Showing papers on "Resuscitation published in 1989"

Outcomes of Cardiopulmonary Resuscitation in the Elderly

Abstract: Study Objective:To determine the success rate of cardiopulmonary resuscitation in the elderly and to define characteristics of elderly patients for whom cardiopulmonary resuscitation is ef...

Plasma tumor necrosis factor and mortality in critically ill septic patients.

Abstract: Tumor necrosis factor (TNF) cachectin has been implicated as an important host mediator responsible for shock and multiple organ failure (MOF) observed during sepsis. Using a sensitive enzyme-linked immunosorbent assay, we measured plasma TNF levels in 43 septic patients suffering from a broad range of diseases. Measurements were taken on the day that sepsis was diagnosed. Eleven patients had detectable TNF plasma levels ranging from 10 to 100 pg/ml (TNF-positive group); in 32 patients circulating TNF could not be detected (TNF-negative group). The groups did not differ significantly as to age, underlying disease, percentage positive bacteremia and bacteriologic profile, sepsis score, and extent of MOF. Eight (73%) of 11 TNF-positive patients died from sepsis during ICU stay, vs. 11 (34%) of 32 TNF-negative patients (p less than .05). This study demonstrates that sepsis is accompanied by detectable circulating TNF in 25% of the cases, and for these patients mortality is twice that for comparable TNF-negative patients.

End-Tidal Carbon Dioxide Monitoring During Cardiopulmonary Resuscitation: A Prognostic Indicator for Survival

Abstract: The effectiveness of ongoing cardiopulmonary resuscitation efforts is difficult to evaluate. Recent studies suggest that carbon dioxide excretion may be a useful noninvasive indicator of resuscitation from cardiac arrest. A prospective clinical study was done to determine whether end-tidal carbon dioxide monitoring during cardiopulmonary resuscitation could be used as a prognostic indicator of resuscitation and survival. Thirty-five cardiac arrests in 34 patients were monitored with capnometry during cardiopulmonary resuscitation during a 1-year period. Nine patients who were successfully resuscitated had higher average end-tidal carbon dioxide partial pressures during cardiopulmonary resuscitation than 26 patients who could not be resuscitated (15±4 vs 7±5 mm Hg). The 3 patients who survived to leave the hospital had a higher average end-tidal carbon dioxide partial pressure than the 32 nonsurvivors (17 ± 6 vs 8 ± 5 mm Hg). All 9 patients who were successfully resuscitated had an average end-tidal carbon dioxide partial pressure of 10 mm Hg or greater. No patient with an average end-tidal carbon dioxide partial pressure of less than 10 mm Hg was resuscitated. Data from this prospective clinical trial indicate that findings from end-tidal carbon dioxide monitoring during cardiopulmonary resuscitation are correlated with resuscitation from and survival of cardiac arrest. ( JAMA . 1989;262:1347-1351)

Decisions about resuscitation: inequities among patients with different diseases but similar prognoses.

Abstract: Study Objective:To assess whether decisions about "do-not-resuscitate" (DNR) orders are made equitably in patients with different diseases but similar prognoses. Design:Retrospective cohor...

Frequency of rupture of the left ventricular free wall or ventricular septum among necropsy cases of fatal acute myocardial infarction since introduction of coronary care units.

Abstract: Review of 18 published reports before the widespread use of cardiac care units disclosed that the frequency of rupture of the left ventricular free wall or ventricular septum among necropsy cases of acute myocardial infarction (AMI) ranged from 4 to 24% (mean 8%) (619 of 7,905 cases). The frequency of rupture of the left ventricular free wall or ventricular septum among necropsy patients with fatal AMI studied in this laboratory since 1968 was analyzed. Of 648 such patients, 204 (31%) had rupture of the left ventricular free wall or ventricular septum. Rupture occurred in 171 (40%) of 431 patients without healed myocardial infarcts (grossly visible left ventricular scars), and in 29 (13%) of 217 patients with a healed myocardial infarct (p < 0.01). Thus, the frequency of rupture of the left ventricular free wall or ventricular septum during AMI appears to have increased substantially since the widespread use of coronary care units. Also, the frequency of rupture is nearly 3 times greater in those in whom rupture occurred during the first AMI compared to those with a previous infarct that healed.

Guidelines for Cardiopulmonary Resuscitation. Advanced life support. Revised recommendations of the Resuscitation Council (UK)

Abstract: The first guidelines for advanced life support promoted by the Resuscitation Council of the United Kingdom were published in 1984. The council adopted a policy of revising and updating them every five years so that policies were kept in line with current research. The new recommendations, together with those for basic life support, are now available. The advanced guidelines are summarised in a chart that shows algorithms for treating different modes of cardiac arrest, together with brief advice on the general conduct of resuscitation. This article draws attention to the major modifications in the algorithms. Since 1984 cooperation has increased greatly with many other European groups that have an interest in cardiopulmonary resuscitation. In particular, we have liaised closely with colleagues from Nordic countries. The recommendations for 1989-and the chart-are substantially the same for the United Kingdom, Sweden, Denmark, Norway, and Finland. We expect that the 1994 recommendations will represent a consensus from a larger group of European countries. The use of the precordial thump has been reintroduced but only for witnessed or monitored arrests, in line with published evidence of its efficacy for pulseless ventricular tachycardia or ventricular fibrillation of very recent onset. The risk of exacerbating a ventricular arrhythmia is recognised, but the likelihood of harm is small when the arrest has been witnessed. Moreover, a proarrhythmic effect is possible with all successful interventions, and the manoeuvre takes little time to execute.

Glucocorticoid treatment does not improve neurological recovery following cardiac arrest. Brain Resuscitation Clinical Trial I Study Group.

Abstract: Glucocorticoids are commonly given to patients with global brain ischemia, although their efficacy has not been proved. The database of the Brain Resuscitation Clinical Trial I, a multi-institutional study designed to evaluate the effect of thiopental sodium therapy on neurological outcome following brain ischemia, was used for a retrospective review of the effects of glucocorticoid treatment on neurological outcome after global brain ischemia. This study included 262 initially comatose cardiac arrest survivors who made no purposeful response to pain after restoration of spontaneous circulation. The standard treatment protocol left glucocorticoid therapy to the discretion of the hospital investigators. This resulted in four patient groups that received either no, low, medium, or high doses of glucocorticoids in the first 8 hours after arrest. Neurological outcome was scored using a modification of the Glasgow Cerebral Performance Category Scale. None of the steroid regimens statistically improved mean group survival rate or neurological recovery rate over that observed in the group that did not receive steroids. The routine clinical practice of administrating glucocorticoids after global brain ischemia may be associated with serious complications and is not justified.

Myocardial acidosis associated with CO2 production during cardiac arrest and resuscitation.

Abstract: Previous studies from our institution demonstrated significant hypercarbic acidosis in the mixed venous (pulmonary artery) blood in animals and human patients during cardiac arrest and cardiopulmonary resuscitation (CPR). In the present study, the acid-base state of the myocardium during cardiac arrest was investigated. Cardiac arrest was electrically induced in 11 pentobarbital-anesthetized and mechanically ventilated domestic pigs. Precordial compression was begun 3 minutes after onset of ventricular fibrillation and continued for 8 minutes. During CPR, there was rapid onset of profound myocardial acidosis with an increase in intramyocardial [H+] from 54 +/- 5 to 146 +/- 20 nmol/l (7.27 +/- 0.04 to 6.88 +/- 0.20 pH units). Great cardiac vein PCO2 increased from 57 +/- 2 to 158 +/- 12 mm Hg. Profound hypercarbic acidosis in great cardiac vein blood was associated with myocardial lactate production to levels of 8.1 +/- 0.7 mmol/l. Only moderate decreases in cardiac vein bicarbonate concentrations from 31 +/- 1 to 23 +/- 1 mmol/l were observed. These acid-base changes were almost completely reversed over an interval of 60 minutes after the animals were successfully resuscitated by DC countershock. The PCO2 in cardiac vein blood was significantly greater than that of mixed venous blood, demonstrating disproportionate myocardial production of CO2 during CPR. Accordingly, it is CO2 production during ischemia that is implicated as the predominant mechanism accounting for myocardial [H+] increases during cardiac arrest. Important clinical implications for buffer therapy during CPR and, in particular, treatment with bicarbonate emerge from these observations.

Discontinuation of Dialysis Therapy as a Cause of Death

Abstract: Discontinuation of life-sustaining dialysis therapy led to death in 282 of 5,208 patients who started therapy for end-stage renal disease (ESRD) in Michigan during 1980–1985 with a follow-up through 1

Benzodiazepine poisoning: experience of 702 admissions to an intensive care unit during a 14‐year period

Abstract: Hojer J, Baehrendtz S, Gustafsson L (Department of Internal Medicine, Southern Hospital, and Department of Clinical Pharmacology, Huddinge Hospital, Karolinska Institute, Stockholm, Sweden). Benzodiazepine poisoning: experience of 702 admissions to an intensive care unit during a 14-year period. A retrospective study covering a 14-year period was carried out to estimate the incidence and assess the clinical features of benzodiazepine (BZD) poisoning. The annual contribution of BZDs to the total number of drug overdose cases admitted to an intensive care unit displayed an increasing trend over the period, and during the last years BZDs were involved in nearly one-third of all cases. Among the 702 cases of BZD overdosage, 144 had ingested BZD alone, 200 had poisoned themselves with BZD combined with alcohol and 358 had taken BZD with other miscellaneous drugs. In 56% of all the cases the patients had severe central nervous system depression on admission. In 47% orotracheal intubation was performed and in 18% artificial ventilation was administered. Complications were recorded in 69 of the 702 cases (9.8%) and five cases were fatal. These clinical features were essentially the same in the group that had overdosed with just BZD. In conclusion, patients with drug overdosage involving BZD have a low hospital mortality, but the acute somatic risk is not negligible. Moreover, they consume a substantial proportion of the resources in the emergency room and the intensive care unit.

Pain and analgesia in the newborn.

Abstract: The traditional view that neonates do not feel pain is now being questioned. Early studies showed what was thought to be a decorticate response in babies with no localisation to painful stimuli and this, together with the belief that the painful experience was not remembered, implied that pain was unimportant. ' As a consequence and because of certain anxieties about the handling of drugs (particularly opiates) in the newborn there has been a reluctance to prescribe analgesia for these patients.2 Data now suggest that infants do feel pain.' 3 4 In this review the underlying neurobiology of pain development in neonates is described, followed by a review of clinical studies indicating that the newborn baby responds (possibly adversely) to pain. We conclude that the arguments in favour of the use of analgesia have become overwhelming.

Changes in the hippocampus and the cerebellum resulting from hypoxic insults: frequency and distribution.

Abstract: Detailed neurohistological studies were undertaken on 35 cases of cardiac arrest, 17 of hypoglycaemia and 16 of status epilepticus. It was found that the frequency and pattern of selective vulnerability in the hippocampus were similar following cardiac arrest, hypoglycaemia and status epilepticus with the exception that the lateral limb of the dentate fascia was more frequently involved in hypoglycaemia than in the other two groups of cases. Within each group, however, CA1 was the most vulnerable. The cerebellum was less frequently affected in hypoglycaemia and status epilepticus than after cardiac arrest. These findings are compared with recent experimental studies in the rodent which have suggested that the pattern of neuronal damage in each of the three conditions is different.

In-Hospital Cardiopulmonary Resuscitation

Abstract: To the Editor. — We read with interest the report by Taffet and collegues 1 concerning their experience with in-hospital cardiopulmonary resuscitation at the Houston (Tex) Veterans Administration Medical Center. Review of the literature and our own experience lead us to believe, as the authors suggest, that their results are not representative of those in many acute-care hospitals. They reported a 6.7% survival for all patients (preponderantly male) and a 0% survival to hospital discharge in patients 70 years of age or older. A 2-year experience (January 1, 1986, to December 31, 1987) with in-hospital resuscitation in our 590-bed community hospital is more favorable, as shown in Table 2. Our overall survival rate was 15.5%: 24.5% for patients younger than age 70 years and 12.7% for patients aged 70 years and older. Of the groups represented in Table 2, survival rate was lowest for men aged 70 years and older, but

Cerebral blood flow in humans following resuscitation from cardiac arrest.

Abstract: Cerebral blood flow was measured by xenon-133 washout in 13 patients 6-46 hours after being resuscitated from cardiac arrest. Patients regaining consciousness had relatively normal cerebral blood flow before regaining consciousness, but all patients who died without regaining consciousness had increased cerebral blood flow that appeared within 24 hours after resuscitation (except in one patient in whom the first measurement was delayed until 28 hours after resuscitation, by which time cerebral blood flow was increased). The cause of the delayed-onset increase in cerebral blood flow is not known, but the increase may have adverse effects on brain function and may indicate the onset of irreversible brain damage.

Successful Resuscitation of Bupivacaine-induced Cardiac Arrest Using Cardiopulmonary Bypass

Abstract: Cardiotoxic responses to local anesthetic agents have been reported as a cause of death in patients undergoing operative procedures, despite close patient monitoring, the presence of personnel fully trained in advanced cardiac life support, and the ready availability of resuscitative drugs and equipment. In this report we present a case of bupivacaine-induced cardiac arrest that after failure of resuscitation by medical means, was successfully treated by the rapid initiation of cardiopulmonary bypass.

Combined hemorrhagic shock and head injury effects of hypertonic saline (7.5%) resuscitation

Abstract: Hypertonic saline resuscitation was compared to isotonic fluid resuscitation in a large animal model combining hemorrhagic shock with head injury. Sheep were subjected to a freeze injury of one cerebral hemisphere as well as 2 hours of hypotension at a mean arterial pressure (MAP) of 40 mm Hg. Resuscitation was then carried out (MAP = 80 mm Hg) for 1 hour with either lactated Ringer's (LR, n = 6) or 7.5% hypertonic saline (HS, n = 6). Hemodynamic parameters and intracranial pressure (ICP) were followed. At the end of resuscitation brain water content was determined in injured and uninjured hemispheres. No differences were detected in cardiovascular parameters; however, ICPs were lower in animals resuscitated with HS (4.2 +/- 1.5 mm Hg) compared to LR (15.2 +/- 2.2 mm Hg, p less than 0.05). Additionally, brain water content (ml H2O/gm dry weight) in uninjured brain hemispheres was lower after HS resuscitation (HS = 3.3 +/- 0.1; LR = 4.0 +/- 0.1; p less than 0.05). No differences were detected in the injured hemispheres. We conclude that hypertonic saline abolishes increases in ICP seen during resuscitation in a model combining hemorrhagic shock with brain injury by dehydrating areas where the blood-brain barrier is still intact. Hypertonic saline may prove useful in the early management of multiple trauma patients.

Hyperglycemia after trauma increases with age.

Abstract: The metabolic responses to trauma and surgery have been well described and are observed most typically in otherwise healthy young and middle-aged individuals. To investigate the effect of age on blood glucose, insulin, and cortisol responses after mild to moderate trauma, we studied 33 patients (Injury Severity Scores, 5-38, and ages 16 to 81 years) before resuscitation and 24-96 hours postinjury. Age was associated with an increase in serum glucose during both "ebb" and "flow" phases of the injury response, but not with serum insulin. Serum glucose also increased with the degree of injury as reflected in Glasgow Coma Scale on admission and Injury Severity Score subsequently. Serum cortisol responses were increased in older patients and tended to decrease with time following injury. A more detailed knowledge of how age may alter the ability of elderly patients to respond to trauma and critical illness is essential to allow the continued development of rational therapies for such patients.

Glucose administration before cardiac arrest worsens neurologic outcome in cats.

Abstract: The effects of glucose on neurologic and neuropathologic outcome following global cerebral ischemia were examined in 20 cats subjected to 14 min of cardiac arrest, followed by closed chest resuscitation and intensive care monitoring. Beginning 30 min prior to cardiac arrest, 15 ml/kg of 5% dextrose

A comparison of the cerebral and cardiovascular effects of complete resuscitation with isotonic and hypertonic saline, hetastarch, and whole blood following hemorrhage.

Abstract: Hemorrhagic shock and closed head injury often accompany severe trauma. Hypertonic saline may be beneficial in these patients, but few have examined its properties when sufficient volume is infused to achieve sustained resuscitation. Solutions of 6% NaCl (HS), 0.9% NaCl (NS), 6% hetastarch (HE), and whole blood (WB) were used to resuscitate swine in hemorrhagic shock (MAP less than 30 mm Hg). The endpoint of resuscitation was normal oxygen delivery (DO2). Measurements of intracranial pressure (ICP), cerebral perfusion pressure (CPP), and intracranial elastance (ICE) were made in the absence and presence of an epidural mass, created by inflating an epidural balloon. HS resuscitation resulted in a lower ICP [5 +/- 1 versus 9 +/- 2 (HE), 17 +/- 3 (NS), and 10 +/- 3 (WB) mm Hg; p = 0.016], and normalization of CPP throughout resuscitation. Animals resuscitated with NS had a lower CPP by the end of resuscitation [CPP = 45 +/- 4 for NS group, versus 63 +/- 4 (HE), 66 +/- 4 (HS), and 63 +/- 5 (WB) mm Hg; p = 0.009]. ICE fell markedly in the HS group, [a decrease of 12 +/- 2 vs. a rise of 5 +/- 3 (HE), 2 +/- 3 (NS), and 6 +/- 3 (WB) mm Hg/ml; p = 0.0005]. This improvement was even more dramatic in the presence of an epidural mass [a fall of 21 +/- 3 vs. no change (HE, WB) and a rise of 4 +/- 3 (NS) mm Hg/ml; p = 0.0005]. For hemorrhage accompanied by severe head injury, resuscitation with HS may benefit victims by decreasing ICP and diminishing the effects of an intracranial mass.

MK-801, an excitatory amino acid antagonist, does not improve neurologic outcome following cardiac arrest in cats.

Abstract: The excitatory amino antagonist MK-801 was administered to cats following resuscitation from cardiac arrest to evaluate its effect on neurologic and neuropathologic outcome in a clinically relevant model of complete cerebral ischemia. In 29 cats studied, cardiac arrest (ventricular fibrillation) was maintained for 18 min and resuscitation was successfully performed in 21 cats. Four animals underwent a sham arrest. MK-801 or placebo was administered in a blinded, randomized manner. Beginning at 5 min post resuscitation (PR), MK-801 330 micrograms/kg over 2 min followed by 73 micrograms/kg/h for 10 h or the same volume of placebo was administered. Resuscitated animals remained paralyzed and sedated in an intensive care setting for 24-30 h PR. Neurologic examinations were performed at 2, 4, and 7 days PR by observers blinded to the treatment groups. Seventeen cats were entered into data analysis (nine MK-801-treated and eight placebo-treated). MK-801-treated animals had a significantly greater neurologic deficit score (NDS) rank (0 = normal, 100 = brain death) 2 days PR (mean rank 12.1 vs. 5.6; p = 0.008). This difference is most likely due to ongoing sedative actions of MK-801. There were no significant differences in NDS rank at 4 (10.3, MK-801 vs. 7.5, placebo) and 7 (9.6, MK-801 vs. 8.3, placebo) days PR. There were no significant differences in frontal cortex, hippocampus, occipital cortex, or cerebellar neuropathology between groups. Sham-arrested cats had normal neurologic and neuropathologic evaluations. In the circumstance of complete cerebral ischemia as employed in the current study, MK-801 had no beneficial effect upon neurologic or neuropathologic outcome.