Showing papers on "Resuscitation published in 1999"

Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation.

Abstract: Background Whether antiarrhythmic drugs improve the rate of successful resuscitation after out-of-hospital cardiac arrest has not been determined in randomized clinical trials. Methods We conducted a randomized, double-blind, placebo-controlled study of intravenous amiodarone in patients with out-of-hospital cardiac arrest. Patients who had cardiac arrest with ventricular fibrillation (or pulseless ventricular tachycardia) and who had not been resuscitated after receiving three or more precordial shocks were randomly assigned to receive 300 mg of intravenous amiodarone (246 patients) or placebo (258 patients). Results The treatment groups had similar clinical profiles. There was no significant difference between the amiodarone and placebo groups in the mean (±SD) duration of the resuscitation attempt (42±16 and 43±16 minutes, respectively), the number of shocks delivered (4±3 and 6±5), or the proportion of patients who required additional antiarrhythmic drugs after the administration of the study drug (66...

Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation.

Abstract: ContextUse of automated external defibrillators (AEDs) by first arriving emergency medical technicians (EMTs) is advocated to improve the outcome for out-of-hospital ventricular fibrillation (VF). However, adding AEDs to the emergency medical system in Seattle, Wash, did not improve survival. Studies in animals have shown improved outcomes when cardiopulmonary resuscitation (CPR) was administered prior to an initial shock for VF of several minutes' duration.ObjectiveTo evaluate the effects of providing 90 seconds of CPR to persons with out-of-hospital VF prior to delivery of a shock by first-arriving EMTs.DesignObservational, prospectively defined, population-based study with 42 months of preintervention analysis (July 1, 1990-December 31, 1993) and 36 months of postintervention analysis (January 1, 1994-December 31, 1996).SettingSeattle fire department–based, 2-tiered emergency medical system.ParticipantsA total of 639 patients treated for out-of-hospital VF before the intervention and 478 after the intervention.InterventionModification of the protocol for use of AEDs, emphasizing approximately 90 seconds of CPR prior to delivery of a shock.Main Outcome MeasuresSurvival and neurologic status at hospital discharge determined by retrospective chart review as a function of early (<4 minutes) and later (≥4 minutes) response intervals.ResultsSurvival improved from 24% (155/639) to 30% (142/478) (P=.04). That benefit was predominantly in patients for whom the initial response interval was 4 minutes or longer (survival, 17% [56/321] before vs 27% [60/220] after; P = .01). In a multivariate logistic model, adjusting for differences in patient and resuscitation factors between the periods, the protocol intervention was estimated to improve survival significantly (odds ratio, 1.42; 95% confidence interval, 1.07-1.90; P = .02). Overall, the proportion of victims who survived with favorable neurologic recovery increased from 17% (106/634) to 23% (109/474) (P = .01). Among survivors, the proportion having favorable neurologic function at hospital discharge increased from 71% (106/150) to 79% (109/138) (P<.11).ConclusionThe routine provision of approximately 90 seconds of CPR prior to use of AED was associated with increased survival when response intervals were 4 minutes or longer.

Diaspirin Cross-Linked Hemoglobin (DCLHb) in the Treatment of Severe Traumatic Hemorrhagic Shock: A Randomized Controlled Efficacy Trial

Abstract: ContextSevere, uncompensated, traumatic hemorrhagic shock causes significant morbidity and mortality, but resuscitation with an oxygen-carrying fluid might improve patient outcomes.ObjectiveTo determine if the infusion of up to 1000 mL of diaspirin cross-linked hemoglobin (DCLHb) during the initial hospital resuscitation could reduce 28-day mortality in traumatic hemorrhagic shock patients.Design and SettingMulticenter, randomized, controlled, single-blinded efficacy trial conducted between February 1997 and January 1998 at 18 US trauma centers selected for their high volume of critically injured trauma patients, but 1 did not enroll patients.PatientsA total of 112 patients with traumatic hemorrhagic shock and unstable vital signs or a critical base deficit, who had a mean (SD) patient age of 39 (20) years. Of the infused patients, 79% were male and 56% were white. An exception to informed consent was used when necessary.InterventionAll patients were to be infused with 500 mL of DCLHb or saline solution. Critically ill patients who still met entry criteria could have received up to an additional 500 mL during the 1-hour infusion period.Main Outcome MeasuresTwenty-eight day mortality, 28-day morbidity, 48-hour mortality, and 24-hour lactate levels.ResultsOf the 112 patients, 98 (88%) were infused with DCLHb or saline solution. At 28 days, 24 (46%) of the 52 patients infused with DCLHb died, and 8 (17%) of the 46 patients infused with the saline solution died (P = .003). At 48 hours, 20 (38%) of the 52 patients infused with DCLHb died and 7 (15%) of the 46 patients infused with the saline solution died (P = .01). The 28-day morbidity rate, as measured by the multiple organ dysfunction score, was 72% higher in the DCLHb group (P = .03). There was no difference in adverse event rates or the 24-hour lactate levels.ConclusionsMortality was higher for patients treated with DCLHb. Although further analysis should investigate whether the mortality difference was solely due to a direct treatment effect or to other factors, DCLHb does not appear to be an effective resuscitation fluid.

The patient-at-risk team: identifying and managing seriously ill ward patients.

Abstract: A 'patient-at-risk team', established to allow the early identification of seriously ill patients on hospital wards, made 69 assessments on 63 patients over 6 months Predefined physiological criteria were not able to reliably predict which patients would be admitted to the intensive care unit The incidence of cardiopulmonary resuscitation before intensive care admission was 36% for patients seen by the team and 304% for those not seen (p < 0005) Of admissions seen by the team, 25% died on the intensive care unit compared with 45% of those not seen (not significant, p = 007) Among those not seen by the team, mortality was 40% for those who did not require resuscitation and 57% for those who did (not significant) Many critically ill ward patients had abnormal physiological values before intensive care unit admission Identification of critically ill patients on the ward and early advice and active management are likely to prevent the need for cardiopulmonary resuscitation and to improve outcome

Physiological values and procedures in the 24 h before ICU admission from the ward

Abstract: Physiological values and interventions in the 24 h before entry to intensive care were collected for admissions from hospital wards. In a 13-month period, there were 79 admissions in 76 patients who had been in hospital for at least 24 h and had not undergone surgery within 24 h of admission to intensive care. Thirty-four per cent of patients underwent cardiopulmonary resuscitation before intensive care admission. Using Acute Physiology and Chronic Health Evaluation II scoring to quantify abnormal physiology in the group as a whole, a significant deterioration in respiratory function before admission was found. During the 6-h period immediately before intensive care admission, 75% of patients received oxygen, 37% underwent arterial blood gas sampling, and oxygen saturation was measured in 61% of patients, 63% of whom had an oxygen saturation of less than 90%. Overall hospital mortality in the study group was 58%. Information collected on the wards identified seriously ill patients who may have benefited from earlier expert treatment.

Secondary abdominal compartment syndrome: an underappreciated manifestation of severe hemorrhagic shock.

Abstract: Objective: Abdominal compartment syndrome (ACS) has multiple well-described etiologies, but almost no attention has focused on ACS in the absence of abdominal injury This study describes a secondary ACS that occurs after severe hemorrhagic shock with no evidence of abdominal injury Methods: The trauma registry at a Level I trauma center was reviewed for a 13-month period beginning July 1, 1997 Results: During the study period, there were 46 of 1,216 intensive care unit admissions (4%) who required laparotomy and mesh closure of the abdominal wall because of visceral edema In that subgroup, six patients (13% of mesh closures, 05% intensive care unit admissions) had hemorrhagic shock (5/1, blunt/penetrating trauma) but no evidence of intra-abdominal injury Associated extremity compartment syndrome developed in two of six (33% Overall mortality was four of six (67% secondary to sepsis (n = 3), and head injury (n = 1) Time from admission to decompression averaged 3 hours in survivors and 25 hours in nonsurvivors (overall average = 18 ± 9 hours) Resuscitation volume before abdominal decompression averaged 19 ± 5 liters of crystalloid and 29 ± 10 units of packed red blood cells Bladder pressure averaged 33 ± 3 mm Hg Decompression significantly improved peak inspiratory pressure (p < 0003) and base deficit (p < 0003) Conclusion: ACS can occur with no abdominal injury; The incidence of secondary ACS was 05% in this cohort trauma intensive care unit patients, so it probably occurs more frequently than is currently appreciated Because survivors were decompressed 20 hours before nonsurvivors, early recognition might improve outcomes On the basis of these observations, we recommend that bladder pressures should be routinely checked and acted on appropriately when resuscitation volumes approach 10 liters of crystalloid or 10 units of packed red cells

Redox imbalance in the critically ill.

Abstract: The majority of deaths amongst critically ill patients requiring intensive care are attributable to sepsis and its sequelae: septic shock, the systemic inflammatory response syndrome (SIRS) and the acute respiratory distress syndrome (ARDS). Clinically, sepsis/SIRS and ARDS are characterised by disordered vascular control, manifest as systemic hypotension and peripheral vasodilation refractory to intravascular volume resuscitation and vasopressor therapy; and pulmonary hypertension. Experimental and clinical evidence demonstrates that these patients suffer from severe oxidative stress. Thus, our own and other groups have shown that the vascular pathology of sepsis/SIRS and ARDS is initiated through the uncontrolled production of reactive oxygen (ROS) and reactive nitrogen species (RNS) which modulate inflammatory cell adhesion and cause direct injury to endothelium (Fig. 1).

Persistent occult hypoperfusion is associated with a significant increase in infection rate and mortality in major trauma patients.

Abstract: Objective: To investigate the hypothesis that occult hypoperfusion (OH) is associated with infectious episodes in major trauma patients. Methods: Data were collected prospectively on all adult trauma patients admitted to the Surgical/Trauma Intensive Care Unit from November of 1996 to December of 1998. Treatment was managed by a single physician according to a defined resuscitation protocol directed at correcting OH (lactic acid [LA] > 2.4 mmol/L). Results: Of a total of 381 consecutive patients, 118 never developed OH and 263 patients exhibited OH. Seventeen patients were excluded because their LA never corrected, and they all subsequently died. One hundred seventy-six infectious episodes occurred in 97 of the 364 patients remaining. The infection rate in patients with no elevation of LA was 13.6% (n = 118) compared with 12.7% (n = 110) in patients whose LA corrected by 12 hours, 40.5% (n = 79; p 12 hours were independently predictive of infection. Conclusion: A clear increase in infections occurred in patients with OH whose lactate levels did not correct by 12 hours, with an associated increase in length of stay, days in surgical/trauma intensive care unit, hospital charges, and mortality.

A Comparison of Standard Cardiopulmonary Resuscitation and Active Compression–Decompression Resuscitation for Out-of-Hospital Cardiac Arrest

Abstract: Background We previously observed that short-term survival after out-of-hospital cardiac arrest was greater with active compression–decompression cardiopulmonary resuscitation (CPR) than with standard CPR. In the current study, we assessed the effects of the active compression–decompression method on one-year survival. Methods Patients who had cardiac arrest in the Paris metropolitan area or in Thionville, France, more than 80 percent of whom had asystole, were assigned to receive either standard CPR (377 patients) or active compression–decompression CPR (373 patients) according to whether their arrest occurred on an even or odd day of the month, respectively. The primary end point was survival at one year. The rate of survival to hospital discharge without neurologic impairment and the neurologic outcome were secondary end points. Results Both the rate of hospital discharge without neurologic impairment (6 percent vs. 2 percent, P=0.01) and the one-year survival rate (5 percent vs. 2 percent, P=0.03) wer...

Fluid Replacement in Dengue Shock Syndrome: A Randomized, Double-Blind Comparison of Four Intravenous-Fluid Regimens

Abstract: Dengue hemorrhagic fever and dengue shock syndrome (DSS) are major causes of childhood morbidity and mortality in many tropical countries. Increased intravascular permeability leading to shock is the cardinal feature of DSS. Fluid resuscitation to counteract massive plasma leakage is the mainstay of treatment. A double-blind, randomized trial comparing four intravenous-fluid regimens for acute resuscitation of 50 children with DSS was conducted. Colloids (dextran 70 or the protein digest gelafundin 35,000) restored cardiac index and blood pressure and normalized hematocrit more rapidly than crystalloids (Ringer's lactate or 0.9%-weight/volume saline). Dextran 70 provided the most rapid normalization of the hematocrit and restoration of the cardiac index, without adverse effects, and may be the preferred solution for acute resuscitation in DSS. Further large-scale double-blind trials are required to provide an evidence-based approach to the management of DSS.

The trauma triad of death: hypothermia, acidosis, and coagulopathy.

Abstract: With the organization of trauma systems, the development of trauma centers, the application of standardized methods of resuscitation, and improvements in modern blood banking techniques, the ability to aggressively resuscitate patients in extremis has evolved. The concept of the "golden hour" has translated into unprecedented speed and efficiency of trauma resuscitation with the ultimate goal of short injury-to-incision times. As the shift in care of patients in extremis has continued to move from the street to the emergency department and beyond, the focus of trauma resuscitation has shifted to the operating room and ultimately to the intensive care unit. The "new" golden hour may well be the time in the operating room before the patient reaches the physiologic limit, defined as the onset of the triad: hypothermia, acidosis and coagulopathy. Critical care nurses must understand this triad, because it forms the basis and underlying logic on which the damage control philosophy has been built. This article explores the pathogenesis and treatment of acidosis, hypothermia, and coagulopathy as it applies to the exsanguinating trauma patient.

Family Presence during Trauma Resuscitation: A Survey of AAST and ENA Members

Abstract: BackgroundThe Emergency Nurses Association (ENA) has formally resolved that family presence (FP) during resuscitation and invasive procedures (TR) is the right of the patient and is beneficial for both patients and family members. Furthermore, FP during TR has been implemented at several trauma cent

Hypothermia in trauma patients

Abstract: Hypothermia occurs commonly in severely injured patients and is associated with a high mortality rate. It perturbs the normal homeostatic response to injury and affects multiple organ systems and physiologic processes. In trauma patients, hypothermia-induced coagulopathy often leads to marked bleeding diathesis and frequently provides a challenge for the surgeon. Once hypothermia occurs, it is often difficult to correct. Efforts to prevent and treat hypothermia in trauma patients should be instituted in the field and continued as an integral part of the resuscitation process. Hospital personnel and physicians at various levels caring for trauma patients from the initial injury and thereafter should bear in mind that a patient's temperature is as important as any other vital sign. Appropriate measures for preventing and treating hypothermia should be instituted promptly and tended to with utmost vigilance.

Controlled resuscitation for uncontrolled hemorrhagic shock.

Abstract: Objective: To test the hypothesis that controlled resuscitation can lead to improved survival in otherwise fatal uncontrolled hemorrhage. Methods: Uncontrolled hemorrhage was induced in 86 rats with a 25-gauge needle puncture to the infrarenal aorta. Resuscitation 5 minutes after injury was continued for 2 hours with lactated Ringer's solution (LR), 7.3% hypertonic saline in 6% hetastarch (HH), or no fluid (NF). Fluids infused at 2 mL.kg -1 .min -1 were turned on or off to maintain a mean arterial pressure (MAP) of 40, 80, or 100 mm Hg in six groups: NF, LR 40, LR 80, LR 100, HH 40, and HH 80. Blood loss was measured before and after I hour of resuscitation. Results: Survival was improved with fluids. Preresuscitation blood loss was similar in all groups. NF rats did not survive 4 hours. After 72 hours, LR 80 rats (80%) and HH 40 rats (67%) showed improved survival over NF rats (0%) (p < 0.05). Rebleeding increased with MAP. Attempts to restore normal MAP (LR 100) led to increased blood loss and mortality. Conclusion: Controlled resuscitation leads to increased survival compared with no fluids or standard resuscitation. Fluid type affects results. Controlled fluid use should be considered when surgical care is not readily available.

Relationship of systemic inflammatory response syndrome to organ dysfunction, length of stay, and mortality in critical surgical illness: effect of intensive care unit resuscitation.

Abstract: Background: A systemic proinflammatory response has been implicated in the pathogenesis of organ dysfunction. The effects of surgery, surgical stress, anesthesia, and subsequent intensive care unit (1CU) resuscitation may affect the components of the systemic inflammatory response syndrome (SIRS) score (temperature, heart rate, respiratory rate, and white blood cell count). Any SIRS scores calculated within 24 hours after surgery or at the onset of nonoperative resuscitation may overestimate the proinflammatory response itself, making quantitation of SIRS at that time potentially too sensitive. We hypothesized that SIRS attributable to ICU resuscitation can be quantitated, and that SIRS after the first day of therapy in the ICU correlates with several outcomes Methods: Prospective analysis of 2300 surgical ICU admissions during a 49-month period. Acute Physiology and Chronic Health Evaluation III (APACHE III) scores were recorded alter 24 hours. Daily and cumulative multiple organ dysfunction scores (0-4 points for each of 6 organs, 24 points total) and SIRS scores ( point for each parameter, 4 points total) were recorded. Defined end points were hospital mortality, days in the ICU, and organ dysfunction. Results: On day 1, 49.4% of patients had SIRS (score ≥2), whereas 34.5% of patients who remained in the ICU had SIRS (score ≥2) on day 2 (P<.001). The SIRS score decreased by a mean of 0.8 points from day 1 to day 2, regardless of the type of admission. A SIRS score that decreased on day 2, in comparison with the score on day 1, resulted in less mortality than a unchanged or higher score on day 2 (11% vs 18% vs 22%, P<.001). Systemic inflammatory response scores were higher for nonsurvivors than survivors on each of the first 7 days in the ICU. The day 2 SIRS score correlated well with the admission APACHE III score (P<.001) and all defined end points (all P<.001). The day 2 SIRS score also correlated with the day 2 multiple organ dysfunction score (P<.001). By multiple logistic regression, APACHE III (P<.001), day 2 SIRS score (P<.01) (but not day 1 SIRS score, P =.99), and day 2 multiple organ dysfunction score (P<.001) (but not day 1 1 multiple organ dysfunction score, P =.81) predicted mortality. Conclusions: Systemic inflammatory response syndrome attributable to surgery or surgical stress can be quantitated. Twenty-four hours of ICU resuscitation results in a decline in the SIRS score. The magnitude of the proinflammatory response on the second ICU day may be a useful predictor of outcome in critical surgical illness.

Intraosseous lines in preterm and full term neonates

Abstract: AIM To evaluate the use of intraosseous lines for rapid vascular access in primary resuscitation of preterm and full term neonates. METHODS Thirty intraosseous lines were placed in 27 newborns, in whom conventional venous access had failed. RESULTS All the neonates survived the resuscitation procedure, with no long term side effects. CONCLUSION Intraosseous infusion is quick, safe, and effective in compromised neonates.

Vasopressin improves vital organ blood flow after prolonged cardiac arrest with postcountershock pulseless electrical activity in pigs.

Abstract: ObjectiveAlthough a benefit of vasopressin when compared with epinephrine was shown during cardiopulmonary resuscitation (CPR) after a short duration of ventricular fibrillation cardiac arrest, the effect of vasopressin during prolonged cardiac arrest with pulseless electrical activity is currently

Quality of Survival After Cardiopulmonary Resuscitation

Abstract: Background Outcome of cardiopulmonary resuscitation (CPR) can be poor, in terms of life expectancy and quality of life. Objectives To determine the impact of patient characteristics before, during, and after CPR on these outcomes, and to compare results of the quality-of-life assessment with published studies. Methods In a cohort study, we assessed by formal instruments the quality of life, cognitive functioning, depression, and level of dependence of survivors after in-hospital CPR. Follow-up was at least 3 months after discharge from the hospital (tertiary care center). Results Of 827 resuscitated patients, 12% (n = 101) survived to follow-up. Of the survivors, 89% participated in the study. Most survivors were independent in daily life (75%), 17% were cognitively impaired, and 16% had depressive symptoms. Multivariate regression analysis showed that quality of life and cognitive function were determined by 2 factors known before CPR—the reason for admission and age. Factors during and after resuscitation, such as prolonged cardiac arrest and coma, did not significantly determine the quality of life or cognitive functioning of survivors. The quality of life of our CPR survivors was worse compared with a reference group of elderly individuals, but better than that of a reference group of patients with stroke. The quality of life did not importantly differ between the compared studies of CPR survivors. Conclusions Cardiopulmonary resuscitation is frequently unsuccessful, but if survival is achieved, a relatively good quality of life can be expected. Quality of life after CPR is mostly determined by factors known before CPR. These findings may be helpful in informing patients about the outcomes of CPR.

Cardiac arrest in infants after congenital heart surgery.

Abstract: Background—The survival rate to discharge after a cardiac arrest in a patient in the pediatric intensive care unit is reported to be as low as 7% The survival rates and markers for survival strictly regarding infants with cardiac arrest after congenital heart surgery are unknown Methods and Results—Infants in our pediatric cardiac intensive care unit database were identified who had a postoperative cardiac arrest between January 1994 and June 1998 Parameters from the perioperative, prearrest, and resuscitation periods were analyzed for these patients Comparisons were made between survivors and nonsurvivors Of 575 infants who underwent congenital heart surgery, 34 (6%) sustained a documented cardiac arrest; of these, 14 (41%) survived to discharge Perioperative parameters, ventricular physiology, and primary rhythm at the time of arrest did not influence outcome Prearrest blood pressure was lower in nonsurvivors than in survivors (P<0001) A high level of inotropic support prearrest was associated

Field triage of the pulseless trauma patient.

Abstract: Hypothesis Trauma patients who are pulseless at the scene of injury and whose electrical cardiac activity is less than 40 beats/min cannot be revived. Design Retrospective review. Setting University hospital, level I trauma center. Patients Pulseless trauma patients who had cardiopulmonary resuscitation at the scene, en route, or in the emergency department and presented between January 1, 1991, and July 1, 1996. Main Outcome Measure Survival after traumatic cardiopulmonary arrest. Results Sixteen thousand seven hundred twenty-four trauma patients were admitted. The study cohort comprised 604 victims of traumatic cardiopulmonary arrest, 304 as a result of blunt injury and 300 as a result of penetrating injury. Transport time for the study patients was 11±6.1 minutes (mean±SD). Cardiopulmonary resuscitation was performed on them for 22±11 minutes. Three hundred four patients (50%) had resuscitative thoracotomy in the emergency department; 160 patients were taken to the operating room for further resuscitation and treatment of their injuries. Sixteen patients (2.6%) survived to discharge from the hospital; 7 had severe neurologic disabilities. No patient (0/212) with electrical asystole survived. Five of 134 patients with an initial electrical heart rate between 1 and 39 beats/min survived long enough to reach the intensive care unit but died within 48 hours (4 died within 24 hours). No patient survived to leave the hospital if the initial electrical heart rate was less than 40 beats/min. All 16 survivors had an initial heart rate of 40 beats/min or greater. Conclusion Trauma victims who are pulseless and have asystole or agonal electrical cardiac activity (heart rate

ILCOR Advisory Statement: Resuscitation of the Newly Born Infant An Advisory Statement From the Pediatric Working Group of the International Liaison Committee on Resuscitation

Abstract: The International Liaison Committee on Resuscitation (ILCOR) was formed in 1992 to provide a forum for liaison between the following principal resuscitation organizations in the developed world: the American Heart Association (AHA), European Resuscitation Council (ERC), Heart and Stroke Foundation of Canada (HSFC), Australian Resuscitation Council (ARC), Resuscitation Council of Southern Africa (RCSA), and Council of Latin America for Resuscitation (CLAR). Since 1992, international consensus conferences and publications have addressed many important resuscitation issues, including uniform Utstein-style reporting for out-of-hospital cardiac arrest, in-hospital cardiac arrest, pediatric arrest, and laboratory animal studies of cardiopulmonary arrest.1 2 3 4 Ten meetings of the ILCOR group and ILCOR working groups in advanced life support, basic life support, and pediatric life support culminated in concurrent multinational publication of consensus international advisory statements on resuscitation in 1997.5 The advisory statement on pediatric resuscitation6 highlighted areas of consensus, conflict, or controversy and provided recommendations in the areas of pediatric basic life support (BLS), pediatric advanced life support (ALS), and BLS for the newly born. The great potential for worldwide improvement in BLS resuscitation for the newly born was acknowledged, but discussion of ALS for the newly born was beyond the scope of the previous document. The ILCOR Pediatric Working Group, with the constituent councils named above, was joined by the Neonatal Resuscitation Program (NRP) Steering Committee of the American Academy of Pediatrics (AAP), New Zealand Resuscitation Council (NZRC), and World Health Organization (WHO) to extend advisory recommendations beyond BLS to ALS for the newly born. Careful review of current constituent organization guidelines7 8 9 10 11 12 13 and current international literature forms the basis for the present document. This advisory statement summarizes the current international consensus on ALS of the newly born, ie, within the first few hours following birth. ### Need for BLS and ALS Guidelines for the Newly Born Resuscitation …

In-hospital cardiopulmonary resuscitation: prearrest morbidity and outcome.

Abstract: Background Considerations about the application of cardiopulmonary resuscitation (CPR) should include the expected probability of survival. The survival probability after CPR may be more accurately estimated by the occurrence in time of the prearrest morbidity of patients. Objective To identify risk factors for poor survival after CPR in relation to the dynamics of prearrest morbidity. Methods Medical records of CPR patients were reviewed. Prearrest morbidity was established by categorizing the medical diagnoses according to 3 functional time frames: before hospital admission, on hospital admission, and during hospital admission. Indicators of poor survival after CPR were identified through a logistic regression model. Results Included in the study were 553 CPR patients with a median age of 68 years (age range, 18-98 years); 21.7% survived to hospital discharge. Independent indicators of poor outcome were an age of 70 years or older (odds ratio [OR]=0.6, 95% confidence interval [CI]=0.4-0.9), stroke (OR=0.3, 95% CI=0.1-0.7) or renal failure (OR=0.3, 95% CI=0.1-0.8) before hospital admission, and congestive heart failure during hospital admission (OR=0.4, 95% CI=0.2-0.9). Indicators of good survival were angina pectoris before hospital admission (OR=2.1, 95% CI=1.3-.3.3) or ventricular dysrhythmia as the diagnosis on hospital admission (OR=11.0, 95% CI=4.1-33.7). Based on a logistic regression model, 17.4% of our CPR patients (n=96) were identified as having a high risk for a poor outcome ( Conclusions Time of prearrest morbidity has a prognostic value for survival after CPR. Patients at risk for poor survival can be identified on or during hospital admission, but the reliability and validity of the model needs further research. Although decisions will not be made by the model, its information can be useful for physicians in discussions about patient prognoses and to make decisions about CPR with more confidence.

Resuscitation with lactated Ringer's solution in rats with hemorrhagic shock induces immediate apoptosis

Abstract: Background: We hypothesize that different resuscitative fluids may immediately affect the degree of apoptosis after hemorrhagic shock. Methods: Rats (n = 35) were hemorrhaged 27 mL/kg over 5 minutes followed by 1 hour of shock, then resuscitation over 1 hour. The six treatment groups were sham hemorrhage, sham resuscitation, whole blood resuscitation, lactated Ringer's solution (LR) resuscitation with three times the volume bled, sham hemorrhage with LR infusion, and 7.5% hypertonic saline resuscitation (9.7 mL/kg). Liver and small intestine were harvested immediately after resuscitation. Apoptosis was evaluated by using in situ cell death detection method. Results: Resuscitation with LR resulted in a significant increase in small intestinal and liver apoptosis. Animals that received LR infusion without hemorrhage had an increased level of apoptosis in the intestine. Apoptosis in the intestine was observed in both the mucosa and muscularis externa. There was no increase in apoptosis in either organ in the animals resuscitated with sham resuscitation, whole blood, and hypertonic saline compared with the sham hemorrhage group. Conclusion: Resuscitation with LR solution after hemorrhagic shock increased immediate cell death by apoptosis in both the small intestine and liver. There was no significant increase in apoptosis in the animals resuscitated with hypertonic saline, whole blood, or in unresuscitated animals. Thus, the type of resuscitation fluid used may affect the apoptotic cellular response to shock.

Prognostic value of blood lactate, base deficit, and oxygen-derived variables in an LD50 model of penetrating trauma

Abstract: Objective: To determine whether blood lactate, base deficit, or oxygen-derived hemodynamic variables correlate with morbidity and mortality rates in a clinically-relevant LD 50 model of penetrating trauma. Design: Prospective, controlled study. Setting: University research laboratory. Subjects: Anesthetized, mechanically-ventilated mongrel pigs (30 ± 2 kg, n = 29). Interventions: A captive bolt gun delivered a penetrating injury to the thigh, followed immediately by a 40% to 60% hemorrhage. After 1 hr, shed blood and supplemental crystalloid were administered for resuscitation. Measurements and Main Results: After penetrating injury, 50.7 ± 0.3% hemorrhage (range 50% to 52.5%), and a 1-hr shock period, seven of 14 animals died, compared with six of six animals after 55% to 60% hemorrhage, and 0 of nine animals after ≤47.5% hemorrhage. Only two of 13 deaths occurred during fluid resuscitation. At the LD 50 hemorrhage, peak lactate concentration and base deficit were 11.2 ± 0,8 mM and 9.3 ± 1.5 mmol/L, respectively, and minimum mixed venous oxygen saturation, systemic oxygen delivery, and systemic oxygen consumption were 33 ± 5%, 380 ± 83 mL/min/kg, and 177 ± 35 mL/min/kg, respectively. For comparison, baseline preinjury values were 1.6 ± 0.1 mM, -6.7 ± 0.6 mmol/L, 71 ± 3%, 2189 ± 198 mL/min/kg, and 628 ± 102 mL/min/kg, respectively. Of all the variables, only lactate was significantly related to blood loss before and after fluid resuscitation in the 16 survivors. However, r 2 values were relatively low (.20 to.50), which indicates that only a small fraction of the hyperlactacidemia was directly related to tissue hypoperfusion. In the whole population of survivors and nonsurvivors, both lactate and base deficit (but none of the oxygen-derived variables) correlated with blood loss. Conclusions: Arterial lactate is a stronger index of blood loss after penetrating trauma than base deficit or oxygen-derived hemodynamic variables. The reliability of arterial lactate depends on several factors, such as the time after injury, the proportion of survivors and nonsurvivors in the study population, and on factors other than tissue hypoxia.

An Advisory Statement From the Pediatric Working Group of the International Liaison Committee on Resuscitation

Abstract: The International Liaison Committee on Resuscitation (ILCOR), with representation from North America, Europe, Australia, New Zealand, Africa, and South America, was formed in 1992 to provide a forum for liaison between resuscitation organizations in the developed world. This consensus document on resuscitation extends previously published ILCOR advisory statements on resuscitation to address the unique and changing physiology of the newly born infant within the first few hours after birth and the techniques for providing advanced life support. After careful review of the international resuscitation literature and after discussion of key and controversial issues, consensus was reached on almost all aspects of neonatal resuscitation, and areas of controversy and high priority for additional research were delineated. Consensus on resuscitation for the newly born infant included the following principles: Common or controversial medications (epinephrine, volume expansion, naloxone, bicarbonate), special resuscitation circumstances affecting care of the newly born, continuing care of the newly born after resuscitation, and ethical considerations for initiation and discontinuation of resuscitation are discussed. There was agreement that insufficient data exist to recommend changes to current guidelines regarding the use of 21% versus 100% oxygen, neuroprotective interventions such as cerebral hypothermia, use of a laryngeal mask versus endotracheal tube, and use of high-dose epinephrine. Areas of controversy are identified, as is the need for additional research to improve the scientific justification of each component of current and future resuscitation guidelines.

Relationship of admission plasma gelsolin levels to clinical outcomes in patients after major trauma.

Abstract: Actin-scavenging proteins, e.g., plasma gelsolin, counteract the pathophysiological consequences of actin leaked into the circulation from dying cells, but the capacity of this defense system can be overwhelmed by massive tissue injury. We examined the prognostic implications of plasma gelsolin levels obtained near the time of admission to our level I Trauma Unit on the subsequent clinical course in a group of patients with severe traumatic injuries. Blood samples were obtained from 13 patients shortly after major trauma and 11 healthy volunteers who served as the control group. Plasma gelsolin levels were assayed by quantitative Western blotting. Duration of mechanical ventilation, stay in the Trauma Intensive Care Unit, and development of acute respiratory distress syndrome (ARDS) were measured as clinical outcomes reflecting the complexity of the hospital course. Subsequently, we evaluated an additional 52 patients after major and minor trauma to extend our earlier observations. Plasma gelsolin concentrations were significantly lower in our 13 original patients compared with healthy controls. Levels below 250 mg/L (> 2 standard deviations below the mean of the control group) were associated with prolonged mechanical ventilation and a stay in the intensive care unit >/= 13 days. Both patients whose gelsolin level was /= 13 days in the Trauma Intensive Unit, ARDS, and/or death. Plasma gelsolin levels appear to be an early prognostic marker in patients experiencing major trauma. Whether circulating gelsolin serves a biologically vital function or is simply depleted after massive trauma cannot be determined from our study. The potential therapeutic benefits of infusions of recombinant human plasma gelsolin for patients in whom multiorgan dysfunction commonly follows a serious but self-limited insult have not yet been investigated.

Factors Associated With Use of Cardiopulmonary Resuscitation in Seriously Ill Hospitalized Adults

Abstract: ContextThe epidemiology of do-not-resuscitate (DNR) orders for hospitalized patients has been reported, but little is known about factors associated with the use of cardiopulmonary resuscitation (CPR).ObjectiveTo identify factors associated with an attempt at CPR for patients who experienced cardiopulmonary arrest.DesignSecondary analysis of data collected in 2 prospective cohort studies: the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT, 1989-1994) and the Hospitalized Elderly Longitudinal Project (HELP, 1994).SettingFive teaching hospitals across the United States.ParticipantsA total of 2505 seriously ill hospitalized patients and nonelectively admitted persons aged 80 years or older who experienced cardiopulmonary arrest.Main Outcome MeasuresMedical records data on CPR efforts, DNR orders, disease severity, age, race, sex, length of stay, and survival; functional status and preferences concerning CPR obtained by interviews with patients or surrogates; and 2-month survival estimates provided by physicians.ResultsFive hundred fourteen study subjects (21%) received CPR during their index hospitalization. Among them, 327 (63.6%) had CPR within 2 days of death and 93 (18.1%) had resuscitation and survived their index hospitalization. Use of CPR was more likely in men (odds ratio [OR], 1.39; 95% confidence interval [CI], 1.12-1.73), younger patients (OR per 10-year increase, 0.90; 95% CI, 0.84-0.96), African Americans (OR, 1.76; 95% CI, 1.33-2.34), patients whose reported preferences were for CPR (OR, 2.60; 95% CI, 1.91-3.55), who reported better quality of life (OR, 1.49; 95% CI, 1.10-2.03), or who had higher physician estimates for 2-month survival (OR per 10% increase, 1.14; 95% CI, 1.09-1.19). Rates varied significantly with geographic location and diagnosis; the adjusted OR for patients with congestive heart failure was 3.31 (95% CI, 2.12-5.15) compared with patients with acute respiratory failure or multiple organ system failure.ConclusionsOur data suggest that a resuscitation attempt is more likely when preferred by patients and when death is least expected. Further study is required to understand variation in use of CPR among sites and for patients with different diagnoses, race, sex, or age.

Abdominal compartment syndrome in patients with burns.

Abstract: Abdominal compartment syndrome (ACS) is a well-recognized perioperative complication that occurs in patients who undergo intra-abdominal operations and who require extensive fluid resuscitation. The classic presentation of this syndrome includes high peak airway pressures; oliguria, despite adequate filling pressures; and intra-abdominal pressures of more than 25 mm Hg. A decompressive laparotomy performed at the bedside can alleviate ACS. If left untreated, sustained intra-abdominal hypertension is often fatal. In the literature, ACS has been described in pediatric patients with burns but not in adult patients with burns. This article describes 3 adults who sustained burns of more than 70% of their body surface areas, who required more than 20 L of crystalloid resuscitation, and who developed ACS during their resuscitation after the burn injury. The mortality rate among these patients was 100%, which confirms the grave consequences of this syndrome. In our institution, intra-abdominal pressure is now routinely measured as part of the burn resuscitation process in an attempt to diagnose and treat this syndrome earlier and more efficaciously. It is recommended that the possibility of ACS be considered when diagnosing any patient with burns who develops high airway pressures, oliguria, or both.