title: Intra-aortic administration of epinephrine above an aortic balloon occlusion during experimental CPR does not further improve cerebral blood flow and oxygenation.
abstract: Balloon occlusion of the descending aorta during cardiopulmonary resuscitation (CPR) improves coronary and cerebral blood flow. In comparison with an equivalent dose administered through a central venous catheter it has been suggested that epinephrine administration above the aortic occlusion might produce a more rapid increase in coronary perfusion pressure and a shorter time to restoration of spontaneous circulation (ROSC). In a recent study, however, outcome was not improved after intra-aortic epinephrine administration. We hypothesised that epinephrine administered above the aortic occlusion could impose adverse effects on cerebral blood flow and oxygenation, possibly because of an alpha-adrenergic mediated vasoconstriction in the cerebral vascular beds. Twenty-six piglets underwent 5 min of non intervention cardiac arrest followed by 8 min of closed-chest CPR. They were randomised to receive bolus doses of 45 microg/kg epinephrine either above the aortic occlusion or through a central venous catheter. Cerebral cortical blood flow was continuously measured using laser-Doppler technique. Cerebral tissue pH and PCO(2) were also measured using a multi-parameter fiberoptic device and cerebral oxygen extraction was calculated. Balloon inflation resulted in an immediate enhancement of cerebral cortical blood flow. Each of the epinephrine boluses through the central venous catheter resulted in a transient increase in cerebral cortical blood flow. When administered above the aortic balloon occlusion, epinephrine did not result in a further increase in cerebral cortical blood flow, though a significant increase in cerebral perfusion pressure was recorded throughout the CPR period. Cerebral tissue pH monitoring revealed severe acidosis during CPR and long after ROSC, which was refractory to buffering. No differences in the cerebral oxygen extraction ratio were observed between the groups. In conclusion, epinephrine administration above an aortic balloon occlusion was unable to improve cerebral blood flow and oxygenation. In fact, it may even attenuate the beneficial effects of aortic balloon occlusion on cerebral blood flow due to an alpha-adrenergic mediated cerebral vasoconstriction. Further studies, including dose-response and volumes of distribution, are needed to identify the effective beneficial dosage of epinephrine during aortic occlusion with the least possible adverse effects.
authors.affiliation: Department of Anaesthesiology and Intensive Care, Uppsala University Hospital, Sweden. ala.nozari@anestei.uu.se
authors.forename: A
authors.initials: A
authors.lastname: Nozari
authors.forename: S
authors.initials: S
authors.lastname: Rubertsson
authors.forename: L
authors.initials: L
authors.lastname: Wiklund
mesh_terms: D000818:Animals; D001013:Aorta, Thoracic; D016887:Cardiopulmonary Resuscitation / Q000379:methods; D002404:Catheterization; D002405:Catheterization, Central Venous; D002560:Cerebrovascular Circulation; D004837:Epinephrine / Q000008:administration & dosage* / Q000494:pharmacology; D005260:Female; D008297:Male; D011897:Random Allocation; D013552:Swine; D014662:Vasoconstrictor Agents / Q000008:administration & dosage* / Q000494:pharmacology
chemical_list: D014662:Vasoconstrictor Agents; D004837:Epinephrine