X-Message-Number: 5447 Date: 19 Dec 95 04:32:33 EST From: Steve Harris <> Subject: Sci.cryonics: Last BPI Suspension Those of you who read message 5432 on Cryonet must have concluded one of three things: 1) Mike Darwin had accidentally posted private or in-house communications to CryoNet. 2) Mike Darwin has lost his marbles completely. 3) Something didn't make sense. Perhaps all three are correct, but the first is the best and truest explanation. Yes, this was a difficult case. Some rotten luck and honest misjudgment occurred during the course of it. But THAT is not the point. The point is that despite these things, this case resulted in a patient in better biological condition during the agonal period, during transport, and during cryoprotective perfusion, than any other case we have ever done. We believe, based on animal data, that it also resulted in the best cryobiological outcome as well. The trouble we had was useful to us (education is painful; pain is educational), and others may benefit from it. But the patient was not hurt. Indeed, he was given a standard of care that, as we reflect on the incoming labs and the notes, we are proud of. We have the numbers. You will see this case described completely in due time, including some warts. But be advised that the end product of this transport was a patient whose blood gases on CPR were essentially normal, whose potassium was essentially normal through 2 hours of computer driven active compression/decompression CPR, and whose serum enzymes showed about as much injury as some people might sustain after 3 or 4 ounces of quality bourbon. We used many new technologies in this case. We had many new problems; some inescapable, as you will see. And also some of our own making. When we finished, we knew the patient had done well, but also that things had not "flowed" right. This case was rocky and difficult. Words of wisdom given to Mike by a surgeon friend many years ago: "The mark of a an excellent surgeon is not that he does not have cases that confront him with terrible crises, that is the nature of surgery and life. No, the mark of a surgeon of quality is to make the errors, confront the crisis, deal with the rotten luck thrown him, and STILL have the patient recover as if nothing had ever happened but another routine day in the O.R." First, a brief and description of relevant problems, starting with those not easily within our control: 1) The 10-liter peritoneal dialysate "cycler bags" which held our washout solution, and which had gone through preliminary evaluation with flying colors, developed leaks at the seams in the cold. The leaks were not "catastrophic" but were very annoying, resulting in perfusate dripping from one leak in each bag. The perfusate is sticky and it got all over the staff handling the bags, and, to prevent the leaks from expanding, three staff members/family were needed to hold and shore up the seams. The cause of this problem appears to have been due to changes in the PVC bag material with *time* in the cold. 2) Because of the seam leaks, optimum use of drain spikes was not possible, slowing down the filling rate of the venous reservoir. This was an annoyance, as it greatly dragged out of the post Viaspan part of the washout. The patient was flushed with initially with 5 liters of Viaspan, but this was to have been quickly chased with 20 liters of our own washout solution *containing cryoprotectant* (another first, and significant step forward in care, in our opinion). Our patient was already cold and already flushed when this problem occurred. Plans were to flush slowly with cryoprotectant flush in any event, to avoid osmotic stress. But it took three times as long as we had planned... 3) The patient turned out to have no right femoral vein, and a right iliac artery which bifurcated intra-abdominally, resulting in two small bore (pencil-sized) right femoral arteries. We thus had to cut him down on the opposite site, at which point we found (thankfully) normal anatomy, after which cannulation proceeded quickly. 4) The patient lived in a second-story apartment. The original plan was to carry the extracorporeal support cart with the patient in it (460 pounds empty) down the stairs, after off-loading batteries and other equipment and most of the ice to lighten the load. The stairs were wide, but it would not have been easy. It became impossible when the first heavy rain in the L.A. area in months chose the night of the transport to render the outside stairs (with their metal wear-guard strips) slick as glass. We thus had to take the patient off the cart and move him down the stairs in the collapsible portable ice bath. 5) Due to the cold, and perhaps a manufacturing defect, the "join" (joint) between the two acrylic halves of the oxygenator housing split during washout. This was very messy. We monitor pressure across at the oxygenator at the filter so we KNOW the pressure at which failure occurred: 240 mmHg; the oxygenator is rated for 760 mmHg (which in practice means it *should* be able to take twice that much pressure before failing). Again, this was no danger to the patient, as he was at 12 C when this occurred. But it was one hell of an annoyance. BPI carries duplicate disposables so we simply got another oxygenator from under the back-table, plugged it in, and rapidly flushed it of gas. The patient did NOT get arterial air, and the oxygenator was changed out and the patient was back on bypass in 9 MINUTES. The patient's temperature at this time was 18.8 C, plenty cold for this length of interruption. 6) A last indignity: two fresh BPI team members could not come in at 08:00, as planned. Instead, one had to take the other to an E.R. with a potentially serious health problem (we are happy to report that the medical problem turned out not to be serious, but our loss of time and manpower by this time, was). There were also problems that were under our control which we should not have had. Among them: 1) Seriously underestimating time to set-up prior to cardiac arrest, causing the patient to continue life support, and the family to wait longer than they had anticipated. 2) Limited staffing due to over-confidence that the number of team members was adequate. It *was* adequate for a "normal case, but not for a case where multiple new modalities were tried at once and where data collection demands were many times those normally required for transports. This resulted in some short-tempers and arguments which were regretted by all afterwards. 3) When we arrived back at the 21st/BPI facility, we were exhausted beyond all our expectations. Surprisingly so. Part of this may have been due to the fact that most of the staff had been attending the A4M Conference and had only returned the day before. This was probably insufficient time to recover the stamina needed for the case. The staff had slept well at A4M, but that is not the same as being "decompressed" and recovering focus and mental energy. 4) After a great deal of preparation to get it set up as a new modality, we simply forgot to turn on the cerebral function monitor in the heat of the moment at the beginning of the cryopreservation. Short summary of results: the patient did great. Some early objective numbers: Within 4 minutes of the start of CPR using AC-DC high impulse machine, we had acquisition of pulse on our pulse oximeter (on the patient's FINGER!) and an oxygen saturation (mixed sat via pulse ox) of 96% on an inspired oxygen concentration (delivered via the Thumper-ventilator) of 80%. This is a normal oxygen saturation for someone breathing room air. End tidal CO2 (EtCO2) during the first 45 minutes of CPR support was between 4% and 5% (normal is 5%, and the best we've ever seen on any cryonics patient was 2%). EtCO2 is a gold standard indicator of adequacy of gas exchange and perfusion (blood circulation and oxygenation) during CPR. It takes energy to pump potassium into cells and sodium out. Most patients, cryonics or otherwise, have rapidly rising potassium levels in their blood during CPR. Most cryonics patients have potassium levels of 8-9 mEq/L during CPR. This patient was pronounced legally dead at 23:11 hours, 12 December. The patient's eardrum (tympanic) temperature at pronouncement was 36.8 C. Ten minutes later at 23:22 hours the patient's tympanic temperature was 28.7 C., representing a drop of 8.1 C in ten minutes, or a temperature decrease of 0.8 C per minute with CPR (!) For comparison, typical cooling rates on bypass with a patient of this mass and a blood heat exchanger with a co-efficient of 0.6, would be about 1 C to 1.5 C per minute. The first VENOUS (and all subsequent values are venous as well) blood gas and potassium (and electrolyte panel) was drawn at 23:50. The results were as follows: TYMPANIC (brain) TEMPERATURE: 25.7 C pH 6.950 pCO2 54.0 mmHg pO2 82.2 mmHg Sodium 132 mmol Potassium 5.5 mmol (normal is 3.5 to 5.3 mmol) Chloride 91mmol Glucose 267 LDH 227 (UL) (normal 0-250 U/L) AST 101 (normal 0-42) ALT 69 (0-48) Lactate 8.40 mmol (NOTE: ALT and AST were elevated before legal death due to liver metastases. Pre lactate was 2.9 mmol.) The next lab was drawn at 00:20 and the results were: TYMPANIC (brain) TEMPERATURE: 23.0 C pH 7.15 pCO2 51.3 mmHg pO2 86.2 mmHg Sodium 132 mmol Potassium 4.3 mmol (normal is 3.5 to 5.3 mmol) Chloride 91mmol Glucose 267 LDH 376 (UL) (normal 0-250 U/L) AST 126 (normal 0-42) ALT 126 (normal 0-48) Lactate: 10.8 mmol Next lab was at 00:50: TYMPANIC (brain) TEMPERATURE: 21.1 C pH 7.087 pCO2 50.4 mmHg pO2 100.9 mmHg Sodium 134 mmol Potassium 4.9 mmol (normal is 3.5 to 5.3 mmol) Chloride 91mmol Glucose 308 LDH 366 (UL) (normal 0-250 U/L) AST 204 (normal 0-42) ALT 140 (normal 0-48) Lactate: 11.4 mmol Bypass was started (blood pump-oxygenator-heat exchanger support) at 01:33 at temperature of 18.6. Gases and pH during washout were excellent. Arterial pH was above 7.8 (the upper limit of the measuring capacity of our in-line blood gas system) and venous pH was consistently above 7.3. Cryoprotective perfusion was uneventful (though exhausting). Very exciting results were obtained in protection of the lungs, and this patient was perfused *closed chest* using a new approach developed by BPI. Central venous pressures were excellent throughout perfusion, as was venous return, indicating the eminent workability of this approach. Terminal glycerol concentration was 5.5 M (which was what we had set as our target; more on why we are not going to 7-8M later) and the brain surface was down 10 mm from the margin of the burr hole with (obviously) no cerebral edema, no peripheral edema, and excellent lactates and enzymes (the latter of which are markers of tissue injury) throughout cryoprotective perfusion. Cooling to -196 was begun within approximately 24 hours of the patient reaching -79 C. Finally, family were present throughout the procedure. They were also copied on the memo inadvertently posted to Cryonet at the same time the memo was sent to Cryonet. They were also copied on all other internal memos (including those NOT inadvertently posted to Cryonet). We have nothing to hide about this case. It went very well physiologically for the patient, if not psychologically for the team. We have the labs to support this conclusion, the videotape to support it, the data sheets to support it, and soon (hopefully!) the full case report to support it. The case report will be posted here. We think you'll find it interesting, and we hope, worthwhile. Mike Darwin, President, BPI Steve Harris, M.D., Medical Advisor, BPI Rate This Message: http://www.cryonet.org/cgi-bin/rate.cgi?msg=5447