Cochabamba - Bolivia2011

Dr. Roberto E. Gutiérrez DoradoMedicina Crítica y Terapia Intensiva

Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes. 2010;3:63– 81.

Stiell IG, Wells GA, Field B, Spaite DW, Nesbitt LP, De Maio VJ, et al. Advanced cardiac life support in out-of-hospital cardiac arrest.

N Engl J Med. 2004;351:647–56.

Peberdy MA, Kaye W, Ornatto JP. Post-resuscitation care: Is it the missing link in the Chain of Survival? Resuscitation. 2005;64:135–7.

Negovsky VA. The second step in resuscitation the treatment of the ‘post-resuscitation disease’. Resuscitation 1972;1:1—7.

Negovsky VA. Postresuscitation disease. Crit Care Med. 1988;16:942—6.

Vladimir A. Negovsky (1909-2003)

Neumar RW , Nolan JP , et al. A consensus statement from the International Liaison Committee on Resuscitation, pathophysiology, treatment, and prognostication. Circulation. 2008;118:2452–83.

Nolan JP, et al. A Scientific Statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee. Resuscitation. 2008;79:350–79.

1. Fase inmediata: los primeros 20 min tras la RCE.

2. Fase precoz: desde los 20 min hasta las 6–12 h.

3. Fase intermedia: desde las 6–12 hasta las 72 h.

4. Fase de recuperación: a partir de las 72 h.

5. Fase de rehabilitación: desde el alta hospitalaria.

Nolan JP, et al. A Scientific Statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee. Resuscitation. 2008;79:350–

79. Neumar RW , Nolan JP , et al. A consensus statement from the International Liaison Committee on

Resuscitation, pathophysiology, treatment, and prognostication. Circulation. 2008;118:2452–83.

Jones AE, Shapiro NI, Kilgannon JH, Trzeciak S. Goal-directed hemodynamic optimization in the post-cardiac arrest syndrome: A systematic review. Resuscitation.2008;77:26–9.

D.F. Gaieski et al. Early goal-directed hemodynamic optimization combined with therapeutichypothermia in comatose survivors of out-of-hospital cardiac arrest. Resuscitation 80 (2009) 418–424

D.F. Gaieski et al. Early goal-directed hemodynamic optimization combined with therapeutichypothermia in comatose survivors of out-of-hospital cardiac arrest. Resuscitation 80 (2009) 418–424

H. Martín-Hernández, J.B. López-Messa, J.L. Pérez-Vela, R. Molina-Latorre, A. Cárdenas-Cruz, A. Lesmes-Serrano, J.A. Álvarez-Fernández, F. Fonseca-San Miguel, L.M. Tamayo-Lomas y P. Herrero-

Ansolai, miembros del Comité Directivo del Plan Nacional de RCP de la SEMICYUC. Manejo del síndrome posparada cardíaca (DOCUMENTO DE CONSENSO). Med Intensiva. 2010;34(2):107–126

Kilgannon JH, Roberts BW, Reihl LR, Chansky ME , Jones AE , Dellinger RP, et al. Early arterial hypotension is common in the post-cardiac arrest syndrome and associated with increased in- hospital

mortality. Resuscitation. 2008;79:410–6.

Kilgannon JH, Jones AE, Shapiro NI, Angelos MG, Milcarek B, Hunter K, Parrillo JE, Trzeciak S; Emergency Medicine Shock Research Network Investigators. Association between arterial hyperoxia

following resuscitation from cardiac arrest and in-hospital mortality. JAMA. 2010; 303:2165–2171.

Nadine Cueni-Villoz et al, Increased blood glucose variability during therapeutic hypothermiaand outcome after cardiac arrest. Crit Care Med 2011; 39:000–000

Ka Wai Cheung, Robert S. Green, Kirk D. Magee. Systematic review of randomized controlled trials of therapeutic hypothermia as a neuroprotectant in post cardiac arrest patients. Can J Emerg Med 2006;8(5):329-37

Ka Wai Cheung, Robert S. Green, Kirk D. Magee. Systematic review of randomized controlled trials of therapeutic hypothermia as a neuroprotectant in post cardiac arrest patients.

Can J Emerg Med 2006;8(5):329-37

60 -

50 -

40 -

30 -

20 -

10 -

0 -

39 %

55 %

The Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve

the neurologic outcome after cardiac arrest. NEJM 2002;346:549-556

60 -

50 -

40 -

30 -

20 -

10 -

0 -

Bernard, S.A. et al. Treatment of comatose survivors of out-of-hospital cardiac arrest

with induced hypothermia. NEJM 2002;346:557-563

Normotermia Hipotermia

26 %

49 %

Normotermia Hipotermia

P = 0,046

P = 0,009

Polderman, D. H. et al. Induced hypothermia improves neurological outcome in asystolic patients with out-of-hospital cardiac arrest. Circulation 2003;108:IV-581

90 -

80 -

70 -

60 -

50 -

40 -

30 -

20 -

10 -

0 -

Grupo control Grupo de hipotermia

20 %

78 %

41 %

56 %

Glasgow de 15 en la UTI

Mortalidad a 6 meses

Laver SR, Padkin A, Atalla A, Nolan JP. Therapeutic hypothermia after cardiac arrest: A survey of practice in intensive care units in the United Kingdom. Anaesthesia. 2006;61:873–7.

¿Cuando?

¿Durante cuánto tiempo?

¿Hasta qué temperatura? y ¿A qué velocidad?

¿Cómo monitorizar la temperatura?

La administración de cristaloides 30–40 ml/kg enfriados a 4 ºC. (SFL 0,9% o solución RL). + Bolsas de hielo

Técnicas de superficie.

Técnicas endovasculares.

Se recomienda a 0,25 – 0,5 ºC por hora.

Michael Holzer, M.D. Targeted Temperature Management for Comatose Survivors of Cardiac Arrest. N Engl J Med 2010;363:1256-64.

Sistema intravascular Coolgard Alsius®

Anna Finley Caulfield, et al,Comparison of Cooling Techniques to Treat Cardiac Arrest Patients with Hypothermia. Stroke Research and Treatment

Volume 2011, Article ID 690506, 6 pages doi:10.4061/2011/690506

Andreas Schneider, Bernd W. Böttiger, Erik Popp. Cerebral Resuscitation After Cardiocirculatory Arrest. Anesth Analg 2009;108:971–9

Muerte neuronal retardada, después de la isquemia cerebral global

Neuronas piramidales del hipocampo (Ratas) después de10 minutos de isquemia cerebro transitoria.

HIP

CA1

24 Horas 36 Horas 48 Horas

CA1

CA3DG

10 min. 1 h. 6 h.

HT local cabeza.

HT Sistémica.

Emanuela Keller, Regina Mudra, Christoph Gugl, Martin Seule, Susanne Mink, Juerg Fröhlich. Theoretical evaluations of therapeutic systemic and local cerebral hypothermia. Journal of

Neuroscience Methods Volume 178, April 2009, 345-349

HT local cuello.

Wolfgang Weihs, Alexandra Schratter, Fritz Sterz, , Andreas Janata, Sandra Högler, Michael Holzer, ∗Udo M. Losert, Harald Herkner, Wilhelm Behringer. The importance of surface area for the cooling

efficacy of mild therapeutic hypothermia. Resuscitation 82 (2011) 74–78

Maaret Castrén. Intra-Arrest Transnasal Evaporative Cooling A Randomized, Prehospital, Multicenter Study (PRINCE: Pre-ROSC IntraNasal Cooling Effectiveness). Circulation. 2010;122:729-736.

Florence Dumas, et al. Immediate Percutaneous Coronary Intervention Is Associated With Better Survival After Out-of-Hospital Cardiac Arrest : Insights From the PROCAT (Parisian Region Out of

Hospital Cardiac Arrest) Registry. Circ Cardiovasc Interv 2010;3;200-207

Bernd W. Böttiger, Et al. for the TROICA Trial Investigators and the European Resuscitation Council Study Group*. Thrombolysis during resuscitation for out-of-hospital cardiac arrest.

N Engl J Med. 2008;359:2651–62. 9;53:409–15.

Matthias Götberg. A Pilot Study of Rapid Cooling by Cold Saline and Endovascular Cooling Before Reperfusion in Patients With ST-Elevation Myocardial Infarction.

Circ Cardiovasc Interv. 2010;3:400-407.

L.M. Batista et al. Feasibility and safety of combined percutaneous coronary intervention andtherapeutic hypothermia following cardiac arrest. Resuscitation 81 (2010) 398–403

Tortorici MA, Kochanek PM, Poloyac SM. Effects of hypothermia on drug disposition, metabolism, and response: A focus of hypothermia mediated alterations on the cytochrome P450 enzyme system.

Crit Care Med. 2007;35:2196–204.

Michael Holzer, M.D. Targeted Temperature Managementfor Comatose Survivors of Cardiac Arrest. N Engl J Med 2010;363:1256-64.

Tortorici MA, Kochanek PM, Poloyac SM. Effects of hypothermia on drug disposition, metabolism, and response: A focus of hypothermia mediated alterations on the cytochrome P450 enzyme system.

Crit Care Med. 2007;35:2196–204.

Wijdicks EFM, Hijdra A, Young GB, et al. Practice parameter: prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidencebased review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2006; 67:203-

10.

G. Bryan Young, M.D. Neurologic Prognosis after Cardiac Arrest. N Engl J Med 2009;361:605-11.

Dion Stub, Stephen Bernard, Stephen J. Duffy and David M. Kaye. Post Cardiac Arrest Syndrome: A Review of Therapeutic Strategies. Circulation 2011;123;1428-1435.

A. C. Binks, R. E. Murphy, R. E. Prout, S. Bhayani, C. A. Griffiths, T. Mitchell, A. Padkin and J. P. Nolan. Therapeutic hypothermia after cardiac arrest implementation in UK intensive care units. Anaesthesia, 2010, 65, pages 260–265.

El uso de hipotermia terapéutica por 208 ICUs. Los valores en número (proporción)