Hands-On Times, Adherence to Recommendations and Variance in Execution among Three Different CPR Algorithms: A Prospective Randomized Single-Blind Simulator-Based Trial

Background: Alternative cardiopulmonary resuscitation (CPR) algorithms, introduced to improve outcomes after cardiac arrest, have so far not been compared in randomized trials with established CPR guidelines. Methods: 286 physician teams were confronted with simulated cardiac arrests and randomly allocated to one of three versions of a CPR algorithm: (1) current International Liaison Committee on Resuscitation (ILCOR) guidelines (“ILCOR”), (2) the cardiocerebral resuscitation (“CCR”) protocol (3 cycles of 200 uninterrupted chest compressions with no ventilation), or (3) a local interpretation of the current guidelines (“Arnsberg“, immediate insertion of a supraglottic airway and cycles of 200 uninterrupted chest compressions). The primary endpoint was percentage of hands-on time. Results: Median percentage of hands-on time was 88 (interquartile range (IQR) 6) in “ILCOR” teams, 90 (IQR 5) in “CCR” teams (p = 0.001 vs. “ILCOR”), and 89 (IQR 4) in “Arnsberg” teams (p = 0.032 vs. “ILCOR”; p = 0.10 vs. “CCR”). “ILCOR” teams delivered fewer chest compressions and deviated more from allocated targets than “CCR” and “Arnsberg” teams. “CCR” teams demonstrated the least within-team and between-team variance. Conclusions: Compared to current ILCOR guidelines, two alternative CPR algorithms advocating cycles of uninterrupted chest compressions resulted in very similar hands-on times, fewer deviations from targets, and less within-team and between-team variance in execution.

Comparison of Continuous Versus Interrupted Chest Compressions during CPR in a Rural Community

Introduction. Cardiopulmonary resuscitation (CPR) in patientswith out-of-hospital cardiac arrest (OHCA) have interruption ofmanual chest compressions for airway management and breathingwhen performed by medical personnel trained by Advanced CardiacLife Support (ACLS) standards. This interruption likely reducesblood flow and possibly survival. Traditional CPR (30:2 compressionsto ventilations) was compared with continuous chest compressions,CCC (also termed Cardiocerebral Resuscitation, CCR) in a ruralcommunity. Methods. A retrospective cohort analysis of three years of traditionalCPR (June 2008 - May 2011) for OHCA was compared tothree years of using CCC protocols (June 2011 - May 2014). Primaryoutcomes were survival at one and six months. Results. There were 58 0HCA patients in the six year study period(June 2008 - May 2014). Forty (69%) received CPR and 18 (31%)received CCC. Two (5%) survived at least one month with CPR andeight (44%) survived at least one month with CCC (p = 0.0007).After six months, 0/40 (0%) who received CPR had survived and6/18 (33%) who received CCC survived (p = 0.0018). For the patientfound in ventricular fibrillation or tachycardia (a shockable rhythm),0/13 (0.0%) survived one month after CPR and 7/9 (78%) survivedwith CCC (p < 0.01). After six months 0/13 (0.0%) survived withCPR and 6/9 (67%) survived with CCC (p < 0.05). Conclusions. For patients in a rural environment with OHCA, CCChad a more favorable outcome than traditional CPR. For the patientfound in ventricular fibrillation or ventricular tachycardia, there wasa profound survival benefit of CCC over CPR.Kans J Med 2018;11(4):110-113.

Featured Article: Pyruvate preserves antiglycation defenses in porcine brain after cardiac arrest

Cardiac arrest (CA) and cardiocerebral resuscitation (CCR)-induced ischemia–reperfusion imposes oxidative and carbonyl stress that injures the brain. The ischemic shift to anaerobic glycolysis, combined with oxyradical inactivation of glyceraldehyde 3-phosphate dehydrogenase (GAPDH), provokes excessive formation of the powerful glycating agent, methylglyoxal. The glyoxalase (GLO) system, comprising the enzymes glyoxalase 1 (GLO1) and GLO2, utilizes reduced glutathione (GSH) supplied by glutathione reductase (GR) to detoxify methylglyoxal resulting in reduced protein glycation. Pyruvate, a natural antioxidant that augments GSH redox status, could sustain the GLO system in the face of ischemia–reperfusion. This study assessed the impact of CA-CCR on the cerebral GLO system and pyruvate’s ability to preserve this neuroprotective system following CA. Domestic swine were subjected to 10 min CA, 4 min closed-chest CCR, defibrillation and 4 h recovery, or to a non-CA sham protocol. Sodium pyruvate or NaCl control was infused (0.1 mmol/kg/min, intravenous) throughout CCR and the first 60 min recovery. Protein glycation, GLO1 content, and activities of GLO1, GR, and GAPDH were analyzed in frontal cortex biopsied at 4 h recovery. CA-CCR produced marked protein glycation which was attenuated by pyruvate treatment. GLO1, GR, and GAPDH activities fell by 86, 55, and 30%, respectively, after CA-CCR with NaCl infusion. Pyruvate prevented inactivation of all three enzymes. CA-CCR sharply lowered GLO1 monomer content with commensurate formation of higher molecular weight immunoreactivity; pyruvate preserved GLO1 monomers. Thus, ischemia–reperfusion imposed by CA-CCR disabled the brain’s antiglycation defenses. Pyruvate preserved these enzyme systems that protect the brain from glycation stress. Impact statement Recent studies have demonstrated a pivotal role of protein glycation in brain injury. Methylglyoxal, a by-product of glycolysis and a powerful glycating agent in brain, is detoxified by the glutathione-catalyzed glyoxalase (GLO) system, but the impact of cardiac arrest (CA) and cardiocerebral resuscitation (CCR) on the brain’s antiglycation defenses is unknown. This study in a swine model of CA and CCR demonstrated for the first time that the intense cerebral ischemia–reperfusion imposed by CA-resuscitation disabled glyoxalase-1 and glutathione reductase (GR), the source of glutathione for methylglyoxal detoxification. Moreover, intravenous administration of pyruvate, a redox-active intermediary metabolite and antioxidant in brain, prevented inactivation of glyoxalase-1 and GR and blunted protein glycation in cerebral cortex. These findings in a large mammal are first evidence of GLO inactivation and the resultant cerebral protein glycation after CA-resuscitation, and identify novel actions of pyruvate to minimize protein glycation in postischemic brain.