X-Message-Number: 7600
Date: Thu, 30 Jan 1997 09:14:37 -0500 (EST)
From: Charles Platt <>
Subject: Cryopreservation report

     Mike Darwin has asked me to post his report of the 
cryopreservation of CryoCare's first patient, James 
     Part One of this report was first published in CryoCare 
Report number 6. Part Two appeared in issue number 9. Many 
photographs and charts appeared in the printed version and 
cannot be reproduced here. 

     Subscriptions to CryoCare Report are available for $9 
(four issues) per year. 

     Because this text is long, I am dividing it into 
subsections. Thus Part 1 will be posted as Part 1a, Part 1b, 
and Part 1c. Part Two will be posted as Part 2a and Part 2b. 

     --Charles Platt 


     PART 1c


Tympanic Temperature: 25.7 degrees C, Descending Colon 
Temperature 19.0 degrees C 

                            measured value            normal range

     pH                     7.34                      7.35 (mean) 
     pCO2                   52.4 mmHg                 45-55 
     pO2                    37.0 mmHg                 40-50 
     O2 Sat                 89%                       70-75 
     BUN                    15.0 mg/dl                7-25 
     Creatinine             1.1 mg/dl                 0.7-1.4 
     Sodium                 120 mEq/l                 135-146 
     Potassium              5.5 mEq/l                 3.5-5.3 
     Chloride               82 mEq/l                  95-108 
     Magnesium              1.7 mEq/l                 1.2-2.0 
     Calcium                7.2 mg/dl                 8.5-10.3 
     Phosphorus             7.8 mg/dl                 2.4-4.5 
     Protein, Total         5.8 g/dl                  6.0-8.5 
     Glucose                251 mg/dl                 70-125 
     Bilirubin,Total        0.8 mg/dl                 0.0-1.3 
     Alk Phosphatase        76 U/L                    20-125 
     LDH, Total             227 U/L                   0-250 
     GGT                    58 U/L                    0-65 
     AST                    101 U/L                   0-42 
     ALT                    69 U/L                    0-48 
     Uric Acid              0.5 mg/dl                 4.0-8.5 
     Iron, Total            138 mcg/dl                25-170 
     Iron Binding Capacity  748 mcg/dl                200-450 
     % Saturation           18                        12-57 
     HCT                    26%                       41-50 

     The next central venous blood sample collected during 
CPR at 0020 on 13 December, yielded the following results: 

     Tympanic Temperature: 23.0 degrees C, Descending Colon 
Temperature13.8 degrees C 

                            measured value            normal range

     pH                     7.115                     7.35 (mean) 
     pCO2                   27.8 mmHg                 45-55 
     pO2                    35.1 mmHg                 40-50 
     O2 Sat                 88%                       70-75 
     BUN                    17.0 mg/dl                7-25 
     Creatinine             1.1 mg/dl                 0.7-1.4 
     Sodium                 132 mEq/l                 135-146 
     Potassium              4.3 mEq/l                 3.5-5.3 
     Chloride               91 mEq/l                  95-108 
     Magnesium              1.8 mEq/l                 1.2-2.0 
     Calcium                7.8 mg/dl                 8.5-10.3 
     Phosphorus             9.9 mg/dl                 2.4-4.5 
     Protein, Total         3.4 g/dl                  6.0-8.5 
     Glucose                300 mg/dl                 70-125 
     Bilirubin, Total       1.1 mg/dl                 0.0-1.3 
     Alkaline Phosphatase   92 U/L                    20-125 
     LDH, Total             376U/L                    0-250 
     GGT                    69 U/L                    0-65 
     AST                    182 U/L                   0-42 
     ALT                    126 U/L                   0-48 
     Uric Acid              0.5 mg/dl                 4.0-8.5 
     Iron, Total            177 mcg/dl                25-170 
     Iron Binding Capacity  779 mcg/dl                200-450 
     % Saturation           18                        12-57 
     HCT                    26                        41-50 

     At 0050 another central venous sample was collected from 
the Hickman catheter and revealed the following results: 

     Tympanic Temperature: 21. degrees C, Descending Colon 
Temperature 9.9 degrees C 

                            measured value            normal range

     pH                     7.087                     7.35 (mean) 
     pCO2                   25.2 mmHg                 45-55 
     pO2                    39.2 mmHg                 40-50 
     O2 Sat                 91%                       70-75 
     BUN                    17.0 mg/dl                7-25 
     Creatinine             1.0 mg/dl                 0.7-1.4 
     Sodium                 134 mEq/l                 135-146 
     Potassium              4.9 mEq/l                 3.5-5.3 
     Chloride               91 mEq/l                  95-108 
     Magnesium              1.9 mEq/l                 1.2-2.0 
     Calcium                7.9 mg/dl                 8.5-10.3 
     Phosphorus             10.6 mg/dl                2.4-4.5 
     Protein, Total         3.5 g/dl                  6.0-8.5 
     Glucose                308 mg/dl                 70-125 
     Bilirubin, Total       1.1 mg/dl                 0.0-1.3 
     Alkaline Phosphatase   91 U/L                    20-125 
     LDH, Total             366 U/L                   0-250 
     GGT                    69 U/L                    0-65 
     AST                    204 U/L                   0-42 
     ALT                    140 U/L                   0-48 
     Uric Acid              0.5 mg/dl                 4.0-8.5 
     Iron, Total            179 mcg/dl                25-170 
     Iron Binding Capacity  778 mcg/dl                200-450 
     % Saturation           23                        12-57 
     HCT                    26                        41-50 

     The final central venous sample taken during CPR was at 
01:20 on 13 December and yielded the following results: 

     Tympanic Temperature: 19.3. C, Descending Colon 
Temperature 7.5 degrees C 

                            measured value            normal range

     pH                     7.047                     7.35 (mean) 
     pCO2                   23.7 mmHg                 45-55 
     pO2                    110.4mmHg                 40-50 
     O2 Sat                 98.1%                     70-75 
     BUN                    17.0 mg/dl                7-25 
     Creatinine             1.0 mg/dl                 0.7-1.4 
     Sodium                 133 mEq/l                 135-146 
     Potassium              5.7mEq/l                  3.5-5.3 
     Chloride               92 mEq/l                  95-108 
     Magnesium              1.9 mEq/l                 1.2-2.0 
     Calcium                7.9 mg/dl                 8.5-10.3 
     Phosphorus             11.3 mg/dl                2.4-4.5 
     Protein, Total         3.5 g/dl                  6.0-8.5 
     Glucose                364 mg/dl                 70-125 
     Bilirubin, Total       1.2 mg/dl                 0.0-1.3 
     Alkaline Phosphatase   92 U/L                    20-125 
     LDH, Total             380 U/L                   0-250 
     GGT                    69 U/L                    0-65 
     AST                    214 U/L                   0-42 
     ALT                    148 U/L                   0-48 
     Uric Acid              0.5 mg/dl                 4.0-8.5 
     Iron, Total            178 mcg/dl                25-170 
     Iron Binding Capacity  777 mcg/dl                200-450 
     % Saturation           23                        12-57 
     HCT                    22                        41-50 

     Intermim Interpretation and Comment On Cooling 

     From the laboratory and temperature data above, several 
important conclusions can be drawn, particularly when taken 
in the context of the protocol used in this case, in 
comparison with results obtained in two previous cases which 
compare with this one closely (Alcor patient A-1260, and ACS 
patient 9577). 
     Direct comparisons of many of the parameters in these 
two cases is not possible owning to absence of data in the 
previous cases. For instance, in patient A-1260 no 
temperature data was acquired until 32 minutes after cardiac 
arrest. Thus, a direct comparison between cooling rates 
during (say) the critical first 10 minutes post arrest is not 
possible here. However, comparisons can still be made where 
data does exist at corresponding intervals. 
     These three patients are of particular interest to 
compare because they match each other closely in sex, weight, 
fat distribution, and body surface areas, and they are of 
reasonably close ages. All patients were cooled at a minimum 
using a portable ice bath and ice-water circulating 
pump/distribution assembly (two with identical equipment). 
All patients had cooling and CPR begun within 2-4 minutes of 
cardiopulmonary arrest, and all were promptly medicated using 
the specified protocol. It is also important to note that all 
patients died of illnesses, two of AIDS and one of 
disseminated cancer, which left them cachectic and which 
involved compromise to multiple organ systems. One notable 
difference was the prolonged agonal course of ACS-9577 
compared to the other two patients, and the poor response to 
cardiopulmonary support this patient exhibited, probably as a 
result of the antemortem ischemic injury and pulmonary 
     Data from one other patient, A-1049, a 32.8 kg severely 
wasted patient who arrested from dehydration secondary to 
end-stage adenocarcinoma of the lung, is also relevant. This 
patient is included since her mass and fat 
content/distribution and response to cardiopulmonary support 
were the most favorable of any patient cryopreserved by 
comparable methods available to this author. This patient 
thus serves as "best-case" for the efficacy of previously 
used methods of cooling, medication and CPR. 

     [missing figure] 

     The number of asterisks after the case number indicates 
the overall score, from zero to ****, for response to 
cardiopulmonary support as evaluated by EtCO2, skin-color, 
femoral pulse, and other parameters when available. 
     A critical determining factor in how well a patient will 
cool during transport in addition to surface area, mass and 
fat quantity and distribution (fat is a good insulator) is 
the adequacy of blood circulation. Warm blood being delivered 
to the surface of the body and to structures with good 
surface to volume ratios that facilitate good exchange (such 
as fingers, toes, arms, and legs) will clearly be superior in 
patients with good cardiac output. The patient's antemortem 
condition will be a major factor in determining how well s/he 
will respond to CPR. However, also of great importance is the 
use of highly efficient means of CPR and the use of drugs 
which prevent shunting of blood away from tissues that need 
it, and which prevent shunting of blood through parts of the 
lung which are fluid filled or not able to exchabfe oxygen. 
No doubt part, but by no means all of the superior cooling 
results observed in this patient were as a result of better 
perfusion during CPR. 
     As can be seen from the table above, patient C-2150, the 
subject of this report, cooled at a rate of approximately 1 
degree C/min during the first ten minutes post arrest, and at 
a rate of 0.56 degrees C/min for the entire 30 minute period 
after arrest. This is a rate twice that of a patient with 
roughly half his mass and with far less subcutaneous fat 
during the first 10 minutes post arrest, and twice that at 30 
minutes post arrest. It is also interesting to note that the 
30-minute post arrest cooling rates of all three other 
patients are well below 0.5 degrees C/min., and are in close 
agreement (0.24 and 0.21) for the two patients whose mass, 
fat distribution and surface area most closely approximate 
those of this patient. 
     We believe that this patient experienced such superior 
rates of cooling--indeed, rates achieveable in a patient of 
his surface area only with extracorporeal (blood/body core) 
cooling--because of the following factors: 

     * Superior perfusion  due (blood circulation) during CPR 
as a result of: 
     a) cardiac arrest in the absence of a long period of 
agonal shock. 
     b)pre-arrest medication which reduced cold 
agglutination, prevented loss of 
     c) normal vasmotion and adequate control and 
distribution of blood flow. 
     d) greatly improved cardiac out, mean arterial pressure 
(MAP) and decreased venous pressure as a result of ACDC-HICPR 
     e) improved oxygenation due to ventilation with each 
compression upstroke using ACDC-CPR 
     f) in hibition of oulmonary edema as a result of lower 
central venous pressures and better mitral valve function as 
a result of ACDC-HICPR 

     *Superior cooling due to the use of colonic and 
peritoneal lavage with ice cold solution in addition to 
external cooling using the portable ice bath (PIB) and a 
circulating water system to pump ice cold water over the 
patient's body. 

     The use of these modalaties and the cooling rates 
achievable with them was established in dog lab. Further, 
other cooling approaches such as the use of ice-slush lavages 
in stomach, inaddition to the colon and peritoneum, and the 
addition of liquid ventilation (using perfluburon chilled to 
0-2 degrees C) or subzero jet gas ventilation, are currently 
under investigation (and patent) and may provide for cooling 
rates approach 1.5 to 2.0 degrees C per minute if added to 
the modalities used in this patient. 
     Administration of all transport medications to this 
parient was completed at 2340. 

     Transport Phase 2: 
     Initiation of Extracorporeal Support 
     and Total Body Washout 

     Surgery to raise the right femoral artery and vein was 
begun at 23:30 following standard prep of the right groin 
with Betadine scrub/solution, and creation of a sterile field 
with sterile muslin towels and disposable drapes. Two femoral 
arteries of 3-5 mm in diameter were rapidly located and a 
pressure line was placed in one at 23:55 (initial pressure 
measured was MAP 47 mmHg). 
     However, despite extensive further dissection of the 
right groin no femoral vein could be located. Dissection 
along the tissue plane of the femoral arteries failed to 
reveal the femoral vein (although the sciatic nerve was 
identified) and the femoral arteries appeared to bifurcate 
within the abdomen. (Subsequent autopsy disclosed that the 
patient had no femoral vein and a right iliac artery that 
bifurcated into two femoral vessels at the terminus of the 
abdominal aorta). Several small veins (3-5 mm in diameter) 
were located and one of these opened to determine feasibility 
of cannula placement for venous return. While this was deemed 
not possible, it was noted that the venous blood was free-
flowing and arterial red in color, indicating adequate oxygen 
delivery to the patient (the patient's tympanic temperature 
at that time was approximately 23 degrees C, colonic 
temperature 14.5 degrees C). 
     By 00:15 a decision had been made to abandon the right 
groin wound and proceed with surgery to raise the left 
femoral artery and vein. Prep of the left groin was made at 
00:21 and the femoral artery and femoral artery and vein were 
rapidly identified. The femoral vein was cannulated with a 
Biomedicus Carmeda-coated, 21 Fr. x 50 cm venous cannula 
     However, a further complication occurred in that the 
femoral artery was invaded with malignancy; apparently 
between the tunica media vasorum and the intima of the 
vessel. The vessel also was moderately atherosclerotic (soft 
yellow atheroma). This complicated arterial cannulation and 
required extensive further dissection of the groin to avoid a 
dissecting aneurysm of the entire arterial tree secondary to 
cannula placement. 
     Thumper support was discontinued at 01:07 at a tympanic 
temperature of 20.2 degrees C and a colonic temperature of 
8.4 degrees C. MAP had dropped to 35 mmHg at this time, and 
it was felt that further Thumper support was not productive. 
     Both cannulae were in place by 01:18 and closed circuit 
femoral-femoral bypass was begun at about 01:18, using a 
prime consisting of 750 cc Dextran 50 in Normal saline, 1500 
cc of Normosol-R pH 7.4, 500 cc 20% mannitol in water, and 50 
cc (1 mEq/cc) of sodium bicarbonate solution. At 01:21 a 
"popping sound" was heard, and the polycarbonate housing of 
the Sarns 9444 Turbo oxygenator was noted to have developed a 
leak at the joint between the two halves of the housing. This 
occurred at a pressure of 260 mmHg, well below the 760 mmHg 
pressure this unit is rated for. 
     The problem (popping sound) was noted at exactly 01:20 
and the pump was shut down and lines were clamped at 01:21. 
The circuit was carefully inspected for air from the 
oxygenator through the filter and up to the patient, and none 
was noted. The oxygenator was changed out of the circuit and 
replaced with a fresh one and the bypass line was used to 
prime the new oxygenator and debubble the circuit. Bypass was 
resumed uneventfully at 01:33, 12 minutes later. Closed 
circuit bypass was continued at a MAP of 45 mmHg and flow 
rate of 2-3 liters per minute (LPM). 
     When the patient's tympanic temperature reached 
approximately 16 degrees C (colonic , 6.2 degrees C) the 
patient was progressively hemodiluted with 10 liters of 
Viaspan using 2 liters of open circuit flush at a MAP of 45-
50 mmHg. At the conclusion of the Viaspan flushes, the 
patient was flushed with 10 liters of 5% (v/v) glycerol in 
21CM-BPI-002 base perfusate. Glycerol-containing flush was 
introduced slowly in two liter aliquots. Flushing with 5% 
glycerol began at 01:42 and was followed by flushing with 10 
liters of 10% w/v glycerol perfused in the same fashion. 
Flushing with 2 liter aliquots of 10% w/v glycerol was 
completed at 02:35. Flushing proceeded more slowly than 
normal due to partial cold and chemical-induced rupture of 
both plastic bags containing the flush solution, with leakage 
which required a great deal of effort to contain. 
     At 02:02 the tympanic probe was replaced with a frontal 
sinus probe to facilitate movement of the patient at the 
conclusion of bypass. It is interesting to note that frontal 
sinus and tympanic temperatures agreed to within 0.2 degrees 
C. Frontal sinus temperature at the conclusion of 
flushing/glycerolization was 5.5 degrees C, colonic, 1.6 
degrees C. 
     Following the conclusion of total body washout and phase 
I glycerolization, the patient was disconnected from the 
extracorporeal circuit with care taken to avoid introduction 
of air into either the arterial or venous cannula (the 
cannulae were cross-connected with a short length of 3/8" x 
3/32" bypass tubing which was filled with perfusate and 
carefully purged of air before the occluding clamps on the 
cannulae were removed). 
     The patient was then removed from the PIB of the MALSS 
and placed in a more easily transportable PIB for transfer to 
the BPI/21CM facility for cryoprotective perfusion. 
Originally it had been planned that the patient would be 
moved with extracorporeal support on the MALSS continuing. 
However, the patient occupied a second story apartment with a 
stairway that became extremely slick and hazardous during 
what was the first (and unexpected) rain of the Los Angeles 
basin's winter season. For the safety of the patient and the 
personnel, a decision was made not to attempt to transport 
the 600 pound-plus MALSS, with the patient in it, down the 
stairs in heavy rain. 
     The patient was transported by BPI ambulance from 
Huntington Beach to Rancho Cucamonga, CA starting at 
approximately 0350.  Driving conditions were very poor with 
heavy rain and an earlier than usual morning rush hour 
traffic beginning by the time the freeway was reached at 
0400.  The patient arrived at the facility at 0545 on 13 


     BioPreservation Staff 


     Michael G. Darwin, C.T.T., C.R.T., Team Leader, Surgeon 
     Steven B. Harris, M.D., C.T.T., Medical Advisior, 
          Surgeon, Airway Management 
     Carlotta Pengelley, L.V.N. Medications, Physiological 
     Sandra Russell, B.S., Surgical Assistant, Physiological 
          Monitoring, Perfusion Assistant 
     Michael Fletcher, C.R.T., Equipment Tech, Logistics 
     Joan O'Farrell, Scribe, Logistics Support 
     Billy Seidel, Videographer 
     Mel Allen, Logistics Support 
     Edwin Shortess, Logistics Suppport 

     Cryoprotective Perfusion: 

     Michael G. Darwin, C.T.T., C.R.T., Team Leader, 
     Steven B. Harris, M.D., C.T.T., Medical Advisior, 
          Sample/Data Collection 
     Carlotta Pengelley, L.V.N. Sample/Data Collection 
     Sandra Russell, B.S., Perfusion Assistant, Data 
          Collection, Logistics Support 
     Mark Connaughton, Perfusate Preparation, Facility 
          Readiness, ABG & Electrolyte Analysis 
     Paul Wakfer, Cryoprotective Ramp Technician, Logistics 


End of Part 1c

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