**11. Pre-hospital cooling**

It has been recommended that the target therapeutic temperature should be reached as soon as possible (Safar, 2002). In successfully resuscitated out-of-hospital cardiac arrest (OHCA) patients, pre-hospital initiation of cooling appears to be the method of choice. However, initiation of cooling in the field is not a simple shift of in-hospital procedure to pre-hospital area. A pre-hospital emergency team frequently operates in demanding conditions and is engaged in the process of cardiopulmonary resuscitation, early post-cardiac arrest stabilisation and decision on transport direction. Therefore, pre-hospital cooling calls for a very simple, efficient and safe cooling method and its usage should not cause a transport delay. A background of regional hospitals practicing TH is essential to ensure cooling continuity.

A few studies demonstrating the efficacy and safety of this strategy, predominantly for the RIVA method, have been published (Kim et al., 2007; Kämäräinen et al., 2008). When performed properly, it can decrease BT by >1.4 °C during transport. Moreover, a dose of 10 – 20 ml/kg of cold normal saline can contribute to hemodynamic stabilization. In addition, this way of cooling exhibits an excelent safety profile with minimal risk of volume overload. Considering its simplicity and low costs, the RIVA method is the first choice for pre-hospital cooling (Figure 6).

A major barrier for a wide recommendation of pre-hospital cooling in successfully resuscitated OHCA patients is the absence of clear evidence of the outcome benefit. Apparently, improved survival is not related to pre-hospital hypothermia itself but to the close coupling of PTH with its in-hospital continuation (Škulec et al., 2010; Castrén et al., 2010). In any case, a large randomized trial is required.

Considering the pros and cons, at present, in the setting of proper collaboration of the emergency medical service and the target in-hospital facility, it is justifiable to implement prehospital cooling even in the absence of unambiguous evidence to support this practice.

Other possibilities suitable for pre-hospital cooling include surface cooling via manufactured cooling pads and intanasal local brain cooling.

Therapeutic Hypothermia in Cardiac Arrest Survivors 87

More or less, implementation has increased over the years. Nevertheless, there are a lot of challenges and room for improvement. Firstly, effort should be focused on enhancing the frequency of TH application in every ICU. Secondly, unavailability of cooling techniques should not be a barrier for TH implementation, it is reliable to start with low-cost simple conventional cooling methods (RIVA, surface cooling). Thirdly, growth of TH implementation has to progress hand in hand with the quality of provided care. The method must be protocol-guided, respecting clear indications and contraindications and applying

complex neuroprotective and cardioprotective post-cardiac arrest care.

resuscitation (also called suspended reanimation).

proved.

clinical studies.

**14. References** 

2791.

S351.

**13. Alternative thermoregulation strategies in cardiac arrest survivors** 

There are two alternative thermoregulation neuroprotective strategies other than postcardiac arrest cooling: intra-arrest cooling and a principle of emergency preservation and

Animals experiments showed that early intra-arrest initiation of cooling resulted in significantly better neurological outcome than cooling after return of spontaneous circulation (Abella et al., 2004; Kuboyama et al., 1993). This concept was also evaluated in a few clinical studies. RIVA method was very effective but clinical outcome was inconclusive (Kämäräinen et al., 2008; Bruel et al., 2008). More promising seems to be the method of intranasal cooling. The recent PRINCE study revealed its safety, effectivity and suggested outcome improvement (Castrén et al., 2010). A large outcome trial is ongoing. Nevertheless, it must be stressed that intra-arrest cooling intervenes in standard cardiopulmonary resuscitation while cooling after return of spontaneous circulation does not. Therefore, intaarrest cooling should be reserved only for clinical studies, until the clinical benefit is clearly

Emergency preservation and resuscitation is a novel approach supposed to treat victims of exsanguination cardiac arrest. Management is to be as follows: a cold aortic flush is used to induce deep hypothermic preservation in the field followed by transport to hospital facility for emergent surgical treatment and delayed resuscitation with cardiopulmonary bypass (Drabek, 2007). This approach has been tested in animal experiments and stands at door of

Abella BS, Zhao D, Alvarado J, Hamann K, Vanden Hoek TL, Becker LB. (2004). Intra-arrest

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Registry Study Group. Clinical application of mild therapeutic hypothermia after

threatening problem during cardiopulmonary resuscitation. *Crit Care Med*,32:S345-

Fig. 6. Refrigerator in the ambulance car with supply of cold saline.

### **12. Worldwide implementation of therapeutic hypothermia**

Nine years have elapsed since randomized clinical studies allowing the use of TH were published. During this period, in-hospital TH utilisation has varied from 8 to 95 % in different countries until now (figure 7) (Škulec et al., 2010).

Fig. 7. TH implementation in different countries in the last years. USA…United States of America, D…Germany, GB…Great Britain, AUS…Australia, FIN…Finland, CA…Canada, CZ…Czech republic, PL…Poland, SCOT…Scotland, NL…Netherlands, TH…therapeutic mild hypothermia

Nine years have elapsed since randomized clinical studies allowing the use of TH were published. During this period, in-hospital TH utilisation has varied from 8 to 95 % in

Fig. 6. Refrigerator in the ambulance car with supply of cold saline.

**12. Worldwide implementation of therapeutic hypothermia** 

different countries until now (figure 7) (Škulec et al., 2010).

Fig. 7. TH implementation in different countries in the last years.

NL…Netherlands, TH…therapeutic mild hypothermia

USA…United States of America, D…Germany, GB…Great Britain, AUS…Australia, FIN…Finland, CA…Canada, CZ…Czech republic, PL…Poland, SCOT…Scotland,

More or less, implementation has increased over the years. Nevertheless, there are a lot of challenges and room for improvement. Firstly, effort should be focused on enhancing the frequency of TH application in every ICU. Secondly, unavailability of cooling techniques should not be a barrier for TH implementation, it is reliable to start with low-cost simple conventional cooling methods (RIVA, surface cooling). Thirdly, growth of TH implementation has to progress hand in hand with the quality of provided care. The method must be protocol-guided, respecting clear indications and contraindications and applying complex neuroprotective and cardioprotective post-cardiac arrest care.

#### **13. Alternative thermoregulation strategies in cardiac arrest survivors**

There are two alternative thermoregulation neuroprotective strategies other than postcardiac arrest cooling: intra-arrest cooling and a principle of emergency preservation and resuscitation (also called suspended reanimation).

Animals experiments showed that early intra-arrest initiation of cooling resulted in significantly better neurological outcome than cooling after return of spontaneous circulation (Abella et al., 2004; Kuboyama et al., 1993). This concept was also evaluated in a few clinical studies. RIVA method was very effective but clinical outcome was inconclusive (Kämäräinen et al., 2008; Bruel et al., 2008). More promising seems to be the method of intranasal cooling. The recent PRINCE study revealed its safety, effectivity and suggested outcome improvement (Castrén et al., 2010). A large outcome trial is ongoing. Nevertheless, it must be stressed that intra-arrest cooling intervenes in standard cardiopulmonary resuscitation while cooling after return of spontaneous circulation does not. Therefore, intaarrest cooling should be reserved only for clinical studies, until the clinical benefit is clearly proved.

Emergency preservation and resuscitation is a novel approach supposed to treat victims of exsanguination cardiac arrest. Management is to be as follows: a cold aortic flush is used to induce deep hypothermic preservation in the field followed by transport to hospital facility for emergent surgical treatment and delayed resuscitation with cardiopulmonary bypass (Drabek, 2007). This approach has been tested in animal experiments and stands at door of clinical studies.

#### **14. References**


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**5** 

R. Ernesto Oqueli

 *Australia* 

*Ballarat Health Services, Victoria* 

**Percutaneous Intervention Post Coronary** 

**Saphenous Vein Graft Disease – State of the Art** 

The success of coronary artery bypass grafting, although the gold standard for the treatment of multivessel coronary artery disease is limited by poor long-term vein graft patency. Despite the superiority of arterial graft patency over that of vein grafts, the multivessel nature of coronary artery disease and ready availability of saphenous veins still result in its use in over 70% of coronary artery bypass graft procedures (Murphy & Angelini, 2004). These thin walled grafts promptly begin to fail with intimal hyperplasia, thrombosis and progressive atherosclerosis when exposed to an abrupt increase in wall stress imparted by

Recurrent ischaemia in patients who have had previous saphenous bypass surgery occurs not only because of attrition of the saphenous vein grafts but also because of progression of

During the first year after bypass surgery up to 15% of venous grafts occlude, between 1 and 6 years the graft attrition rate is 1% to 2% per year, and between 6 and 10 years it is 4% per year. By 10 years after surgery only 60% of vein grafts are patent and only 50% of patent vein grafts are free of significant stenosis. In addition, native coronary artery disease

Reflecting this graft and native vessel attrition, angina recurs in up to 20% of patients during the first year after saphenous vein grafting and in approximately 4% of patients annually

Angiographic studies have shown that 70% to 80% of bypass surgery patients who present with acute coronary syndrome have their culprit lesion located in the saphenous vein graft

Further revascularisation, either reoperative bypass surgery or percutaneous intervention, is required in approximately 4% of patients by 5 years, 19% of patients by 10 years, and 31% of

Both surgical and percutaneous forms of repeat revascularisation have considerable limitations. As compared with initial surgery, reoperation carries a higher mortality rate (3%

coronary artery disease in the native coronary arteries (de Feyter et al., 1993).

progresses in approximately 5% of patients annually (Motwani & Topol, 1998).

**1. Introduction** 

systemic arterial pressure (Hiscock et al., 2007).

during the ensuing 5 years (Motwani & Topol 1998).

patients by 12 years after initial bypass surgery.

(Pregowski J et al., 2005).

 **Artery Graft Surgery in Patients with** 

