Showing papers on "Resuscitation published in 1986"

Difference in Acid-Base State between Venous and Arterial Blood during Cardiopulmonary Resuscitation

Abstract: We investigated the acid-base condition of arterial and mixed venous blood during cardiopulmonary resuscitation in 16 critically ill patients who had arterial and pulmonary arterial catheters in place at the time of cardiac arrest. During cardiopulmonary resuscitation, the arterial blood pH averaged 7.41, whereas the average mixed venous blood pH was 7.15 (P less than 0.001). The mean arterial partial pressure of carbon dioxide (PCO2) was 32 mm Hg, whereas the mixed venous PCO2 was 74 mm Hg (P less than 0.001). In a subgroup of 13 patients in whom blood gases were measured before, as well as during, cardiac arrest, arterial pH, PCO2, and bicarbonate were not significantly changed during arrest. However, mixed venous blood demonstrated striking decreases in pH (P less than 0.001) and increases in PCO2 (P less than 0.004). We conclude that mixed venous blood most accurately reflects the acid-base state during cardiopulmonary resuscitation, especially the rapid increase in PCO2. Arterial blood does not reflect the marked reduction in mixed venous (and therefore tissue) pH, and thus arterial blood gases may fail as appropriate guides for acid-base management in this emergency.

Randomized clinical study of thiopental loading in comatose survivors of cardiac arrest. Brain resuscitation clinical trial I study group

Abstract: 262 malades encore en etat de coma apres un arret cardiaque et une reanimation ayant ramene la circulation et la ventilation spontanee sont traites par soins intensifs cerebraux standardises avec ou sans addition d'une dose i.v. de thiopental de 30 mg/kg au debut. Pas de difference significative entre les 2 groupes quant aux pourcentages a long terme de: morts, survies avec deficits minimes, survies avec deficits importants

Enteral versus Parenteral Nutritional Support following Laparotomy for Trauma: A Randomized Prospective Trial

Abstract: Although enteral nutrition is considered more 'physiologic' than parenteral nutrition, there is greater published experience with parenteral nutrition in trauma patients. To compare the efficacy of these two techniques, we prospectively randomized multiple trauma patients during their admission laparotomy to receive either central venous parenteral nutritional (TPN: n = 23) or enteral nutrition by jejunostomy (Jej: n = 23). Nutritional support began on the first postoperative day; the study period continued a maximum of 14 days. There were no significant differences between the two groups in age, sex, injury severity, estimated caloric needs (3,322 TPN; 3,114 Jej), hours to achieve full prescription (77 PTN; 79 Jej), or the number of days on nutritional support (22 TPN; 25 Jej). Average daily caloric intakes, nitrogen balance results, and complication rates were also comparable. These results suggest that early postoperative jejunostomy feeding is a safe and efficacious choice for multiple trauma patients undergoing laparotomy.

Arteriovenous carbon dioxide and pH gradients during cardiac arrest.

Abstract: In a porcine preparation of cardiac arrest, we demonstrated that there is a marked paradox of venous acidemia and arterial alkalemia. This paradox is related to decreased clearance of CO2 from the lungs when pulmonary blood flow is critically reduced. Accordingly, increased venous PCO2 rather than metabolic acidosis due to lactic acidosis predominates during the initial 8 min of cardiopulmonary resuscitation. Arterial blood gases fail as indicators of systemic acid-base status and therefore as indicators of tissue acidosis.

Vest inflation without simultaneous ventilation during cardiac arrest in dogs: improved survival from prolonged cardiopulmonary resuscitation.

Abstract: Myocardial and cerebral blood flow can be generated during cardiac arrest by techniques that manipulate intrathoracic pressure. Augmentation of intrathoracic pressure by high-pressure ventilation simultaneous with compression of the chest in dogs has been shown to produce higher flows to the heart and brain, but has limited usefulness because of the requirement for endotracheal intubation and complex devices. A system was developed that can produce high intrathoracic pressure without simultaneous ventilation by use of a pneumatically cycled vest placed around the thorax (vest cardiopulmonary resuscitation [CPR]). The system was first tested in a short-term study of the maximum achievable flows during arrest. Peak vest pressures up to 380 mm Hg were used on eight 21 to 30 kg dogs after induction of ventricular fibrillation and administration of epinephrine. Microsphere-determined myocardial blood flow was 108 +/- 17 ml/min/100 g (100 +/- 16% of prearrest flow) and cerebral flow was 51 +/- 12 ml/min/100 g (165 +/- 39% of prearrest). Severe lung or liver trauma was noted in three of eight dogs. If peak vest pressure was limited to 280 mm Hg, however, severe trauma was no longer observed. A study of the hemodynamics during and survival from prolonged resuscitation was then performed on three groups of seven dogs. Vest CPR was compared with manual CPR with either conventional (300 newtons) or high (430 newtons) sternal force. After induction of ventricular fibrillation, each technique was performed for 26 min. Defibrillation was then performed.(ABSTRACT TRUNCATED AT 250 WORDS)

Sepsis from triple- vs single-lumen catheters during total parenteral nutrition in surgical or critically ill patients.

Abstract: • We prospectively studied the infection rates for 59 triple-lumen (TLC) and 68 single-lumen (SLC) subclavian catheters during the administration of total parenteral nutrition (TPN) to surgical or critically ill patients. A standard protocol was used for catheter insertion and maintenance. The infection control committee determined independently whether patients had catheter-related sepsis, an infected insertion site only, or no catheter infection. The TLCs had an increased incidence of catheter sepsis (19%) compared with the SLCs (3%). Low rates (5% for TLCs and 3% for SLCs) of infected catheter sites only indicated that the catheter care was comparable for both groups. The patients in the two groups were similar but not identical; those with TLCs appeared to be sicker and, therefore, at greater risk to develop catheter sepsis than patients with SLC. However, since TLCs were involved in six times more catheter sepsis than were SLCs, limiting the use of a subclavian catheter to giving TPN only and strict adherence to a TPN protocol are necessary to minimize the risk of catheter sepsis. ( Arch Surg 1986;121:591-594)

Quality of life and resuscitation decisions in elderly patients.

Abstract: Quality of life considerations may be an important factor in medical decisions, but it is not known how well physician's assessments match those of their patients. The authors studied the assessments of elderly inpatients (n = 65) and their physicians (n = 50) concerning patient quality of life and resuscitation decisions for the patients' current health situations and for two hypothetical situations. Physicians rated current patient quality of life more negatively than did patients; differences ranged from 0.35 to 0.80 on a 5-point scale with end points labeled "very poor quality of life" and "possible to have good quality of life." Physicians were also less likely to favor resuscitation in the two hypothetical scenarios (p less than 0.01); differences ranged from 0.66 to 1.40 on a 5-point scale with end points labeled "definitely yes" and "definitely no." In both patient and physician groups, quality of life assessments were significantly correlated with resuscitation decisions for some situations but not for others. These results indicate that elderly patients and their physicians may differ on patient quality of life assessments and that these assessments may be associated with resuscitation decisions.

Liver packing for uncontrolled hemorrhage: a reappraisal

Abstract: The efficacy of liver packing for uncontrolled hemorrhage was assessed in 345 patients with hepatic injuries divided into two groups: Group I (1977-1980; n = 177), when packing was not used and Group II (1981-1985; n = 168) when the technique was employed. Despite similar clinical details, mortality from bleeding was unchanged (19.2% and 19.4% overall, and 63.7% and 61.7% for Grade IV, V, VI liver injuries). Packing was used in 14 patients who were in clinical coagulopathy after debridement-resection of the injured liver: eight patients (57%) expired from continued bleeding; five of the six survivors (83.3%) developed intra-abdominal abscesses despite early removal of the pack. The incidence of sepsis was significantly (p less than 0.002) increased as compared to that of 15 similar patients who had debridement-resection without packing. Liver packing, in our experience, has not altered the mortality from major hepatic trauma and appeared to increase the incidence of abdominal sepsis.

Deferred consent. A new approach for resuscitation research on comatose patients.

Abstract: Methodological constraints inherent in the rapidly growing field of resuscitation research have created an apparent conflict with newly promulgated federal regulations, especially those concerning informed consent requirements. We propose that two new concepts be applied to resuscitation research to satisfy the current federal regulations governing biomedical research. The first of these concepts is "minimal differential risk," ie, in resuscitation medicine, the difference between the risk of an undesirable outcome when standard, commonly accepted therapy may be used and the risk of an undesirable outcome with experimental therapy is minimal. The second concept is "deferred consent," ie, obtaining consent to continue with an experimental therapy after administration of that therapy has already begun. We believe that the emergency exception to informed consent applies to resuscitation research. Recognition of the applicability of these concepts to resuscitation research should allow compliance with federal and state regulations that otherwise might inhibit or preclude such research endeavors.

Neurologic outcome and blood glucose levels during out‐of‐hospital cardiopulmonary resuscitation

Abstract: We examined the interrelations of outcome, time elapsed during cardiopulmonary resuscitation (CPR), and blood glucose levels drawn from 83 patients with out-of-hospital cardiac arrest. Levels rose significantly during CPR. Although slope and intercept of regression lines differed for those dying in the field and those admitted, regression lines were similar for those who awoke and never awoke after admission. These results suggest that the previously reported association between poor neurologic recovery and high blood glucose level on admission after cardiac arrest is best explained by prolonged CPR, leading to both higher rise of blood glucose and worse neurologic outcome.

Revaccination of renal transplant and hemodialysis recipients with pneumococcal vaccine.

Abstract: • Two years after pneumococcal vaccine was given to patients on a university renal transplant and hemodialysis service, vaccine failures began to occur. Serologic studies showed a threefold decrease in antibody levels during this period, from 913 ng of antibody nitrogen per milliliter to 315 ng/mL. The decrease was greater in patients undergoing hemodialysis than in renal transplant recipients (879 to 215 ng/mL vs 932 to 385 ng/mL). The lowest antibody levels were to types 4,6A, and 19F. Patients were revaccinated, without serious reactions, and pneumococcal infections decreased as they had after the original vaccination program. After revaccination, there was a twofold increase in antibody levels (315 to 602 ng/mL), but the levels did not reach those seen after primary vaccination. The increase was greater in hemodialysis than in renal transplant recipients (215 to 757 ng/mL vs 385 to 536 ng/mL). This experience indicates that pneumococcal vaccines may be effective in patients undergoing hemodialysis and in asplenic renal transplant recipients, but these groups will require revaccination sooner than normal subjects to maintain immunity. ( Arch Intern Med 1986;146:1554-1556)

Identification of a high-risk group for sudden infant death syndrome among infants who were resuscitated for sleep apnea.

Abstract: Of the 1,153 infants who completed monitoring by Aug 1, 1984, through our program at Massachusetts General Hospital, 76 infants had an initial apnea spell during sleep which was characterized by a change in tone and color, was unresponsive to repeated vigorous stimulation, and was terminated only after mouth to mouth resuscitation. The infants were hospitalized for observation and evaluation, and no cause could be identified. All were discharged on a home apnea or cardiorespiratory monitor, and subsequent episodes of apnea and/or bradycardia were reviewed. We grouped infants based on the intervention used to terminate subsequent episodes: Group 1, resuscitation; group 2, vigorous stimulation; and group 3, neither resuscitation or vigorous stimulation. There was no significant difference in clinical features or in the results of the initial evaluation in groups 1 and 2, compared with group 3. However, the mortality rate was significantly higher in group 1 (4/13) and group 2 (3/12) than in group 3 (3/51) (P less than .007). Siblings of victims of sudden infant death syndrome (n = 8) were at a significantly higher risk of an adverse outcome (two deaths and four resuscitations) than nonsiblings (P less than .02). A seizure disorder that developed during monitoring was associated with a high mortality (4/11 v 6/65, P less than .02). We conclude that these relatively rare infants who have sleep-onset apnea that responded only to resuscitation and have a subsequent similar episode or are siblings of victims of sudden infant death syndrome or develop a seizure disorder during monitoring have a very high risk of dying (31%, 25%, and 36% respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Liberal use of emergency center thoracotomy

Abstract: Emergency center thoracotomy is a heroic technique of resuscitation and treatment which was revived in the 1960s to improve the survival of patients presenting with cardiac wounds. With excellent survival rates attained in such patients, the technique was extended to victims of trauma with other mechanisms and locations of injury. At present, the technique has a survival rate ranging from 3 to 20 percent; however, most recent series of unselected patients show a survival rate of 8 to 10 percent. In this series, there were no survivors when emergency center thoracotomy was utilized after a period of prehospital cardiopulmonary resuscitation. Patients with isolated stab wounds to the thorax, especially those with cardiac injuries, had the best survival rate of any subgroup in the series. If emergency center thoracotomy was utilized for patients with some vital signs on admission and with neck or truncal gunshot wounds, blunt trauma, or abdominal trauma, the survival rate decreased to 2 to 4 percent; however, the small but constant survival rate in all of these groups justifies its continued use.

Failure of sodium bicarbonate to improve resuscitation from ventricular fibrillation in dogs

Abstract: To determine the value of sodium bicarbonate in resuscitation from ventricular fibrillation and the prevention of spontaneous refibrillation, sodium bicarbonate (1 meq/kg) or placebo was administered on a random basis to 16 pentobarbital-anesthetized dogs 18 min after the induction of ventricular fibrillation and cardiopulmonary resuscitation. Defibrillation was attempted 2 min after the administration of bicarbonate or placebo. All animals were successfully defibrillated, but three of eight bicarbonate-treated and two of eight control animals died in electromechanical dissociation (p = NS). Spontaneous refibrillation occurred in three animals in each group (p = NS). Successful resuscitation was not dependent on treatment, arterial or mixed venous Pco2, or arterial or mixed venous pH but correlated strongly with coronary perfusion pressure (p less than .003). Spontaneous refibrillation occurred without relation to any identifiable variable. The gradient between diastolic aortic and right atrial pressures was 24 +/- 2 mm Hg in controls and 23 +/- 2 mm Hg in treated animals over the entire 20 min of cardiopulmonary resuscitation (p = NS). However, among animals successfully resuscitated, mean diastolic coronary perfusion pressure averaged 27 +/- 2 mm Hg compared with 20 +/- 1 mm Hg among those dying in electromechanical dissociation (p less than .02). For the final 2 min of resuscitation, after drug administration, these gradients were 31 +/- 2 and 23 +/- 2 mm Hg, respectively (p less than .01). Microsphere determined myocardial perfusion correlated with the diastolic aortic-right atrial perfusion pressure gradient (r = .86) and was 0.43 +/- 0.03 ml/min/g in survivors and 0.22 +/- 0.01 ml/min/g in nonsurvivors (p less than .01).(ABSTRACT TRUNCATED AT 250 WORDS)

Resuscitation from hemorrhagic shock. Alterations of the intracranial pressure after normal saline, 3% saline and dextran-40.

Abstract: Resuscitation from hemorrhagic shock by infusion of isotonic (normal) saline (NS) is accompanied by a transient elevation in intracranial pressure (ICP), although cerebral edema, as measured by brain weights at 24 hours, is prevented by adequate volume resuscitation. The transient increase in ICP is not observed during hypertonic saline (HS) resuscitation. The effect of colloid resuscitation on ICP is unknown. Beagles were anesthetized, intubated, and ventilated, maintaining pCO2 between 30-45 torr. Femoral artery, pulmonary artery, and urethral catheters were positioned. ICP was measured with a subarachnoid bolt. Forty per cent of the dog's blood volume was shed and the shock state maintained for 1 hour. Resuscitation was done with shed blood and a volume of either NS (n = 5), 3% HS (n = 5), or 10% dextran-40 (D-40, n = 5) equal to the amount of shed blood. Intravascular volume was then maintained with NS. ICP fell from baseline values (4.7 +/- 3.13 mmHg) during the shock state and increased greatly during initial fluid resuscitation in NS and D-40 groups, to 16.0 +/- 5.83 mmHg and 16.2 +/- 2.68 mmHg, respectively. ICP returned to baseline values of 3.0 +/- 1.73 mmHg in the HS group with initial resuscitation and remained at baseline values throughout resuscitation. NS and D-40 ICP were greater than HS ICP at 1 hour (p less than .001) and 2 hours (p less than .05) after resuscitation. These results demonstrate that NS or colloid resuscitation from hemorrhagic shock elevates ICP and that HS prevents elevated ICP.

Factors influencing outcome of cardiopulmonary resuscitation in children

Abstract: We evaluated 47 pediatric patients after cardiopulmonary arrest. Patients entered the study with the onset of advanced life support. We followed them until death, or discharge from the hospital, occurred. We identified three groups of patients: long-term survivors, who survived to discharge, short-term survivors, who survived longer than 24 hours after CPR but not until discharge, and nonsurvivors, who died within 24 hours of their arrest. All of the long-term surviving patients were discharged from the hospital without gross neurologic deficit attributable to the arrest or resuscitation effort. Twenty-seven (57%) children were successfully resuscitated. Eighteen (38%) were long term-survivors, while nine (19%) were short-term survivors. Favorable outcome is associated with the following factors: inhospital arrest, extreme bradycardia as the presenting arrhythmia, successful resuscitation with only ventilation, oxygen and closed chest massage, and a duration of CPR of less than 15 minutes. Age, sex, and race, as well as pupillary reaction and motor response at the onset of advanced life support, did not correlate with long-term survival.

Acute renal failure in the intensive care unit today.

Abstract: Although there are isolated reports of what would now be called acute reversible renal failure dating back a century, particularly in the German literature describing injuries in the First World War [1], it was not until the second major conflict that a number of sets of clinical and experimental data were brought together to produce the current concept: an acute, potentially-reversible failure of renal function in previously normal, unobstructed kidneys, in response to events as diverse as mismatched transfusion, abortions, cardiovascular collapse, sepsis, crush injuries, and a variety of nephtrotoxic substances [2, 3]. Unfortunately there is still no satisfactory term for this condition, since \"acute renal failure\" is too broad, and \"acute tubular necrosis\" too narrow. At this time the mortality of \"acute tubular necrosis\" was very high, especially in those injured: in the Second World War, the death rate amongst wounded servicemen was 91%0 [4]. A major leap forward was the introduction of haemodialysis by Kolff during this same conflict: the first patient (who had sulphonamide toxicity) to survive acute renal failure thanks to haemodialysis was treated 42 years ago. Immediately upon the introduction of haemodialysis the mortality in both civilian post-surgical renal failure [5] and military trauma[6] fell to about 50% or 60%0, and the oliguric and diuretic stages of acute renal failure were observed and studied. It is distressing to find that thirty years on the mortality of the more severe forms of acute renal failure has remained approximately the same, only one patient in three surviving on average. Why is this? First, many patients with \"uncomplicated\" acute renal failure are managed in general wards or renal units, and these patients have a very low mortality. The most recent figures, those of the EDTA-European Renal Association's 1985 report [7] notes that in a survey of 474 patients with acute renal failure from 114 renal units treated during a six week period in 1984, the mortality in those where renal failure was the only problem was 8%. However, these were only 61 patients out of 474, the other 413 (87%) carrying an average mortality of over 60% (Fig. 1). These are, of course, just those patients who are treated in intensive care units. Thus, despite what most of us would regard as improvements in ventilation, nutrition, anaesthesia, antibiotic chemotherapy and the diagnosis of infection, cardiovascular monitoring and management, and techniques of substitution for renal failure, we appear to be doing no better than 30 years ago [8]. Of course, one possible explanation is that although the mortality remains high, the proportion of more severe cases is greater, and the group of those going into renal failure are a higher risk group than in 1964 or 1974. We know, of course, that there are patients who go into renal failure now after procedures undreamt of in the past, and a few causes like septic abortions are now uncommon in the developed world;