What is the advice for using TTM after cardiac arrest for those patients with ROSC who are on two vasopressors and require the impella device or IABP for additional support?

摘要

There are several hemodynamic effects of therapeutic hypothermia (TH) including decrease in heart rate, cardiac output and vasoconstriction of peripheral arteries or arteriole which leads to an increase systemic vascular resistance (Saigal S. et al. 2015). Currently in post cardiac arrest patients the use of inotropic are used to increase myocardial contractility and vasopressor therapy increases vascular tone (Bangashm MN., et al. 2012). Inotropes are potentially hazardous in ischemic heart failure due to the increased myocardial oxygen demand, and vasopressors can worsen peripheral tissue perfusion and microcirculation (Bangashm MN., et al. 2012). The CVad Registry indicates there is increased mortality with the increased numbers of inotropes and vasopressor (Basir M, et al.,2016). Mechanical circulatory support (MCS) is considered the standard of care in the treatment of refractory cardiogenic shock. The Intra-aortic balloon pump (IABP) has been used for many years in critical care as a mechanical circulatory support to increase coronary perfusion pressure and reduce the end-diastolic pressure. More recently a single-arm, mul-ticenter study in Detroit using the Impella for mechanical circulatory support showed a significant improvement in mortality (Basir M, et al.,2016; O'Neil et al. 2014). The Impella is placed percutaneously or surgically and produces continuous flow from the left ventricle into the aorta which directly increases cardiac output and reduces cardiac workload. Based on this study and the recent FDA approval for Impella use in cardiogenic shock, there has been an increase use of the Impella devices used in patient undergoing therapeutic hypothermia post cardiac arrest.