Re: Neural injury after use of vasopressin and adrenaline during porcine cardiopulmonary resuscitati Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=iups20 Upsala Journal of Medical Sciences ISSN: 0300-9734 (Print) 2000-1967 (Online) Journal homepage: https://www.tandfonline.com/loi/iups20 Re: Neural injury after use of vasopressin and adrenaline during porcine cardiopulmonary resuscitation Eric M Rottenberg To cite this article: Eric M Rottenberg (2015) Re: Neural injury after use of vasopressin and adrenaline during porcine cardiopulmonary resuscitation, Upsala Journal of Medical Sciences, 120:3, 213-214, DOI: 10.3109/03009734.2015.1021936 To link to this article: https://doi.org/10.3109/03009734.2015.1021936 © Informa Healthcare Published online: 15 Mar 2015. Submit your article to this journal Article views: 316 View related articles View Crossmark data https://www.tandfonline.com/action/journalInformation?journalCode=iups20 https://www.tandfonline.com/loi/iups20 https://www.tandfonline.com/action/showCitFormats?doi=10.3109/03009734.2015.1021936 https://doi.org/10.3109/03009734.2015.1021936 https://www.tandfonline.com/action/authorSubmission?journalCode=iups20&show=instructions https://www.tandfonline.com/action/authorSubmission?journalCode=iups20&show=instructions https://www.tandfonline.com/doi/mlt/10.3109/03009734.2015.1021936 https://www.tandfonline.com/doi/mlt/10.3109/03009734.2015.1021936 http://crossmark.crossref.org/dialog/?doi=10.3109/03009734.2015.1021936&domain=pdf&date_stamp=2015-03-15 http://crossmark.crossref.org/dialog/?doi=10.3109/03009734.2015.1021936&domain=pdf&date_stamp=2015-03-15 Upsala Journal of Medical Sciences. 2015; 120: 213–214 LETTER TO THE EDITOR Re: Neural injury after use of vasopressin and adrenaline during porcine cardiopulmonary resuscitation ERIC M ROTTENBERG Columbus, Ohio, USA Dear Editor, Halvorsen and colleagues (1) investigated cerebral and cardiac tissue injury subsequent to use of vaso- pressin and adrenaline in combination compared with vasopressin alone during cardiopulmonary resuscita- tion (CPR). They concluded that combined use of vasopressin and adrenaline caused greater signs of cerebral and cardiac injury than use of vasopressin alone during experimental CPR. However, given that epinephrine was administered after 12 min of untreated ventricular fibrillation (VF), these results are not surprising. First, neurologically intact survival to hospital discharge after in-hospital cardiac arrest has been found to be significantly more likely after earlier epi- nephrine administration (2). This recent retrospective evaluation of more than 25,000 patients (at 570 US hospitals), who were not in intensive care units or emergency departments and who exhibited initial rhythms of asystole or pulseless electrical activity (PEA), found that delayed administration of epineph- rine (>3 min) was associated significantly with lower chance for survival to hospital discharge, in stepwise fashion (12%, 10%, 8%, and 7% survival, respectively, for patients receiving their first epinephrine dose £3, 4–6, 7–9, and >9 min after arrest (p < 0.001). Second, as the authors already understand from their previous work in a swine model of hemorrhagic circulatory arrest that applied 15 min of open-chest CPR after 8 min of untreated VF, intracranial pressure (ICP) in the post-resuscitation phase is greaterwith use of adrenalin versus vasopressin, but with no significant difference in neuronal injury (3). However, one pos- sible explanation for the lack of difference in neuronal injury could be that open-chest CPR does not raise intrathoracic pressure; therefore, it does not raise ICP. It has been postulated that without effective-depth chest compressions with complete recoil and/or gasp- ing to maintain lower ICP, adrenaline administration has a strong potential to result in poor survival and neurological outcome (4). The elevation of intratho- racic pressure during chest compression generates carotid pressure and flow but also increases ICP, which may be what limits cerebral blood flow (5-7). The lower the ICP is, the lower is the resistance to forward blood flow to the brain. Allowing complete sternal recoil after effective-depth compressions results in less intrathoracic pressure; this in turn produces greater coronary and cerebral perfusion (because of the greater perfusion pressures produced by the effective-depth chest compressions) and lower increases in ICP (because of the complete sternal recoil). While Lund University Cardiopulmonary Assist System (LUCAS) CPR ensures effective-depth compression with complete recoil, it may not mitigate enough the increased ICP generated during chest compressions without the aid of gasping, unless per- haps an inspiratory impedance valve is used (8). Gasping alone during VF arrest improves cerebral perfusion and decreases ICP (9). Therefore, without a means to mitigate intracranial pressure adequately during CPR, late adrenaline administration resulted in greater neural injury and, as evidenced, has a strong potential to result in poor survival and neurological outcome. Declaration of interest: The author reports no conflicts of interest. Correspondence: Eric M. Rottenberg, AAS, 301B Fenway Road, Columbus, Ohio 43214, USA. E-mail: rottenberg.1@osu.edu (Received 8 February 2015; accepted 17 February 2015) ISSN 0300-9734 print/ISSN 2000-1967 online � 2015 Informa Healthcare DOI: 10.3109/03009734.2015.1021936 http://informahealthcare.com/journal/ups mailto:rottenberg.1@osu.edu References 1. Halvorsen P, Sharma HS, Basu S, Wiklund L. Neural injury after use of vasopressin and adrenaline during porcine cardio- pulmonary resuscitation. Ups J Med Sci. 2015;120:11–19. 2. Donnino MW, Salciccioli JD, Howell MD, Cocchi MN, Giberson B, Berg K, et al. Time to administration of epineph- rine and outcome after in-hospital cardiac arrest with non- shockable rhythms: retrospective analysis of large in-hospital data registry. BMJ. 2014;348:g3028. 3. Semenas E, Sharma HS, Wiklund L. Adrenaline increases blood-brain-barrier permeability after haemorrhagic cardiac arrest in immature pigs. Acta Anaesthesiol Scand. 2014;58: 620–9. 4. Rottenberg EM. Should unobstructed gasping be facilitated and confirmed before administering adrenaline, otherwise, give titrated vasopressin? Am J Emerg Med 2015;33:286–9. 5. Yannopoulos D, McKnite S, Aufderheide TP, Sigurdsson G, Pirrallo RG, Benditt D, et al. Effects of incomplete chest wall decompression during cardiopulmonary resuscitation on coronary and cerebral perfusion pressures in a porcine model of cardiac arrest. Resuscitation. 2005;64:363–72. 6. Rubertsson S, Karlsten R. Increased cortical cerebral blood flow with LUCAS; a new device for mechanical chest compres- sions compared to standard external compressions during experimental cardiopulmonary resuscitation. Resuscitation. 2005;65:357–63. 7. Guerci AD, Shi AY, Levin H, Tsitlik J, Weisfeldt ML, Chandra N. Transmission of intrathoracic pressure to the intracranial space during cardiopulmonary resuscitation in dogs. Circ Res. 1985;56:20–30. 8. Pantazopoulos IN, Xanthos TT, Vlachos I, Troupis G, Kotsiomitis E, Johnson E, et al. Use of the impedance threshold device improves survival rate and neurological outcome in a swine model of asphyxial cardiac arrest. Crit Care Med. 2012; 40:861–8. 9. Srinivasan V, Nadkarni VM, Yannopoulos D, Marino BS, Sigurdsson G, McKnite SH, et al. Spontaneous gasping decreases intracranial pressure and improves cerebral perfusion in a pig model of ventricular fibrillation. Resuscitation. 2006; 69:329–34. 214 E. M. Rottenberg http://www.ncbi.nlm.nih.gov/pubmed/24846323?dopt=Abstract http://www.ncbi.nlm.nih.gov/pubmed/24846323?dopt=Abstract http://www.ncbi.nlm.nih.gov/pubmed/24846323?dopt=Abstract http://www.ncbi.nlm.nih.gov/pubmed/24846323?dopt=Abstract http://www.ncbi.nlm.nih.gov/pubmed/24580085?dopt=Abstract http://www.ncbi.nlm.nih.gov/pubmed/24580085?dopt=Abstract http://www.ncbi.nlm.nih.gov/pubmed/24580085?dopt=Abstract http://www.ncbi.nlm.nih.gov/pubmed/15733767?dopt=Abstract http://www.ncbi.nlm.nih.gov/pubmed/15733767?dopt=Abstract http://www.ncbi.nlm.nih.gov/pubmed/15733767?dopt=Abstract http://www.ncbi.nlm.nih.gov/pubmed/15733767?dopt=Abstract http://www.ncbi.nlm.nih.gov/pubmed/15919574?dopt=Abstract http://www.ncbi.nlm.nih.gov/pubmed/15919574?dopt=Abstract http://www.ncbi.nlm.nih.gov/pubmed/15919574?dopt=Abstract http://www.ncbi.nlm.nih.gov/pubmed/15919574?dopt=Abstract http://www.ncbi.nlm.nih.gov/pubmed/3967345?dopt=Abstract http://www.ncbi.nlm.nih.gov/pubmed/3967345?dopt=Abstract http://www.ncbi.nlm.nih.gov/pubmed/3967345?dopt=Abstract http://www.ncbi.nlm.nih.gov/pubmed/21983368?dopt=Abstract http://www.ncbi.nlm.nih.gov/pubmed/21983368?dopt=Abstract http://www.ncbi.nlm.nih.gov/pubmed/21983368?dopt=Abstract http://www.ncbi.nlm.nih.gov/pubmed/16494991?dopt=Abstract http://www.ncbi.nlm.nih.gov/pubmed/16494991?dopt=Abstract http://www.ncbi.nlm.nih.gov/pubmed/16494991?dopt=Abstract ss1 Declaration of interest References