Crit Care Med Res Grp, FI-33521 Tampere, Finland..
    Huhtala, Heini
    Univ Tampere, Sch Hlth Sci, FI-33014 Tampere, Finland..
    Eilevstjonn, Joar
    Laerdal Med AS, N-4002 Stavanger, Norway..
    Olkkola, Klaus T.
    Univ Helsinki, Dept Anaesthesiol Intens Care Emergency Care & Pa, FI-00029 Helsinki, Finland.;Univ Helsinki, Cent Hosp, Meilahti Hosp, FI-00029 Helsinki, Finland..
    Tenhunen, Jyrki
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Tampere Univ Hosp, Dept Intens Care Med, Crit Care Med Res Grp, FI-33521 Tampere, Finland..
    Simultaneous beat-to-beat assessment of arterial blood pressure and quality of cardiopulmonary resuscitation in out-of-hospital and in-hospital settings2015In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 96, p. 163-169Article in journal (Refereed)
    Abstract [en]

    Objective: The current recommendation for depth and rate of chest compression (CC) during cardiopulmonary resuscitation (CPR) is based on limited hemodynamic data recorded during human CPR. We have evaluated the possible association between CC depth and rate and continuously measured arterial blood pressure during adult CPR. Methods: This prospective study included data from 104 patients resuscitated inside or outside hospital. Adequate data on continuously measured invasive arterial blood pressure (BP) and the quality of CPR from a defibrillator capable recording CPR quality parameters was successful in 39 patients. We used logistic regression and mixed effects modeling to identify CC depths and rates associated with systolic blood pressure (SBP) >= 85 mmHg and diastolic blood pressure (DBP) >= 30 mmHg. Results: We analyzed 41,575 compression-BP pairs. The values for blood pressure varied greatly between the patients. SBP varied from 25 to 225 mmHg and DBP from 2 to 59 mmHg. CC rate 100-120/min and CC depth >= 60 mm (without mattress deflection correction) was associated with DBP >= 30 mmHg in both femoral (OR 1.14; 95% CI 1.03, 1.26; p < 0.05) and radial (OR 4.70; 95% CI 3.92, 5.63; p < 0.001) recordings. For any given subject there was a weak upward trend in blood pressure as CC depth increased. Conclusion: Deeper CC does not equal higher BP in every patient. The heterogeneity of patients creates a challenge to find the optimal way to resuscitate patients individually.

  • 45. Schneider, Antoine G
    et al.
    Eastwood, Glenn M
    Bellomo, Rinaldo
    Bailey, Michael
    Lipcsey, Miklos
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Pilcher, David
    Young, Paul
    Stow, Peter
    Santamaria, John
    Stachowski, Edward
    Suzuki, Satoshi
    Woinarski, Nicholas C
    Pilcher, Janine
    Arterial carbon dioxide tension and outcome in patients admitted to the intensive care unit after cardiac arrest2013In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 84, no 7, p. 927-934Article in journal (Refereed)
    Abstract [en]

    Background

    Arterial carbon dioxide tension (PaCO2) affects neuronal function and cerebral blood flow. However, its association with outcome in patients admitted to intensive care unit (ICU) after cardiac arrest (CA) has not been evaluated.

    Methods and results

    Observational cohort study using data from the Australian New Zealand (ANZ) Intensive Care Society Adult-Patient-Database (ANZICS-APD). Outcomes analyses were adjusted for illness severity, co-morbidities, hypothermia, treatment limitations, age, year of admission, glucose, source of admission, PaO2 and propensity score.

    We studied 16,542 consecutive patients admitted to 125 ANZ ICUs after CA between 2000 and 2011. Using the APD-PaCO2 (obtained within 24 h of ICU admission), 3010 (18.2%) were classified into the hypo- (PaCO2 < 35 mmHg), 6705 (40.5%) into the normo- (35–45 mmHg) and 6827 (41.3%) into the hypercapnia (>45 mmHg) group. The hypocapnia group, compared with the normocapnia group, had a trend toward higher in-hospital mortality (OR 1.12 [95% CI 1.00–1.24, p = 0.04]), lower rate of discharge home (OR 0.81 [0.70–0.94, p < 0.01]) and higher likelihood of fulfilling composite adverse outcome of death and no discharge home (OR 1.23 [1.10–1.37, p < 0.001]). In contrast, the hypercapnia group had similar in-hospital mortality (OR 1.06 [0.97–1.15, p = 0.19]) but higher rate of discharge home among survivors (OR 1.16 [1.03–1.32, p = 0.01]) and similar likelihood of fulfilling the composite outcome (OR 0.97 [0.89–1.06, p = 0.52]). Cox-proportional hazards modelling supported these findings.

    Conclusions

    Hypo- and hypercapnia are common after ICU admission post-CA. Compared with normocapnia, hypocapnia was independently associated with worse clinical outcomes and hypercapnia a greater likelihood of discharge home among survivors.

  • 46.
    Semenas, Egidijus
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Nozari, Ala
    Department of Anesthesia and Critical Care, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, 02114 Boston, Massachusetts, USA.
    Thiblin, Ingemar
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Forensic Medicine.
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Wiklund, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Modulation of nitric oxide expression with methylene blue does not improve outcome after hypovolemic cardiac arrest2011In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 82, no 10, p. 1344-1349Article in journal (Refereed)
    Abstract [en]

    Aim of the study: We recently reported that female sex protects against cerebral and cardiac injury after hypovolemiccardiac arrest (CA), independent of sex hormone effects. As female sex was also associated with a smaller increase in inducible and neuronal nitric oxide synthase (NOS), we hypothesised that nitric oxide inhibition with methylene blue (MB) improves the outcome, primarily in male animals. Methods: Twenty sexually immature piglets (10 males and 10 females) were bled to mean arterial blood pressure of 35 mmHg, and were subjected to 2 min of untreated CA followed by 8 min of open chest cardiopulmonary resuscitation (CPR). Volume resuscitation was started during CPR with intravenous administration of 3 ml kg(-1) hypertonic saline-dextran. Methyleneblue was then administered as bolus of 2.5 mg kg(-1) over 20 min, followed by 1.5 mg kg(-1) infusion over 40 min. Historical data from 21 animals were used as control (no MB). Hemodynamic parameters, myocardial injury (troponin I), and short-term survival (3-h) were evaluated. Histopathological evaluation of heart specimens was performed. Results: There were no differences between male and female animals in survival or resuscitation rate. After CA female pigletshad significantly greater systolic and mean arterial pressures, and had lower troponin I plasma concentrations compared to malepiglets, with or without MB. No difference was observed in histopathological analysis of heart specimens between sexes. Conclusions: After resuscitation from hypovolemic CA, female sex protects against cardiac injury, independent of sex hormones. Modulation of NO expression with MB does not improve survival or myocardial histological injury in either sex. 

  • 47.
    Semenas, Egidijus
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Nozari, Ala
    Wiklund, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Sex differences in cardiac injury after severe haemorrhage and ventricular fibrillation in pigs2010In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 81, no 12, p. 1718-1722Article in journal (Refereed)
    Abstract [en]

    Aim of the study: Experimental studies have shown sex differences in haemodynamic response and outcome after trauma and haemorrhagic shock. We recently reported that female sex protects against cerebral injury after exsanguination cardiac arrest (CA), independent of sexual effects of hormones. The current study examines if female sex is also cardioprotective.

    Methods: In this study 21 sexually immature piglets (12 males and 9 females) were subjected to 5min of haemorrhagic shock followed by 2min of ventricular fibrillation and 8min of cardiopulmonary resuscitation (CPR). Volume resuscitation was started during CPR with intravenous administration of 3mlkg−1 hypertonic saline-dextran (HSD) solution for 20min. Sexually immature animals were used to differentiate innate sex differences from the effects of sexual hormones. Sex differences in haemodynamics, myocardial injury (troponin I), and short-term survival (3-h) were evaluated.

    Results: After resuscitation female animals had a higher blood pressure, lower heart rate, lower troponin I concentrations, and higher survival rate (100% and 63% in 3h) despite comparable sex hormone levels.

    Conclusions: After resuscitation from haemorrhage and circulatory arrest, haemodynamic parameters are better preserved and myocardial injury is smaller in female piglets. This difference in outcome is independent of sexual hormones.

  • 48.
    Smekal, David
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Hansen, Tomas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Radiology, Oncology and Radiation Science, Radiology.
    Sandler, Håkan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Forensic Medicine.
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Comparison of computed tomography and autopsy in detection of injuries after unsuccessful cardiopulmonary resuscitation2013In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 84, no 3, p. 357-360Article in journal (Refereed)
    Abstract [en]

    AIM:

    Computed tomography (CT) has been suggested as an aid or even a replacement for autopsy. The aim of this trial was to study the conformity of the two methods in finding injuries in non-surviving patients after unsuccessful cardiopulmonary resuscitation.

    METHODS:

    In this prospective study, 31 patients were submitted to a CT prior to autopsy after unsuccessful resuscitation attempts. Pathological findings were noted by both the radiologist and the pathologists in a specified protocol. The pathologists and radiologist were blinded from each other's results.

    RESULTS:

    CT and autopsy revealed rib fractures in 22 and 24 patients respectively (kappa=0.83). In 8 patients, CT revealed more rib fractures than autopsy; and in 12 patients, autopsy revealed more rib fractures than CT. In 7 patients, neither method showed any rib fractures. The mean difference between the two methods in detecting rib fractures was 0.16 (S.D.: ±3.174, limits of agreement: -6.19 to 6.51). The kappa value for sternal fractures was 0.49. A total of 260 pathological findings were noted by CT and 244 by autopsy. The average patient showed a median of 9 injuries (every fracture counted as one injury), independent of the method used in detecting the injuries.

    CONCLUSIONS:

    There was a strong concordance between the two methods in finding rib fractures but not sternal fractures and these results support the concept of CT as a valuable complement to autopsy in detecting rib fractures after unsuccessful cardiopulmonary resuscitation but not as a replacement. Other injuries did not show the same concordance.

  • 49.
    Smekal, David
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Johansson, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Huzevka, Tibor
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    A pilot study of mechanical chest compressions with the LUCAS (TM) device in cardiopulmonary resuscitation2011In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 82, no 6, p. 702-706Article in journal (Refereed)
    Abstract [en]

    Aim: The LUCASTM device has been shown to improve organ perfusion during cardiac arrest in experimental studies. In this pilot study the aim was to compare short-term survival between cardiopulmonary resuscitation (CPR) performed with mechanical chest compressions using the LUCASTM device and CPR performed with manual chest compressions. The intention was to use the results for power calculation in a larger randomised multicentre trial. Methods: In a prospective pilot study, from February 1, 2005, to April 1, 2007, 149 patients with out-of hospital cardiac arrest in two Swedish cities were randomised to mechanical chest compressions or standard CPR with manual chest compressions. Results: After exclusion, the LUCAS and the manual groups contained 75 and 73 patients, respectively. In the LUCAS and manual groups, spontaneous circulation with a palpable pulse returned in 30 and 23 patients (p = 0.30), spontaneous circulation with blood pressure above 80/50 mmHg remained for at least 5 min in 23 and 19 patients (p = 0.59), the number of patients hospitalised alive >4 h were 18 and 15 (p = 0.69), and the number discharged, alive 6 and 7 (p = 0.78), respectively. Conclusions: In this pilot study of out-of-hospital cardiac arrest patients we found no difference in early survival between CPR performed with mechanical chest compression with the LUCASTM device and CPR with manual chest compressions. Data have been used for power calculation in a forthcoming multicentre trial.

  • 50.
    Smekal, David
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Johansson, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Huzevka, Tibor
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    No difference in autopsy detected injuries in cardiac arrest patients treated with manual chest compressions compared with mechanical compressions with the LUCAS device--a pilot study2009In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 80, no 10, p. 1104-1107Article in journal (Refereed)
    Abstract [en]

    AIM: To compare the variety and incidence of internal injuries after manual and mechanical chest compressions during CPR. METHODS: In a prospective pilot study conducted in two Swedish cities, 85 patients underwent autopsy after unsuccessful resuscitation attempts with manual or mechanical chest compressions, the latter with the LUCAS device. Autopsy was performed and the results were evaluated according to a specified protocol. RESULTS: No injuries were found in 26/47 patients in the manual group and in 16/38 patients in the LUCAS group (p=0.28). Sternal fracture was present in 10/47 in the manual group and 11/38 in the LUCAS group (p=0.46), and there were multiple rib fractures (> or =3 fractures) in 13/47 in the manual group and in 17/38 in the LUCAS group (p=0.12). Bleeding in the ventral mediastinum was noted in 2/47 and 3/38 in the manual and LUCAS groups respectively (p=0.65), retrosternal bleeding in 1/47 and 3/38 (p=0.32), epicardial bleeding in 1/47 and 4/38 (p=0.17), and haemopericardium in 4/47 and 3/38 (p=1.0) respectively. One patient in the LUCAS group had a small rift in the liver and one patient in the manual group had a rift in the spleen. These injuries were not considered to have contributed to the patient's death. CONCLUSION: Mechanical chest compressions with the LUCAS device appear to be associated with the same variety and incidence of injuries as manual chest compressions.

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