Vasopressin combined with epinephrine during cardiac resuscitation: a solution for the future?

Epinephrine given during cardiopulmonary resuscitation (CPR) may cause beta-mimetic complications in the postresuscitation phase. Vasopressin may be an alternative vasopressor drug during CPR. A subgroup analysis of a large prospective CPR investigation and of retrospective CPR studies suggests that vasopressin may be especially beneficial when combined with epinephrine. Beneficial effects of adding vasopressin were observed in other catecholamine-refractory shock states as well, such as vasodilatory shock and haemorrhagic shock. In order to maximize effects of any vasopressor during CPR, rapid aggressive chest compressions must be ensured to maximize blood flow and to enable advanced cardiac life support drugs to reach the arterial vasculature. We suggest alternating injections of 1 mg epinephrine i.v. and 40 IU vasopressin i.v. every 3–5 minutes during CPR until spontaneous circulation can be achieved or CPR efforts are terminated.     

Why measure cardiac output?

Although cardiac output is a primary determinant of global O₂ transport there are no absolute values that reflect circulatory adequacy, though very low values are of negative prognostic use. There is no agreement as to what constitutes a clinically relevant change in cardiac output. A recent clinical trial suggests that early goal-directed therapy aimed at increasing cardiac output improves survival. Thus, in some patients, measurement of cardiac output is indicated as an aid to prognosis, diagnosis and to monitor the adequacy of therapy. Gonzalez et al. compared PAC thermodilution cardiac output with indirect Fick measures of cardiac output. They found that at lower cardiac outputs (< 5 l/min) the agreement between the two techniques is good, whereas at higher flows increased differences exist between the two measures. As discussed in this commentary, this study did not address the three potential questions related to PAC monitoring of cardiac output. These questions are: can the PAC cardiac output data be used to monitor cardiac output? Do technical and physiological constraints limit the accuracy of PAC cardiac output? And; are PAC cardiac output measurement errors due to respiratory variation in pulmonary blood flow? Ways of answering each question are given.     

Where is the future of cardiac lead extraction heading?

Introduction: Transvenous lead extraction (TLE) is the gold standard for lead removal. The increasing rate of cardiac implantable electronic device (CIED) implantations and of CIED related complications highlight the importance of transvenous lead extraction .

Areas covered: The TLE scenario is constantly changing. Optimizing lead related technology and improving TLE practice across the world are the cornerstones to improving safety and efficacy. We review the state of the art in TLE, focusing on potential future implications and improvements in terms of skills and technologies.

Expert commentary: The increased number of extractions will increase the necessity of safe and effective TLE. New technologies, techniques and appropriate training is warranted across the world.     

Therapeutic CD154 antibody for lupus: promise for the future?

Systemic lupus erythematosus (SLE) is a prototypical systemic autoimmune disease characterized by the production of pathogenic autoantibodies. A new study demonstrates that passive antibody specific for the TNF family member, CD154, ameliorates disease by reducing levels of self-reactive antibody in the serum. This study demonstrates a substantial potential for anti-CD154 antibody in the treatment of humoral autoimmunity.