Showing papers on "Resuscitation published in 1996"
TL;DR: In this article, the authors discuss the issues in patient care organization and management of Critical Care Ethical Decision Making in Critically Ill Patients, including the following:Resuscitation Cell Injury and Cell Death Monitoring Imaging Pulmonary Abdominal Organ Dysfunction Metabolism and Pharmacology Infectious Diseases Hematology/Oncology Trauma Central Nervous System Transplantation Issues in Patient Care Organization and Management of critical care
Abstract: Resuscitation Cell Injury and Cell Death Monitoring Imaging Pulmonary Abdominal Organ Dysfunction Metabolism and Pharmacology Infectious Diseases Hematology/Oncology Trauma Central Nervous System Transplantation Issues in Patient Care Organization and Management of Critical Care Ethical Decision Making in Critically Ill Patients.
475 citations
TL;DR: Myocardial systolic and diastolic dysfunction is severe after 10 to 15 min of untreated cardiac arrest and successful resuscitation, and full recovery of this postresuscitation myocardial stunning is seen by 48 h in this experimental model of ventricular fibrillation cardiac arrest.
348 citations
TL;DR: The lack of standardization and the use of nonuniform terminology in reports of studies of cardiac arrest in humans have been described as a "Tower of Babel" as mentioned in this paper.
Abstract: Both laboratory and clinical investigators contribute to the multidisciplinary knowledge base of resuscitation science While diversity can be a strength, it can also be a hindrance because of the lack of a common language and poor communication among investigators
Modern cardiopulmonary resuscitation (CPR) research depends on the use of animal models that are designed to simulate cardiac arrest in humans1 2 Such models are used to explore important new treatments and to refine protocols used in standard interventions, including doses of drugs, chest compression techniques, defibrillation energies, and cerebral resuscitation, before they are applied to humans3 When favorable results are reported in animal models, the new or refined techniques are often implemented soon afterward in human victims of cardiac arrest Unfortunately, the results obtained in one laboratory may not be reproducible in another laboratory or in human trials For example, high-dose epinephrine therapy significantly improves survival in most animal models of cardiac arrest but does not improve survival in humans4 5 6 7 In addition, some animal studies have documented the efficacy of administering bicarbonate during cardiac arrest, while others have shown it to be ineffective or deleterious8 Some of these differences are to be expected because an animal simulation is not a perfect model of cardiac arrest in humans However, it is likely that some of these conflicting results are due to differences in experimental methods and laboratory model design Variations in study design, such as the quality of chest compressions and ventilation, definitions of variables, or time intervals between an event and the beginning of therapy, are probably responsible for many of the inconsistencies and contradictions reported
The lack of standardization and the use of nonuniform terminology in reports of studies of cardiac arrest in humans have been described as a “Tower of Babel” …
286 citations
TL;DR: It was concluded that additional therapy is required in the majority of critically ill patients to restore adequate systemic oxygenation after initial resuscitation and hemodynamic stabilization in the ED and the measurement of ScvO2 and Lact can be utilized to guide this phase of additional therapy in theED.
Abstract: To describe the simultaneous responses of systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial blood pressure (MAP), heart rate (HR), shock index (SI = HRSBP), central venous oxyhemoglobin saturation (ScvO2), and arterial blood lactate concentration (Lact) to resuscitation of critically ill patients in the emergency department (ED), an observational descriptive study was conducted in the ED of an urban teaching hospital. Thirty-six patients admitted from the ED to the medical intensive care unit were studied. Vital signs were measured immediately on arrival to the ED (phase 1). After initial resuscitation and stabilization, ie, HR between 50 and 120 beats/min and MAP between 70 and 110 mm Hg (phase 2), ScvO2 and Lact were measured and additional therapy was given in the ED to increase ScvO2 to >65% and decrease Lact to 2.0 mmol/L in 31 of 36 patients at phase 2, and additional therapy was required. Lact was decreased (from 4.6 ± 3.8 to 2.6 ± 2.5 mmol/L, P < .05) and ScvO2 was increased (from 52 ± 18 to 65 ± 13%, P < .05) without significant additional changes in SBP, DBP, MAP, HR, or SI at phase 3. The in-hospital mortality was 14% for this group of patients. It was concluded that additional therapy is required in the majority of critically ill patients to restore adequate systemic oxygenation after initial resuscitation and hemodynamic stabilization in the ED. Additional therapy to increase ScvO2 and decrease Lact may not produce substantial responses in SBP, DBP, MAP, HR, and SI. The measurement of ScvO2 and Lact can be utilized to guide this phase of additional therapy in the ED.
261 citations
TL;DR: Cardiopulmonary bypass is associated with increases in gut permeability, which precede gut mucosal ischemia, and the increased intestinal absorption of 51Cr-EDTA and gastric mucosal acidosis occur as independent phenomena and are not related in severity or time of onset.
Abstract: Objective —To examine the relationship between gastric intramucosal pH, intestinal permeability, endotoxemia, and oxygen delivery in patients undergoing cardiopulmonary bypass (CPB) Design —Prospective, observational study Setting —Tertiary care center Patients —Fifty patients undergoing elective cardiac surgery and 10 patients awaiting elective cardiac surgery Interventions —Patients received chromium 51—labeled ethylenediaminetetraacetic acid (51Cr-EDTA) as a marker of intestinal permeability; insertion of a nasogastric tonometer to measure intramucosal pH (pHi); insertion of a pulmonary artery catheter to measure systemic oxygen delivery and consumption variables; arterial blood sampling for plasma endotoxin by theLimulusamebocyte lysate assay; and blood and urine sampling for measurement of51Cr-EDTA Main Outcome Measures —Systemic oxygen delivery, duration of gastric mucosal acidosis, absorption of51Cr-EDTA, appearance of systemic endotoxemia, renal dysfunction, and duration of hospital stay Results —Median (range) 24-hour urinary recovery of51Cr-EDTA in patients was 106% (21% to 402%) while that in controls was 12% (07% to 20%,P 02 endotoxin unit per milliliter) in the plasma of 21 patients (42%) during the study, most of whom were endotoxemic by the end of CPB There was no evident relationship between the degree of gut permeability, endotoxemia, gut ischemia, or systemic oxygen dynamics Conclusions —Cardiopulmonary bypass is associated with increases in gut permeability, which precede gut mucosal ischemia In cardiac surgical patients, a low pHi is not necessarily indicative of an adverse clinical outcome Endotoxemia as measured by theLimulusamebocyte lysate assay is common The increased intestinal absorption of51Cr-EDTA and gastric mucosal acidosis occur as independent phenomena and are not related in severity or time of onset (JAMA 1996;275:1007-1012)
257 citations
Journal Article•
TL;DR: Gastric mucosal pH may be an important marker to assess the adequacy of resuscitation in the postresuscitation period and was the first finding in all the nonsurvivors at least 48 to 72 hours before death.
Abstract: BACKGROUND Gastric tonometry, as a method of organ-specific monitoring of the status of the splanchnic circulation, has demonstrated prognostic and therapeutic implications in critically ill patients. The experience with this method in patients with trauma has been limited. STUDY DESIGN Fifty-seven patients were prospectively randomized into two groups: group 1, n = 30, normalization and maintenance of gastric mucosal pH (pHi) at or above 7.3 and group 2, n = 27, maintenance of oxygen delivery index of 600 or an oxygen consumption index of greater than 150. The groups had statistically similar injury severity scores, lactate levels, and base deficits. RESULTS Of the 44 patients with pHi greater than 7.3 at 24 hours, three (6.8 percent) died of multiple organ dysfunction syndrome as compared with seven (53.9 percent) of 13 in whom pHi was not optimized, p = 0.006. Optimization times for oxygen delivery index, oxygen consumption index, lactate levels, and base excess were similar between survivors and nonsurvivors. The time for pHi optimization was significantly longer in nonsurvivors. Multiple organ dysfunction syndrome points were significantly higher in patients who did not have pHi optimized within 24 hours (6.08 compared with 2.5, p = 0.03). Optimization time for pHi was predictive of mortality on multiple regression. Persistently low pHi was frequently associated with systemic or intra-abdominal complications. It was the first finding in all the nonsurvivors at least 48 to 72 hours before death. CONCLUSIONS Gastric mucosal pH may be an important marker to assess the adequacy of resuscitation. Monitoring of pHi may provide early warning for systemic complications in the postresuscitation period.
228 citations
TL;DR: A review of studies and clinical trials from the past to the present include fluid resuscitation, sepsis, immune function, hypermetabolism, early excision, wound healing, scar formation, and inhalation injury.
Abstract: Objective The authors provide an update on a multidisciplinary approach to the treatment of severely burned patients. A review of studies and clinical trials from the past to the present include fluid resuscitation, sepsis, immune function, hypermetabolism, early excision, wound healing, scar formation, and inhalation injury. Summary background data Advances in treating initial burn shock, infection control, early wound closure, and modulation of the hypermetabolic response have decreased morbidity and mortality in the last two decades. Specialized burn care centers, using a multidisciplinary approach, not only successfully treat large burns and their complications, but provide the necessary rehabilitation and psychological support required for readjustment back into society. Conclusions Thermal injury results in a number of physiologic alterations that can be minimized by adequate fluid resuscitation to maintain tissue perfusion, early excision of burn wounds, and rapid wound coverage. These measures, in combination with antibiotic coverage and nutritional support in the form of early enteral tube feedings, will decrease the hypermetabolic response and the incidence of sepsis that can lead to hemodynamic instability and organ failure. Ongoing clinical trials using anabolic agents (e.g., recombinant human growth hormone) and pharmacologic agents that modulate inflammatory and endocrine mediators (e.g., ibuprofen and propranolol) show promise in the treatment of severe burn injuries.
224 citations
TL;DR: Eight patients having refractory in-hospital cardiac arrest were treated with vasopressin after standard therapies, including intravenous administration of epinephrine, had failed, and a supraventricular rhythm with a palpable carotid pulse was recorded.
Abstract: Background: Successful outcomes after cardiopulmonary resuscitation remain disappointingly infrequent. In animal studies, administration of exogenous vasopressin during closed- and open-chest cardi...
215 citations
TL;DR: Clinical potentials in need of research are shifting from normotensive to hypotensive (limited) fluid resuscitation with plasma substitutes, and animal outcome models of combined trauma and shock are needed; a challenge is to find a humane and clinically realistic long-term method for analgesia that does not interfere with cardiovascular responses.
Abstract: The potential to be successfully resuscitation from severe traumatic hemorrhagic shock is not only limited by the "golden 1 hr", but also by the "brass (or platinum) 10 mins" for combat casualties and civilian trauma victims with traumatic exsanguination. One research challenge is to determine how best to prevent cardiac arrest during severe hemorrhage, before control of bleeding is possible. Another research challenge is to determine the critical limits of, and optimal treatments for, protracted hemorrhagic hypotension, in order to prevent "delayed" multiple organ failure after hemostasis and all-out resuscitation. Animal research is shifting from the use of unrealistic, pressure-controlled, hemorrhagic shock models and partially realistic, volume-controlled hemorrhagic shock models to more realistic, uncontrolled hemorrhagic shock outcome models. Animal outcome models of combined trauma and shock are needed; a challenge is to find a humane and clinically realistic long-term method for analgesia that does not interfere with cardiovascular responses. Clinical potentials in need of research are shifting from normotensive to hypotensive (limited) fluid resuscitation with plasma substitutes. Topics include optimal temperature, fluid composition, analgesia, and pharmacotherapy. Hypotensive fluid resuscitation in uncontrolled hemorrhagic shock with the addition of moderate resuscitative (28 degrees to 32 degrees C) hypothermia looks promising in the laboratory. Regarding the composition of the resuscitation fluid, despite encouraging results with new preparations of stroma-free hemoglobin and hypertonic salt solutions with colloid, searches for the optimal combination of oxygen-carrying blood substitute, colloid, and electrolyte solution for limited fluid resuscitation with the smallest volume should continue. For titrating treatment of shock, blood lactate concentrations are of questionable value although metabolic acidemia seems helpful for prognostication. Development of devices for early noninvasive monitoring of multiple parameters in the field is indicated. Molecular research applies more to protracted hypovolemic shock followed by the systemic inflammatory response syndrome or septic shock, which were not the major topics of this discussion.
186 citations
Book•
01 Jan 1996
TL;DR: This presentation discusses emergency resuscitation and acute airway management, as well as cardiac and circulatory failure, and Renal, endocrine, and metabolic disorders.
Abstract: Part 1 Emergency resuscitation and acute airway management. Part 2 Respiratory failure. Part 3 Cardiac and circulatory failure. Part 4 Neurologic intensive care. Part 5 Immunologic and infectious disease considerations. Part 6 Nutrition and gastrointestinal emergencies. Part 7 Renal, endocrine, and metabolic disorders. Part 8 Haematologic and oncologic conditions. (Part contents)
170 citations
TL;DR: The present data demonstrate that thrombolytic therapy improves microcirculatory reperfusions of the cat brain when administered during reperfusion after cardiac arrest.
Abstract: Objective
Successful resuscitation of the brain requires complete microcirculatory reperfusion, which, however, may be impaired by activation of blood coagulation after cardiac arrest. The study addresses the question of whether postischemic thrombolysis is effective in reducing cerebral noreflow phenomenon.
TL;DR: High-dose epinephrine administration during cardiopulmonary resuscitation in a swine pediatric asphyxial cardiac arrest model improves outcome but did not improve 2-hr survival rate, 24-hr Survival rate, or neurologic outcome.
Abstract: ObjectiveTo determine whether high-dose epinephrine administration during cardiopulmonary resuscitation (CPR) in a swine pediatric asphyxial cardiac arrest model improves outcome (i.e., resuscitation rate, survival rate, and neurologic function) compared with standard-dose epinephrine.DesignA random
TL;DR: New guidelines regarding initiation and termination of CPR should be instituted in light of poor outcome in patients over 60 years of age with co-morbid conditions, specifically after 10 min of CPR.
TL;DR: In this article, the authors assess whether plasma endothelin, adrenaline, noradrenaline, arginine vasopressin, adrenocorticotropin, and cortisol concentrations were higher during cardiopulmonary resuscitation in patients in whom resuscitation was successful than in those in whom it failed, and to measure the concentrations of these hormones in the immediate post-resuscitation phase.
Abstract: OBJECTIVE: To assess whether plasma endothelin, adrenaline, noradrenaline, arginine vasopressin, adrenocorticotropin, and cortisol concentrations were higher during cardiopulmonary resuscitation in patients in whom resuscitation was successful than in those in whom it failed, and to measure the concentrations of these hormones in the immediate post-resuscitation phase. DESIGN: Prospective, descriptive study. SETTING: Emergency medical service at a university hospital. PATIENTS: 60 patients with cardiac arrest out of hospital. INTERVENTIONS: Blood samples were drawn and blood pressure and heart rate were measured during cardiopulmonary resuscitation, before and after the first dose of adrenaline was given and at 5, 15, 30, and 60 minutes after the restoration of spontaneous circulation. Plasma hormone concentrations were measured by radio-immunoassays. RESULTS: 24 of the 60 patients were successfully resuscitated and admitted to hospital: 36 were not. During cardiopulmonary resuscitation before adrenaline was given, the plasma concentration of endothelin (mean (SEM)) in resuscitated and in not resuscitated patients was 4.3 (0.9) pg/ml and 5.5 (0.4) pg/ml respectively (NS), adrenaline was 14.1 (2.0) ng/ml and 25.3 (3.6) ng/ml (P < 0.01), noradrenaline was 5.0 (0.9 ng/ml) and 8.4 (1.1 ng/ml) (P < 0.05), arginine vasopressin was 193 (28) pg/ml and 70 (9) pg/ml (P < 0.001), adrenocorticotropin was 128 (34) pg/ml and 57 (6) pg/ml (P < 0.05), and cortisol was 18 (3) microgram/dl and 15 (2) microgram/dl (NS). During cardiopulmonary resuscitation after adrenaline was given endothelin in resuscitated and in not resuscitated patients was 4.0 (1.0) pg/ml and 5.3 (0.5) pg/ml (NS), adrenaline was 145 (16) ng/ml and 201 (21) ng/ml (P < 0.05), noradrenaline was 3.9 (0.9) ng/ml and 8.3 (1.1) ng/ml (P < 0.01), arginine vasopressin was 177 (27) pg/ml and 58 (9) pg/ml (P < 0.001), adrenocorticotropin was 234 (92) pg/ml and 85 (9) pg/ml (P < 0.001), and cortisol was 17 (2) microgram/dl and 13 (2) microgram/dl (NS). CONCLUSIONS: Despite a tremendous adrenosympathetic response, the lower arginine vasopressin and adrenocorticotropin concentrations during cardiopulmonary resuscitation in patients in whom resuscitation failed may influence vital organ perfusion and hence the success of resuscitation. Plasma concentrations of arginine vasopressin and adrenocorticotropin may have a more important effect on outcome than previously thought.
TL;DR: The pathogenesis and the management of lactic acidosis in septic patients are subjects of great clinical interest because of the high mortality rates and high uncertainty in the prognosis.
Abstract: The development of lactic acidosis in septic patients is an ominous event. Blood lactate concentrations > 5 mM at the time of admission to the intensive care unit are associated with patient mortality rates of 59% at 3 days and 83% at 30 days [1]. Furthermore, the mortality rate after resuscitation from acute circulatory failure exceeds 90% in patients with blood lactate values > 8 mmol/L [2]. Given these sobering statistics, it is not surprising that the pathogenesis and the management of lactic acidosis in septic patients are subjects of great clinical interest.
TL;DR: It is recommended that resuscitation training manikins are recalibrated to indicate satisfactory ventilation at tidal volumes of 400-600 ml to reduce the risk of gastric inflation and permit more chest compressions to be carried out in a minute because the ventilation fraction of the CPR sequence is shorter.
TL;DR: ACD CPR did not improve survival or neurologic outcomes in any group of patients with cardiac arrest and exploration of clinically important subgroups failed to identify any patients who appeared to benefit from ACD CPR.
Abstract: Objective. —To compare the impact of active compression-decompression (ACD) cardiopulmonary resuscitation (CPR) and standard CPR on the outcomes of in-hospital and prehospital victims of cardiac arrest. Design. —Randomized controlled trial with blinding of allocation using a sealed container. Settings. —(1) Emergency departments, wards, and intensive care units of 5 university hospitals and (2) all locations outside hospitals in 2 midsized cities. Patients. —A total of 1784 adults who had cardiac arrest. Intervention. —Patients received either standard or ACD CPR throughout resuscitation. Main Outcome Measures. —Survival for 1 hour and to hospital discharge and the modified Mini—Mental State Examination (MMSE). Results. —All characteristics were similar in the standard and ACD CPR groups for the 773 in-hospital patients and the 1011 prehospital patients. For in-hospital patients, there were no significant differences between the standard (n=368) and ACD (n=405) CPR groups in survival for 1 hour (35.1% vs 34.6%;P=.89), in survival until hospital discharge (11.4% vs 10.4%;P=.64), or in the median MMSE score of survivors (37 in both groups). For patients who collapsed outside the hospital, there were also no significant differences between the standard (n=510) and ACD (n=501) CPR groups in survival for 1 hour (16.5% vs 18.2%;P=.48), in survival to hospital discharge (3.7% vs 4.6%;P=.49), or in the median MMSE score of survivors (35 in both groups). Exploration of clinically important subgroups failed to identify any patients who appeared to benefit from ACD CPR. Conclusions. —ACD CPR did not improve survival or neurologic outcomes in any group of patients with cardiac arrest. (JAMA. 1996;275:1417-1423)
TL;DR: The data suggest that given adequate volume resuscitation, oxygen-based parameters are more useful as predictors of outcome than as endpoints for resuscitation.
Abstract: Objective : Oxygen consumption (Vo 2 I) and delivery (Do 2 I) indices have been stated to be superior to conventional parameters as endpoints for resuscitation. However, another interpretation of published data is that inability to increase Vo 2 I/Do 2 I given adequate volume resuscitation reflects inadequate physiologic reserve and poor outcome. Design : Fifty-eight critically ill patients were randomized to two groups. In group 1 (27 patients) attempts were made to maintain Vo 2 I ≥ 150 or Do 2 I ≥ 600 mL/min/m 2 . If Do 2 I was >600, no attempt was made to increase Vo 2 I even if it was <150. Group 2 (31 patients) was resuscitated based on conventional parameters. Volume resuscitation protocols and goals for pulmonary capillary wedge pressure were the same in both groups. Vo 2 I/Do 2 1 were recorded in group 2, but physicians were blinded to this data. Age, Injury Severity Score, and Acute Physiology and Chronic Health Evaluation (APACHE II) score were not different between groups. Main Results : Three patients in group 1 and two patients in group 2 died of organ failure (OF). One additional patient in group 2 died of refractory shock within 24 hours. Two of the patients in group 1 who died failed to meet Vo 2 I/Do 2 I goals within 24 hours despite maximal resuscitation. Mortality was not different between the groups even with exclusion of the group 1 patients who failed to meet Vo 2 I/Do 2 I goals (p = 0.66). After exclusion of the patient in group 2 who died of refractory shock, OF occurred in 18 of 27 (67%) in group 1 and in 22 of 30 (73%) in group 2 (p = 0.58). Length of ventilator support, intensive care unit stay, and hospital stay were not different between groups. When all patients were assessed, no difference was found in the incidence of OF between patients who attained the Vo 2 I goal and those who did not. OF occurred in 20 of 34 (59%) patients who maintained a mean Do 2 I ≥ 600 during the first 24 hours of the study and in 21 of 24 (88%) of those who did not (p < 0.02). Conclusions : No difference was found in the incidence of OF or death in patients resuscitated based on oxygen transport parameters compared to conventional parameters. These data suggest that given adequate volume resuscitation, oxygen-based parameters are more useful as predictors of outcome than as endpoints for resuscitation.
TL;DR: The case is made that self-efficacy is likely to influence the development of and real-time access to cognitive, affective, psychomotor, and social aspects of resuscitation proficiency.
Abstract: Objective This article examines the relevance of self-efficacy--a cognitive process indicating people's confidence in their ability to effect a given behavior--to training and performance of pediatric resuscitation. The case is made that self-efficacy is likely to influence the development of and real-time access to cognitive, affective, psychomotor, and social aspects of resuscitation proficiency. Methods Comprehensive literature reviews were conducted on relevant topic areas, including self-efficacy theory and empirical investigations of self-efficacy in clinical practice. Three case studies are used to illustrate the influence of self-efficacy on resuscitation practice. Results The limited empirical evidence on the role of self-efficacy in clinical practice is consistent with self-efficacy theory: clinicians are less likely to initiate and sustain behaviors for which they lack confidence. This performance-based confidence can be distinguished from both knowledge and skills necessary to perform the behavior. Conclusions Even clinicians who are knowledgeable and skilled in resuscitation techniques may fail to apply them successfully unless they have an adequately strong belief in their capability. General guidelines for promoting self-efficacy are presented, and specific recommendations are made for enhancing resuscitation self-efficacy during resuscitation training and postresuscitation procedures.
TL;DR: Advances in respiratory care, and particularly in mechanical ventilation, allowed more patients to survive ARDS, and the number of patients dying with ARDS remains high; this is because the actual cause of death has shifted to MOF.
Abstract: failure was blamed for over 50 % of later fatalities [127]. Basic scientific investigations supported the addition of crystalloid solutions to blood transfusions. More vigorous fluid resuscitation during the Vietnam War led to a 20- to 30-fold reduction in the incidence of renal failure compared with the Korean experience. However, a new problem came to the forefront in Vietnam: “shock lung”—the acute respiratory distress syndrome (ARDS) [8]. Of note, in accounts of the Korean conflict, there was virtually no mention of pulmonary problems. Advances in respiratory care, and particularly in mechanical ventilation, allowed more patients to survive ARDS. Today, while our ability to sustain patients on mechanical ventilation has improved, the number of patients dying with ARDS remains high; this is because the actual cause of death has shifted to MOF. The identification of MOF as a distinct entity dates back to 1973, when Tilney, Bailey and Morgan [128] described the progressive failure of organ systems in patients following repair of ruptured abdominal aortic aneurysms. Baue [15] first suggested there was a sequential pattern to the MOF syndrome. In 1977, Eiseman, Beart and Norton [40] at our institution described its clinical presentation and coined the term “multiple organ failure”. Since that time, intensive research efforts have targeted the syndrome.
TL;DR: End-tidal CO2 represents a valuable tool for monitoring patients presenting with asystole during prehospital CPR and the utility of end-t tidal CO2 in detecting return of spontaneous circulation justify its continuous measurement.
Abstract: Objective To determine whether continuous semiquantitative assessment of end-tidal CO2 could provide a highly sensitive predictor of return of spontaneous circulation during cardiopulmonary resuscitation (CPR).Design Prospective, clinical study.Setting Prehospital CPR.Patients One hundred twenty pat
TL;DR: Significant iatrogenic injuries are rare in children who receive CPR; they occur in approximately 3% of cases; recognizing the possibility of a complication may help in the management of children who survive cardiac arrest.
TL;DR: This study illustrated the impact of the videotape review process on the education of eight senior residents in surgery with an unblased, indisputable accurate documentation of the sequential application of the protocols of evaluation and resuscitation espoused in the ATLS course.
Abstract: A novel strategy using videotape recordings of initial trauma resuscitations was incorporated into the quality assurance program at a level 1 trauma center. Described are the process of taping the resuscitations, the multidisciplinary nature of the resuscitation team, the security measures taken to assure patient confidentiality, and the review process involved. The videotape review process was incorporated into a multidisciplinary educational trauma conference. The videotapes were used to evaluate the adherence to Advanced Trauma Life Support (ATLS) resuscitation protocols. Resident performance in six aspects of the ATLS resuscitation process were specifically highlighted on each videotape and graded for adherence to preestablished standards. The videotape process allowed an unbiased, indisputable accurate documentation of the sequential application of the protocols of evaluation and resuscitation espoused in the ATLS course. We found 23% overall deviation from ATLS resuscitation principles, with at least one aspect of the resuscitation deviating from expected ATLS performance in 64% of the patients. In addition to documenting adherence to ATLS principles, this study illustrated the impact of the videotape review process on the education of eight senior residents in surgery.
TL;DR: In vivo cell-mediated immune function 24 hr after hemorrhage was improved by HTS, and the effects of HTS resuscitation on immunosuppression following hemorrhage were studied.
TL;DR: It is concluded that spectral analysis of VF can provide reliable information relating to successful resuscitation in this model after elimination of oscillations due to mechanical CPR, median fibrillation frequency best reflects the probability of resuscitation success.
TL;DR: The results suggest that NO induced by hemorrhagic shock in rats is an important mediator for pathophysiological alterations associated with cardiovascular abnormalities, multiple organ dysfunction, and even lethality.
Abstract: In an attempt to evaluate the role of nitric oxide (NO) in pathophysiological alterations and multiple organ damage caused by hemorrhagic shock, we employed NG-monomethyl-L-arginine (L-NMMA), an inhibitor of NO synthase, in anesthetized rats subjected to a prolonged hypovolemic insult (30-35 mmHg for 180 min). Infusion of 2.0 mg/kg L-NMMA at the end of resuscitation diminished the fall in mean arterial pressure (MAP) and significantly increased the cardiac index and stroke volume, together with remarkable protection from multiple organ damage compared with the controls. The 48-h survival rate was significantly improved from 26.7% in the control group to 68.8% in the treatment group (P < 0.05). In contrast, the high dose of 20.0 mg/kg L-NMMA resulted in a strong blood pressure response, but a marked reduction in cardiac index and stroke volume concomitant with an increased total peripheral resistance index within the observation period, and tended to increase damage to various organs at 2 h after treatment. In addition, marked elevation in both endotoxin and tumor necrosis factor levels were observed in animals subjected to shock insult. The results suggest that NO induced by hemorrhagic shock in rats is an important mediator for pathophysiological alterations associated with cardiovascular abnormalities, multiple organ dysfunction, and even lethality. Regulation of NO generation and use of NO inhibitors might provide new aspects in the treatment of hemorrhage-related disorders, whereas the administration of L-NMMA would be either deleterious or salutary in a dose-dependent manner.
TL;DR: In this model of asphyxia-induced cardiac arrest, continued cardiac output prior to arrest allows continued delivery of CO2 to the lungs, resulting in higher alveolar CO2; this, in turn, is reflected as increased ETCO2 once ventilation is resumed during CPR.
Abstract: A study was undertaken to determine the pattern of end-tidal carbon dioxide (ETCO2) changes during asphyxia-induced cardiac arrest in a pediatric canine model. Eleven intubated, anesthetized, paralyzed dogs (mean age, 4.1 mo; mean weight, 5.5 kg) were used. Asphyxia was induced by clamping the endotracheal tube (ETT) and discontinuing ventilation. Cardiac arrest ensued a few minutes later, after which closed-chest cardiopulmonary resuscitation (CPR) and ventilation were initiated. The ETCO2 level was recorded at baseline and every minute during CPR. Mean baseline ETCO2 was 31.9 mm Hg. The initial ETCO2 immediately after unclamping the ETT (mean, 35 mm Hg) was higher than subsequent values (mean, 12.4 mm Hg; P < .001). There was a sudden increase in ETCO2 to a mean of 27.0 mm Hg at or just before return of spontaneous circulation (ROSC) in all 11 cases (P < .01). During CPR, ETCO2 levels were initially high, decreased to low levels, and increased again at ROSC. This pattern, not previously described, is different from that observed in animal and adult cardiac arrest caused by ventricular fibrillation, during which ETCO2 decreases to almost zero after the onset of arrest, begins to increase after the onset of effective CPR, and increases to normal levels at ROSC. In this model of asphyxial arrest, continued cardiac output prior to arrest allows continued delivery Of CO2 to the lungs, resulting in higher alveolar CO2; this, in turn, is reflected as increased ETCO2 once ventilation is resumed during CPR. Further study is needed to determine whether the pattern Of ETCO2 changes can be used prospectively to define the etiology of cardiac arrest.
TL;DR: A review ofentricular free wall rupture using the experience with a patient whose condition was diagnosed by transthoracic echocardiography and who successfully underwent emergency operation is illustrated.
TL;DR: The majority of authors believe that seeking a breakthrough in suspendedAnimation is not utopian, that ongoing communication between relevant research groups is indicated, and that a coordinated multicenter research effort, basic and applied, on suspended animation is justified.
Abstract: Suspended animation is defined as the therapeutic induction of a state of tolerance to temporary complete systemic ischemia, i.w., protection-preservation of the whole organism during prolonged circulatory arrest ( > or = 1 hr), followed by resuscitation to survival without brain damage. The objectives of suspended animation include: a) helping to save victims of temporarily uncontrollable (internal) traumatic (e.g., combat casualties) or nontraumatic (e.g., ruptured aortic aneurysm) exsanguination, without severe brain trauma, by enabling evacuation and resuscitative surgery during circulatory arrest, followed by delayed resuscitation; b) helping to save some nontraumatic cases of sudden death, seemingly unresuscitable before definite repair; and c) enabling selected (elective) surgical procedures to be performed which are only feasible during a state of no blood flow. In the discussion session, investigators with suspended animation-relevant research interests brainstorm on present knowledge, future research potentials, and the advisability of a major research effort concerning this subject. The following topics are addressed: the epidemiologic facts of sudden death in combat casualties, which require a totally new resuscitative approach; the limits and potentials of reanimation research; complete reversibility of circulatory arrest of 1 hr in dogs under profound hypothermia ( < 10 degrees C), induced and reversed by portable cardiopulmonary bypass; the need for a still elusive pharmacologic or chemical induction of suspended animation in the field; asanguinous profound hypothermic low-flow with cardiopulmonary bypass; electric anesthesia; opiate therapy; lessons learned by hypoxia tolerant vertebrate animals, hibernators, and freeze-tolerant animals (cryobiology); myocardial preservation during open-heart surgery; organ preservation for transplantation; and reperfusion-reoxygenation injury in vital organs, including the roles of nitric oxide and free radicals; and how cells (particularly cerebral neurons) die after transient prolonged ischemia and reperfusion. The majority of authors believe that seeking a breakthrough in suspended animation is not utopian, that ongoing communication between relevant research groups is indicated, and that a coordinated multicenter research effort, basic and applied, on suspended animation is justified.
TL;DR: The objectives of this Consensus Conference were to evaluate the existing literature and the experts' presentations at a Conference held at Versailles (December 1995), with a view to answering the fondamental question asked to this jury: among the numerous concepts and strategies developed in this field which one(s) have ultimately gained enough scientific credibility to be proposed for routine use in intensive care units.
Abstract: A tremendous amount of energy, research and dedication have been devoted during the past 15 years to the understanding, detection and treatment of the manifestations of tissue hypoxia in acutely ill patients. The objectives of this Consensus Conference were to evaluate the existing literature and the experts' presentations at a Conference held at Versailles (December 1995), with a view to answering the fondamental question asked to this jury : among the numerous concepts and strategies developed in this field ie : lactate measurement, gastric mucosal pH, mixed venons oxygen saturation monitoring, tracing of oxygen transport oxygen consomption graphs, maximisation of oxygen transport etc. which one(s) have ultimately gained enough scientific credibility to be proposed for routine use in intensive care units. These issues are timely and crucial in most of our hospitals, due to the scarcity of resources and cost-control measures.