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
Gallagher.
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
CryoCare
-------------------------------------------------------------
PART 1c
RESULTS
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
compromise.
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
(#34284).
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
December.
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BioPreservation Staff
Transport:
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
Monitoring
Sandra Russell, B.S., Surgical Assistant, Physiological
Monitoring, Perfusion Assistant
Michael Fletcher, C.R.T., Equipment Tech, Logistics
Support
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,
Perfusionist
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
Support
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End of Part 1c
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