Effect of Remote Ischemic Post-conditioning on Out-of-hospital Cardiac Arrest

Effect of Remote Ischemic Post-conditioning on Neurologic and Cardiac Recovery in Out-of-hospital Cardiac Arrest

Ischemia-reperfusion leads to mitochondrial injury, ion-pump injury, cell membrane damage, cytotoxic edema, and excessive oxygen free radical formation, and eventually destroys cells. Cardiac arrest is an example of global ischemia; after spontaneous circulation is restored, ischemia-reperfusion injury develops in cardiac arrest survivors.

Remote ischemic postconditioning (RIPoC) involves the application of brief, reversible episodes of ischemia and reperfusion to a vascular bed or tissue, rendering remote tissues and organs resistant to ischemia-reperfusion injury. Accordingly, RIPoC has been suggested as adjunctive therapy to mitigate ischemia-reperfusion injury. RIPoC applied by repeated brief inflation-deflation of a blood pressure cuff protects against myocardial injury, and has been proven effective in acute myocardial infarction.

This study aims to perform a randomized controlled trial to determine whether RIPoC has a neuroprotective effect and aids in myocardial recovery in out-of-hospital cardiac arrest patients after restoration of spontaneous circulation.

Neuron-specific enolase (NSE) at 48 hours after restoration of spontaneous circulation will be measured as a primary outcome.

Inclusion Criteria:

• Adult (19 years and older)
• comatose out-of-hospital cardiac arrest with sustained restoration of spontaneous circulation
• Undergoing targeted temperature management
• Time of enrollment ≤ 6hrs from restoration of spontaneous circulation
• cardiac arrest from medical cause (cardiac or other medical cause)

Exclusion Criteria:

• Pre-existing dementia, brain injury, or dependence on others (cerebral performance category scale greater than 3)
• Traumatic etiology for cardiac arrest
• Protected population (pregnant, prisoner)
• in-hospital cardiac arrest
• Known bleeding diathesis
• suspected or confirmed acute intracranial hemorrhage
• suspected or confirmed acute ischemic stroke
• Known limitations in therapy and do-not-resuscitate order
• known disease making 180-day survival unlikely
• >6 hours from restoration of spontaneous circulation to randomization
• cardiac arrest from asphyxia (hanging, foreign body airway obstruction), drowning, drug overdose, or electrocution
• peripheral vascular disease (Deep vein thrombosis, arteriosclerosis obliterans)
• systolic blood pressure < 80 mmHg in spite of fluid loading/vasopressor and/or inotropic medication