Brain-Oriented Intensive Care: Standardization of Postresuscitation Therapy

  • R. O. Roine
Conference paper


In the United States and in other developed countries, approximately 200 people per 1 million inhabitants are being successfully resuscitated from out-of-hospital cardiac arrest each year. The secondary survival rate, that is, the proportion of patients surviving hospitalization, varies widely and some large metropolitan cities such as Chicago and New York have reported surprisingly low secondary survival rates of out-of-hospital cardiac arrest [1,2]. Of patients admitted to the hospital, more than one-half will die within a few weeks, many of them of hypoxic-ischemic encephalopathy. Hypoxic-ischemic encephalopathy with severe cognitive dysfunction or vegetative state is a feared consequence of cardiac arrest. The severity of global ischemic brain injury cannot be reliably assessed by any conventional neuroradiological or neurophysiological method, nor are there any laboratory tests to differentiate between subsequent recovery and death in comatose patients soon after cardiac arrest.


Cardiac Arrest Global Ischemia Severe Head Injury Global Cerebral Ischemia Advanced Life Support 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


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  1. 1.
    Lombardi G, Gallagher J, Gennis P (1994) Outcome of out-of-hospital cardiac arrest in New York City. The prehospital arrest survival evaluation ( PHASE) study. JAMA 271: 678–683PubMedCrossRefGoogle Scholar
  2. 2.
    Becker LB, Ostrander MP, Barrett J, Kondos GT (1991) Outcome of CPR in a large metropolitan area—where are the survivors? Ann Emerg Med 20: 355–361PubMedCrossRefGoogle Scholar
  3. 3.
    Roine RO, Kaste M, Nikki P, Kinnunen A, Kajaste S (1990) Nimodipine after resuscitation from out-of-hospital ventricular fibrillation: a placebo-controlled, double-blind, randomized trial. JAMA 264: 3171–3177PubMedCrossRefGoogle Scholar
  4. 4.
    Roine RO, Kajaste S, Kaste M (1993) Neuropsychological sequelae of cardiac arrest. JAMA 269: 237–242PubMedCrossRefGoogle Scholar
  5. 5.
    Brain Resuscitation Clinical Trial II Study Group (1991) A randomized clinical study of a calcium-entry blocker (lidoflazine) in the treatment of comatose survivors of cardiac arrest. N Engl J Med 324: 1225–1231CrossRefGoogle Scholar
  6. 6.
    American Heart Association (1992) Guidelines for cardiopulmonary resuscitation and emergency cardiac care. JAMA 268: 2171–2298CrossRefGoogle Scholar
  7. 7.
    European Resuscitation Council Working Party (1993) Adult advanced cardiac life support: the European Resuscitation Council Guidelines 1992 (abridged). Br Med J 306: 1589–1593CrossRefGoogle Scholar
  8. 8.
    Cummins RO, Chamberlain DA, Abramson NS, Allen M, Baskett PJ, Becker L, Bossaert L, DeLooz HH, Dick WF, Eisenberg MS, Evans TR, Holmberg S, Kerber R, Mullie A, Ornato JP, Sandoe E, Skulberg A, Tunsdall-Pedoe H, Swanson R, Thies WH (1991) Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein style. A statement for health professionals from a task force of the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, and the Australian Resuscitation Council. Circulation 84: 960–975PubMedGoogle Scholar
  9. 9.
    Safar P, Bircher NG (1988) Cardiopulmonary cerebral resuscitation. Saunders, LondonGoogle Scholar
  10. 10.
    Safar P (1993) Cerebral resuscitation after cardiac arrest: research initiatives and future directions. Ann Emerg Med 22: 324–349PubMedCrossRefGoogle Scholar
  11. 11.
    Cole SL, Corday E (1956) Four-minute limit for cardiac resuscitation. JAMA 161: 1454–1458CrossRefGoogle Scholar
  12. 12.
    Hossmann K-A, Kleihues P (1973) Reversibility of ischemic brain damage. Arch Neurol 29: 375–384PubMedCrossRefGoogle Scholar
  13. 13.
    Pulsinelli WA, Brierley JB, Plum F (1984) Temporal profile of neuronal damage in a model of transient forebrain ischemia. Ann Neurol 11: 491–498CrossRefGoogle Scholar
  14. 14.
    Astrup J, Symon L, Branston NM, Lassen NA (1977) Cortical evoked potential and extracellular K+ and H+ at critical levels of brain ischemia. Stroke 8: 51–57PubMedCrossRefGoogle Scholar
  15. 15.
    Lewis LM, Gomez CR, Ruoff BE, Gomez SM, Hall IS, Gasirowski B (1990) Transcranial Doppler determination of cerebral perfusion in patients undergoing CPR: methodology and preliminary findings. Ann Emerg Med 19: 1148–1151PubMedCrossRefGoogle Scholar
  16. 16.
    Madl C, Grimm G, Kramer L, Yeganehfar W, Sterz F, Schneider B, Kranz A, Schneeweiss B, Lenz B (1993) Early prediction of individual outcome after cardiopulmonary resuscitation. Lancet 341: 855–858PubMedCrossRefGoogle Scholar
  17. 17.
    Jordan KG (1992) Non-convulsive seizures (NCS) and non-convulsive status epilepticus (NCSE) detected by continuous EEG monitoring in the neuro-ICU (abstr). Neurology 42 (suppl 3): 194Google Scholar
  18. 18.
    Cruz J (1993) On-line monitoring of global cerebral hypoxia in acute brain injury. Relationship to intracranial hypertension. J Neurosurg 79: 228–233PubMedCrossRefGoogle Scholar
  19. 19.
    Harper AM, Glass HI (1965) Effect of alterations in the arterial carbon dioxide tension on the blood flow through the cerebral cortex at normal and low arterial blood pressures. J Neurol Neurosurg Psychiatry 28: 449–452PubMedCrossRefGoogle Scholar
  20. 20.
    Muizelaar JP, Marmarou A, Ward JD, Kontos HA, Choi SC, Becker DP (1991) Adverse effects of prolonged hyperventilation in patients with severe head injury. A randomized clinical trial. J Neurosurg 75: 731–739PubMedCrossRefGoogle Scholar
  21. 21.
    Andrews BT, Weinstein PR (1990) Protection from cerebral ischemia by hyperoxygenation. In: Weinstein PR, Faden AI (eds) Protection of the brain from ischemia. Williams and Wilkins, Baltimore, pp 207–212Google Scholar
  22. 22.
    Mickel HS, Vaishnav YN, Kempski O, Von Lubitz D, Weiss JF, Feuerstein G (1987) Breathing 100% oxygen after global brain ischemia in mongolian gerbils results in increased lipid peroxidation and increased mortality. Stroke 18: 426–430PubMedCrossRefGoogle Scholar
  23. 23.
    Rockswold GL, Ford SE, Anderson DC, Bergman TA, Sherman RE (1992) Results of a prospective randomized trial for treatment of severely brain-injured patients with hyperbaric oxygen. J Neurosurg 76: 929–934PubMedCrossRefGoogle Scholar
  24. 24.
    Piek J, Chestnut RM, Marshall LF, Van Berkum-Clarke M, Klauber MR, Blunt BA, Eisenberg HM, Jane JA, Marmarou A, Foulkes MA (1992) Extracranial complications of severe head injury. J Neurosurg 77: 901–907PubMedCrossRefGoogle Scholar
  25. 25.
    Thomas DJ (1982) Whole blood viscosity and cerebral blood flow. Stroke 12: 285–287CrossRefGoogle Scholar
  26. 26.
    Leonov Y, Sterz F, Safar P, Johnson DW, Tisherman SA, Oku K (1992) Hypertension with hemodilution prevents multifocal cerebral hypoperfusion after cardiac arrest in dogs. Stroke 23: 45–53PubMedCrossRefGoogle Scholar
  27. 27.
    Strandgaard S (1976) Autoregulation of cerebral blood flow in hypertensive patients. The modifying influence of prolonged antihypertensive treatment on the tolerance to acute, drug-induced hypotension. Circulation 53: 720–727PubMedGoogle Scholar
  28. 28.
    Castillo J, Martinez F, Leira R, Prieto JM, Lema M, Noya M (1994) Mortality and morbidity of acute cerebral infarction related to temperature and basal analytic parameters. Cerebrovasc Dis 4: 66–71CrossRefGoogle Scholar
  29. 29.
    Astrup J, Srensen PM, Srensen HR (1981) Inhibition of cerebral oxygen and glucose consumption in the dog by hypothermia, pentobarbital and lidocaine. Anesthesiology 55: 263–268PubMedCrossRefGoogle Scholar
  30. 30.
    Steinman AM (1986) Cardiopulmonary resuscitation and hypothermia. Circulation 74 (suppl 4): 29–32Google Scholar
  31. 31.
    Crittenden MD, Roberts CS, Rosa L, Vatsia SK, Katz D, Clark RE, Swain JA (1991) Brain protection during surgery. Ann Thorac Surg 51: 942–947PubMedCrossRefGoogle Scholar
  32. 32.
    Busto R, Dietrich WD, Globus MY-T, Valdes I, Scheinberg P, Ginsberg M (1987) Small differences in intraischemic brain temperature critically determine the extent of ischemic neuronal injury. J Cereb Blood Flow Metab 7: 729–738PubMedCrossRefGoogle Scholar
  33. 33.
    Weinrauch V, Safar P, Tisherman S, Kuboyama K, Radovsky A (1992) Beneficial effect of mild hypothermia and detrimental effect of deep hypothermia after cardiac arrest in dogs. Stroke 23: 1454–1462PubMedCrossRefGoogle Scholar
  34. 34.
    Sterz F, Safar P, Tisherman S, Radovsky A, Kuboyama K, Oku K (1991) Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs. Crit Care Med 19: 379–389PubMedCrossRefGoogle Scholar
  35. 35.
    Baiping L, Xiujuan T, Hongwei C, Qiming X, Outing G (1993) Effect of moderate hypothermia on lipid peroxidation in canine brain tissue after cardiac arrest and resuscitation. Stroke 25: 147–152Google Scholar
  36. 36.
    Takino M, Okada Y (1991) Hyperthermia following cardiopulmonary resuscitation. Intensive Care Med 17: 419–420PubMedCrossRefGoogle Scholar
  37. 37.
    Gueugniaud PY, Garcia Darennes F, Gaussorgues P, Bancalari G, Petit P. Robert D (1991) Prognostic significance of early intracranial and cerebral perfusion pressures in post-cardiac arrest anoxic coma. Intensive Care Med 17: 392–398PubMedCrossRefGoogle Scholar
  38. 38.
    Dougherty JH, Rawlinson DG, Levy DE, Plum F (1981) Hypoxic-ischemic brain injury and the vegetative state: clinical and neuropathologie correlation. Neurology 31: 991–997PubMedGoogle Scholar
  39. 39.
    Lanier WL, Strangland KJ, Scheithauer BW, Milde JH, Michenfelder JD (1987) The effects of dextrose infusion and head position on neurologic outcome after complete cerebral ischemia in primates: examination of a model. Anesthesiology 66: 39–48PubMedCrossRefGoogle Scholar
  40. 40.
    Myers RE, Yamaguchi S (1977) Nervous system effects of cardiac arrest in monkeys. Arch Neurol 34: 65–74PubMedCrossRefGoogle Scholar
  41. 41.
    Chopp M. Welch KMA, Tidwell CD, Helpern JA (1988) Global cerebral ischemia and intracellular pH during hyperglycemia and hypoglycemia in cats. Stroke 19: 1383–1387PubMedCrossRefGoogle Scholar
  42. 42.
    Strong AJ. Fairfield JE, Montero E, Kirby M, Hogg AR, Snape M. Ross-Field L (1990) Insulin protects cognitive function in experimental stroke. J Neurol Neurosurg Psychiatry 53: 847–853PubMedCrossRefGoogle Scholar
  43. 43.
    Lundy EF, Kuhn JE, Kwon JM (1987) Infusion of 5% dextrose increases mortality and morbidity following six minutes of cardiac arrest in resuscitated dogs. J Crit Care 2: 4–14CrossRefGoogle Scholar
  44. 44.
    Sieber FE, Traystman RJ (1992) Special issues: glucose and the brain. Crit Care Med 20: 104–114PubMedCrossRefGoogle Scholar
  45. 45.
    Lam AM, Winn HR. Cullen BF. Sundling N (1991) Hyperglycemia and neurological outcome in patients with head injury. J Neurosurg 75: 545–551PubMedCrossRefGoogle Scholar
  46. 46.
    Lanzing G, Kassell NF, Germanson T, Truskowski L, Alves W (1993) Plasma glucose levels and outcome after aneurysmal subarachnoid hemorrhage. J Neurosurg 79: 885–891CrossRefGoogle Scholar
  47. 47.
    Longstreth WT, Inui TS (1984) High blood glucose level on hospital admission and poor neurological recovery after cardiac arrest. Ann Neurol 15: 59–63PubMedCrossRefGoogle Scholar
  48. 48.
    Scriabine A, Teasdale GM, Tettenborn D, eds (1991) Nimodipine. Pharmacological and clinical results in cerebral ischemia. Springer, BerlinGoogle Scholar
  49. 49.
    Gaab MR, Hollerhage HG. Walter GF. Hocheder M. Haubitz I (1990) Brain edema, autoregulation, and calcium antagonism. An experimental study with nimodipine. Adv Neurol 52: 391–400PubMedGoogle Scholar
  50. 50.
    Uematsu D, Araki N, Greenberg JH (1991) Combined therapy with MK-801 and nimodipine for protection of ischaemic brain damage. Neurology 41: 88–94PubMedGoogle Scholar
  51. 51.
    Ward JD, Becker DP, Miller DJ (1985) Failure of prophylactic barbiturate coma in the treatment of severe head trauma. J Neurosurg 62: 383–388PubMedCrossRefGoogle Scholar
  52. 52.
    Brain Resuscitation Clinical Trial I Study Group (1986) Randomized clinical study of thiopental loading in comatose survivors of cardiac arrest. N Engl J Med 314: 397–403CrossRefGoogle Scholar
  53. 53.
    Grafton ST, Longstreth WT (1988) Steroids after cardiac arrest: a retrospective study with concurrent, nonrandomized controls. Neurology 38: 1315–1316PubMedGoogle Scholar
  54. 54.
    Jastremski M, Sutton-Tyrrell K, Vaagenes P. Abramson N, Heiselman D, Safar P, the Brain Resuscitation Clinical Trial I Study Group (1989) Glucocorticoid treatment does not improve neurological recovery following cardiac arrest. JAMA 262: 3427–3430PubMedCrossRefGoogle Scholar
  55. 55.
    Braakman R, Schouten HJ, Dishoeck MB, Minderhoud JM (1983) Megadose steroids in severe head injury: results of a prospective double-blind clinical trial. J Neurosurg 58: 326–330PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Tokyo 1995

Authors and Affiliations

  • R. O. Roine
    • 1
  1. 1.Department of NeurologyUniversity of HelsinkiHelsinkiFinland

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