Showing papers on "Resuscitation published in 2004"
TL;DR: In patients in the ICU, use of either 4 percent albumin or normal saline for fluid resuscitation results in similar outcomes at 28 days, with no significant differences between the groups.
Abstract: background It remains uncertain whether the choice of resuscitation fluid for patients in intensive care units (ICUs) affects survival. We conducted a multicenter, randomized, double-blind trial to compare the effect of fluid resuscitation with albumin or saline on mortality in a heterogeneous population of patients in the ICU. methods We randomly assigned patients who had been admitted to the ICU to receive either 4 percent albumin or normal saline for intravascular-fluid resuscitation during the next 28 days. The primary outcome measure was death from any cause during the 28-day period after randomization. results Of the 6997 patients who underwent randomization, 3497 were assigned to receive albumin and 3500 to receive saline; the two groups had similar baseline characteristics. There were 726 deaths in the albumin group, as compared with 729 deaths in the saline group (relative risk of death, 0.99; 95 percent confidence interval, 0.91 to 1.09; P=0.87). The proportion of patients with new single-organ and multiple-organ failure was similar in the two groups (P=0.85). There were no significant differences between the groups in the mean (±SD) numbers of days spent in the ICU (6.5±6.6 in the albumin group and 6.2±6.2 in the saline group, P=0.44), days spent in the hospital (15.3±9.6 and 15.6±9.6, respectively; P = 0.30), days of mechanical ventilation (4.5±6.1 and 4.3±5.7, respectively; P = 0.74), or days of renal-replacement therapy (0.5±2.3 and 0.4±2.0, respectively; P = 0.41). conclusions In patients in the ICU, use of either 4 percent albumin or normal saline for fluid resuscitation results in similar outcomes at 28 days.
2,360 citations
TL;DR: A task force of the International Liaison Committee on Resuscitation (ILCOR) met in Melbourne, Australia, to review worldwide experience with the Utstein definitions and reporting templates as mentioned in this paper.
Abstract: Outcome after cardiac arrest and cardiopulmonary resuscitation is dependent on critical interventions, particularly early defibrillation, effective chest compressions, and advanced life support. Utstein-style definitions and reporting templates have been used extensively in published studies of cardiac arrest, which has led to greater understanding of the elements of resuscitation practice and progress toward international consensus on science and resuscitation guidelines. Despite the development of Utstein templates to standardize research reports of cardiac arrest, international registries have yet to be developed. In April 2002, a task force of the International Liaison Committee on Resuscitation (ILCOR) met in Melbourne, Australia, to review worldwide experience with the Utstein definitions and reporting templates. The task force revised the core reporting template and definitions by consensus. Care was taken to build on previous definitions, changing data elements and operational definitions only on the basis of published data and experience derived from those registries that have used Utstein-style reporting. Attention was focused on decreasing the complexity of the existing templates and addressing logistical difficulties in collecting specific core and supplementary (ie, essential and desirable) data elements recommended by previous Utstein consensus conferences. Inconsistencies in terminology between in-hospital and out-of-hospital Utstein templates were also addressed. The task force produced a reporting tool for essential data that can be used for both quality improvement (registries) and research reports and that should be applicable to both adults and children. The revised and simplified template includes practical and succinct operational definitions. It is anticipated that the revised template will enable better and more accurate completion of all reports of cardiac arrest and resuscitation attempts. Problems with data definition, collection, linkage, confidentiality, management, and registry implementation are acknowledged and potential solutions offered. Uniform collection and tracking of registry data should enable better continuous quality improvement within every hospital, emergency medical services system, and community.
2,277 citations
TL;DR: Lactate clearance early in the hospital course may indicate a resolution of global tissue hypoxia and is associated with decreased mortality rate, and patients with higher lactate clearance after 6 hrs of emergency department intervention have improved outcome compared with those with lower lactate cleared.
Abstract: Objective: Serial lactate concentrations can be used to examine disease severity in the intensive care unit. This study examines the clinical utility of the lactate clearance before intensive care unit admission (during the most proximal period of disease presentation) as an indicator of outcome in severe sepsis and septic shock. We hypothesize that a high lactate clearance in 6 hrs is associated with decreased mortality rate. Design: Prospective observational study. Setting: An urban emergency department and intensive care unit over a 1-yr period. Patients: A convenience cohort of patients with severe sepsis or septic shock. Interventions: Therapy was initiated in the emergency department and continued in the intensive care unit, including central venous and arterial catheterization, antibiotics, fluid resuscitation, mechanical ventilation, vasopressors, and inotropes when appropriate. Measurements and Main Results: Vital signs, laboratory values, and Acute Physiology and Chronic Health Evaluation (APACHE) II score were obtained at hour 0 (emergency department presentation), hour 6, and over the first 72 hrs of hospitalization. Therapy given in the emergency department and intensive care unit was recorded. Lactate clearance was defined as the percent decrease in lactate from emergency department presentation to hour 6. Logistic regression analysis was performed to determine independent variables associated with mortality. One hundred and eleven patients were enrolled with mean age 64.9 16.7 yrs, emergency department length of stay 6.3 3.2 hrs, and overall in-hospital mortality rate 42.3%. Baseline APACHE II score was 20.2 6.8 and lactate 6.9 4.6 mmol/L. Survivors compared with nonsurvivors had a lactate clearance of 38.1 34.6 vs. 12.0 51.6%, respectively (p .005). Multivariate logistic regression analysis of statistically significant univariate variables showed lactate clearance to have a significant inverse relationship with mortality (p .04). There was an approximately 11% decrease likelihood of mortality for each 10% increase in lactate clearance. Patients with a lactate clearance >10%, relative to patients with a lactate clearance <10%, had a greater decrease in APACHE II score over the 72-hr study period and a lower 60-day mortality rate (p .007). Conclusions: Lactate clearance early in the hospital course may indicate a resolution of global tissue hypoxia and is associated with decreased mortality rate. Patients with higher lactate clearance after 6 hrs of emergency department intervention have improved outcome compared with those with lower lactate clearance. (Crit Care Med 2004; 32:1637‐1642)
999 citations
TL;DR: It now appears that patients with moderate hypotension from bleeding may benefit by delaying massive fluid resuscitation until they reach a definitive care facility, and maintaining a higher hemoglobin level of 10 g/dl is a reasonable goal in actively bleeding patients, the elderly, or individuals who are at risk for myocardial infarction.
Abstract: This review addresses the pathophysiology and treatment of hemorrhagic shock – a condition produced by rapid and significant loss of intravascular volume, which may lead sequentially to hemodynamic instability, decreases in oxygen delivery, decreased tissue perfusion, cellular hypoxia, organ damage, and death. Hemorrhagic shock can be rapidly fatal. The primary goals are to stop the bleeding and to restore circulating blood volume. Resuscitation may well depend on the estimated severity of hemorrhage. It now appears that patients with moderate hypotension from bleeding may benefit by delaying massive fluid resuscitation until they reach a definitive care facility. On the other hand, the use of intravenous fluids, crystalloids or colloids, and blood products can be life saving in those patients who are in severe hemorrhagic shock. The optimal method of resuscitation has not been clearly established. A hemoglobin level of 7–8 g/dl appears to be an appropriate threshold for transfusion in critically ill patients with no evidence of tissue hypoxia. However, maintaining a higher hemoglobin level of 10 g/dl is a reasonable goal in actively bleeding patients, the elderly, or individuals who are at risk for myocardial infarction. Moreover, hemoglobin concentration should not be the only therapeutic guide in actively bleeding patients. Instead, therapy should be aimed at restoring intravascular volume and adequate hemodynamic parameters.
534 citations
TL;DR: An inversely proportional relationship between mean intratracheal pressure and coronary perfusion pressure during CPR is demonstrated, demonstrating that professional rescuers consistently hyperventilated patients during out-of-hospital CPR.
Abstract: Context:This translational research initiative focused on the physiology of cardiopulmonary resuscitation (CPR) initiated by a clinical observation of consistent hyperventilation by professional rescuers in out-of-hospital cardiac arrest. This observation generated scientific hypotheses that could o
479 citations
TL;DR: In this study, patients with hypotension and severe TBI who received prehospital resuscitation with HTS had almost identical neurological function 6 months after injury as patients who received conventional fluid.
Abstract: ContextPrehospital hypertonic saline (HTS) resuscitation of patients with traumatic
brain injury (TBI) may increase survival but whether HTS improves neurological
outcomes is unknown.ObjectiveTo determine whether prehospital resuscitation with intravenous HTS
improves long-term neurological outcome in patients with severe TBI compared
with resuscitation with conventional fluids.Design, Setting, and PatientsDouble-blind, randomized controlled trial of 229 patients with TBI who
were comatose (Glasgow Coma Scale score, <9) and hypotensive (systolic
blood pressure, <100 mm Hg). The patients were enrolled between December
14, 1998, and April 9, 2002, in Melbourne, Australia.InterventionsPatients were randomly assigned to receive a rapid intravenous infusion
of either 250 mL of 7.5% saline (n = 114) or 250 mL of Ringer's lactate solution
(n = 115; controls) in addition to conventional intravenous fluid and resuscitation
protocols administered by paramedics. Treatment allocation was concealed.Main Outcome MeasureNeurological function at 6 months, measured by the extended Glasgow
Outcome Score (GOSE).ResultsPrimary outcomes were obtained in 226 (99%) of 229 patients enrolled.
Baseline characteristics of the groups were equivalent. At hospital admission,
the mean serum sodium level was 149 mEq/L for HTS patients vs 141 mEq/L for
controls (P<.001). The proportion of patients
surviving to hospital discharge was similar in both groups (n = 63 [55%] for
HTS group and n = 57 [50%] for controls; P = .32);
at 6 months, survival rates were n = 62 (55%) in the HTS group and n = 53
(47%) in the control group (P = .23). At 6 months,
the median (interquartile range) GOSE was 5 (3-6) in the HTS group vs 5 (5-6)
in the control group (P = .45). There was no significant
difference between the groups in favorable outcomes (moderate disability and
good outcome survivors [GOSE of 5-8]) (risk ratio, 0.99; 95% confidence interval,
0.76-1.30; P = .96) or in any other measure of postinjury
neurological function.ConclusionIn this study, patients with hypotension and severe TBI who received
prehospital resuscitation with HTS had almost identical neurological function
6 months after injury as patients who received conventional fluid.
412 citations
TL;DR: Postresuscitation abnormalities after cardiac arrest mimic the immunologic and coagulation disorders observed in severe sepsis, which suggests that therapeutic approaches used recently with success in severe Sepsis should be investigated in patients successfully resuscitated after cardiac cardiac arrest.
Abstract: Purpose of review Despite advances in cardiac arrest resuscitation, neurologic impairments and other organ dysfunctions cause considerable mortality and morbidity after restoration of spontaneous cardiac activity. The mechanisms underlying this postresuscitation disease probably involve a whole-body ischemia and reperfusion syndrome that triggers a systemic inflammatory response. Recent findings Postresuscitation disease is characterized by high levels of circulating cytokines and adhesion molecules, the presence of plasma endotoxin, and dysregulated leukocyte production of cytokines: a profile similar to that seen in severe sepsis. Transient myocardial dysfunction can occur after resuscitation, mainly as a result of myocardial stunning. However, early successful angioplasty is independently associated with better outcomes after cardiac arrest associated with myocardial infarction. Coagulation abnormalities occur consistently after successful resuscitation, and their severity is associated with mortality. For example, plasma protein C and S activities after successful resuscitation are lower in nonsurvivors than in survivors. Low baseline cortisol levels may be associated with an increased risk of fatal early refractory shock after cardiac arrest, suggesting adrenal dysfunction in these patients. Summary Postresuscitation abnormalities after cardiac arrest mimic the immunologic and coagulation disorders observed in severe sepsis. This suggests that therapeutic approaches used recently with success in severe sepsis should be investigated in patients successfully resuscitated after cardiac arrest.
392 citations
01 Jan 2004
382 citations
TL;DR: Timing of hypothermia is a crucial determinant of survival in the murine arrest model, and early intra-arrest cooling appears to be significantly better than delayed post-ROSC cooling or normothermic resuscitation.
Abstract: Background— Recent clinical studies have demonstrated that hypothermia to 32° to 34°C provides significant clinical benefit when induced after resuscitation from cardiac arrest. However, cooling during the postresuscitation period was slow, requiring 4 to 8 hours to achieve target temperatures after return of spontaneous circulation (ROSC). Whether more rapid cooling would further improve survival remains unclear. We sought to determine whether cooling during cardiac arrest before ROSC (ie, “intra-arrest” hypothermia) has survival benefit over more delayed post-ROSC cooling, using a murine cardiac arrest model. Methods and Results— A model of potassium-induced cardiac arrest was established in C57BL/6 mice. After 8 minutes of untreated cardiac arrest, resuscitation was attempted with chest compression, ventilation, and intravenous fluid. Mice were randomized to 3 treatment groups (n=10 each): an intra-arrest hypothermia group, in which mice were cooled to 30°C just before attempted resuscitation, and then...
364 citations
TL;DR: A better comprehension of the multifactorial mechanisms of activation of coagulation, inflammation, and fibrinolytic pathways during CPB may enable a more effective use of the technical and pharmaceutical options which are currently available.
Abstract: Background
Postoperative bleeding is one of the most common complications of cardiac surgery.
351 citations
TL;DR: The 8.6% survival rate after out-of-hospital pediatric cardiopulmonary arrest is poor, and administration of >3 doses of epinephrine or prolonged resuscitation is futile.
Abstract: Background. This study reports the epi- demiologic features, survival rates, and neurologic out- comes of the largest population-based series of pediatric out-of-hospital cardiopulmonary arrest patients with prospectively collected data. Methods. Secondary analysis of data from a prospec- tive, interventional trial of out-of-hospital pediatric air- way management conducted from 1994 to 1997 (Gausche M, Lewis RJ, Stratton SJ, et al. JAMA. 2000;283:783-790). Consecutive out-of-hospital patients from 2 large urban counties in California 3 doses of epinephrine or were resuscitated for >31 minutes in the emergency depart- ment. Conclusions. The 8.6% survival rate after out-of- hospital pediatric cardiopulmonary arrest is poor. Ad- ministration of >3 doses of epinephrine or prolonged resuscitation is futile. Pediatrics 2004;114:157-164; cardio- pulmonary arrest, cardiopulmonary resuscitation, out-of- hospital, prehospital, pediatric.
TL;DR: Standardised protocols for resuscitation, representing the best and most current knowledge of the clinical process, could be devised and widely implemented as interactive computerised applications among trauma centres in the USA and Europe.
TL;DR: Absence of leadership behaviour and absence of explicit task distribution were associated with poor team performance and failure to translate theoretical knowledge into effective team activity appears to be a major problem.
TL;DR: Physician estimates of intensive care unit survival <10% are associated with subsequent life support limitation and more powerfully predictintensive care unit mortality than illness severity, evolving or resolving organ dysfunction, and use of inotropes or vasopressors.
Abstract: Objective:Predicting outcomes for critically ill patients is an important aspect of discussions with families in the intensive care unit. Our objective was to evaluate clinical intensive care unit survival predictions and their consequences for mechanically ventilated patients.Design:Prospective coh
TL;DR: Measurement of extravascular lung water using transpulmonary thermodilution with a single indicator is very closely correlated with gravimetric measurement of lung water in both increased permeability and hydrostatic pulmonary edema.
Abstract: Objective:Pulmonary edema is a severe and often life-threatening condition. The diagnosis of pulmonary edema and its quantification have great clinical significance and yet can be difficult. A new technique based on thermodilution measurement using a single indicator has recently been developed (PiC
TL;DR: Initial hypoglycemia is an important risk factor for perinatal brain injury, particularly in depressed term infants who require resuscitation and have severe fetal acidemia, however, it remains unclear whether earlier detection of hypglycemia, such as in the delivery room, in this population could modify subsequent neurologic outcome.
Abstract: Objective. To determine the potential contribution of initial hypoglycemia to the development of neonatal brain injury in term infants with severe fetal acidemia. Methods. A retrospective chart review was conducted of 185 term infants who were admitted to the neonatal intensive care unit between January 1993 and December 2002 with an umbilical arterial pH Results. Forty-one (22%) infants developed an abnormal neurologic outcome, including 14 (34%) with severe hypoxic ischemic encephalopathy who died, 24 (59%) with moderate to severe hypoxic ischemic encephalopathy, and 3 (7%) with seizures. Twenty-seven (14.5%) of the 185 infants had an initial blood sugar ≤40 mg/dL. Fifteen (56%) of 27 infants with a blood sugar ≤40 mg/dL versus 26 (16%) of 158 infants with a blood sugar >40 mg/dL had an abnormal neurologic outcome (odds ratio [OR]: 6.3; 95% confidence interval [CI]: 2.6–15.3). Infants with abnormal outcomes and a blood sugar ≤40 mg/dL versus >40 mg/dL had a higher pH (6.86 ± 0.07 vs 6.75 ± 0.09), a lesser base deficit (−19 ± 4 vs −23.8 ± 4 mEq/L), and lower mean arterial blood pressure (34 ± 10 vs 45 ± 14 mm Hg), respectively. There was no difference between groups in the proportion of infants who required cardiopulmonary resuscitation (7 [46%] vs 15 [57%]) and those with a 5-minute Apgar score 40 mg/dL (OR: 18.5; 95% CI: 3.1–111.9), cord arterial pH ≤6.90 versus >6.90 (OR: 9.8; 95% CI: 2.1–44.7), a 5-minute Apgar score ≤5 versus >5 (OR: 6.4; 95% CI: 1.7–24.5), and the requirement for intubation with or without cardiopulmonary resuscitation versus neither (OR: 4.7; 95% CI: 1.2–17.9). Conclusion. Initial hypoglycemia is an important risk factor for perinatal brain injury, particularly in depressed term infants who require resuscitation and have severe fetal acidemia. It remains unclear, however, whether earlier detection of hypoglycemia, such as in the delivery room, in this population could modify subsequent neurologic outcome.
TL;DR: Basal distribution was associated with greater impairment of FEV(1), but less impairment of gas exchange and alveolar-arterial oxygen gradient than the apical distribution, and the use of single physiologic parameters as a surrogate measure of emphysema severity may introduce systematic bias in the staging of subjects with emphySEma.
Abstract: FEV1 is fundamental to the diagnosis and staging of chronic obstructive pulmonary disease. In emphysema, airflow obstruction usually coexists with impairment of gas exchange, but discordance is not infrequent. We hypothesized that variations in the distribution of emphysema would be associated with functional differences and therefore account for discordant physiology. We used quantitative computed tomography to assess emphysema severity and distribution in 119 subjects with 1-antitrypsin deficiency (PiZ phenotype) and grouped them according to distribution pattern. In the 102 subjects with emphysema, 65 had a predominantly basal pattern (“basal”), but 37 (36%) had greater involvement of the upper regions (“apical”). Subjects from each group were matched for total volume of emphysema and age, and matched pairs analysis was used to relate emphysema distribution to clinical phenotype. Basal distribution was associated with greater impairment of FEV1 (mean difference, 9.9% predicted; 95% confidence interval, 3.8 to 16.0; p 0.002) but less impairment of gas exchange (PaO2 mean difference, 0.5 kPa, 0.03 to 0.1; p 0.016) and alveolar–arterial oxygen gradient (mean difference, 0.7 kPa; 0.2 to 1.2; p 0.007) than the apical distribution. Emphysema distribution correlated with physiologic discordance (r 0.409, p 0.001). The use of single physiologic parameters as a surrogate measure of emphysema severity may introduce systematic bias in the staging of subjects with emphysema.
TL;DR: It is concluded that serum S100B is a sensitive marker of brain injury, which correlates with the severity of the injury, and has a high negative predictive power, and should exclude significant brain injury with a high accuracy.
Abstract: Background:Serum protein S100B determinations have been recently suggested as markers of traumatic brain injury. However, little is known about the effects of extracranial injuries on S100B levels in trauma patients.Methods:We studied 224 patients with head trauma (54 of whom also had extracranial i
TL;DR: Early and vigorous fluid resuscitation followed by mannitol-alkaline diuresis prevents acute renal failure in crush victims, resulting in a more favorable outcome.
Abstract: This study analyzes the effects of fluid resuscitation in the crush victims of the Bingol earthquake, which occurred in May 2003 in southeastern Turkey. Questionnaires asking about demographic, clinical, laboratory, and therapeutic features of 16 crush victims were filled in retrospectively. Mean duration under the rubble was 10.3 +/- 7 h, and all patients had severe rhabdomyolysis. Fourteen patients were receiving isotonic saline at admission, which was followed by mannitol-alkaline fluid resuscitation. All but two patients were polyuric. Admission serum creatinine level was lower than and higher than 1.5 mg/dl in 11 and 5 patients, respectively. Marked elevations were noted in muscle enzymes in all patients. During the clinical course, hypokalemia was observed in nine patients, all of whom needed energetic potassium chloride replacement. Four (25%) of 16 victims required hemodialysis. Duration between rescue and initiation of fluids was significantly longer in the dialyzed victims as compared with nondialyzed ones (9.3 +/- 1.7 versus 3.7 +/- 3.3 h, P < 0.03). Sixteen fasciotomies were performed in 11 patients (68%), nine of which were complicated by wound infections. All patients survived and were discharged from the hospital with good renal function. Early and vigorous fluid resuscitation followed by mannitol-alkaline diuresis prevents acute renal failure in crush victims, resulting in a more favorable outcome.
TL;DR: It is demonstrated that soluble ST2, a marker for Th2 cytokine producing cells, is increased in sepsis and trauma patients, and they provide further evidence for a shift from Th1- to Th2-biased cells.
Abstract: T1/ST2, a member of the interleukin (IL)-1 receptor superfamily, is predominantly expressed on type-2 T helper (Th2) cells but not Th1 cells, and plays a role in cell proliferation and Th2 immune response. The relation of soluble ST2, Th1-Th2 cytokine profile, and immunoglobulin (Ig) production in sepsis and trauma patients is not well known. Case-control study at a university hospital intensive care unit. Fifteen patients recruited within 24–48 h of diagnosis of sepsis, 13 trauma patients recruited within 24 h after admission to the ICU, 11 patients who underwent abdominal surgery, and 15 healthy volunteers served as control. ELISA was utilized to detect serum soluble ST2, IL-2, IFN-γ, IL-10, and Ig production. Serum levels of soluble ST2 were significantly increased in septic patients (8420±2169 pg/ml) as compared with trauma (2936±826 pg/ml), abdominal surgery (1423±373 pg/ml), and healthy controls (316±72 pg/ml; p<0.001, respectively). These results were accompanied by an increase of IgG1 and IgG2 production, and decrease of IL-2 and IFN-γ synthesis in septic patients. IL-10 was significantly increased in both septic and trauma patients. Our results demonstrate that soluble ST2, a marker for Th2 cytokine producing cells, is increased in sepsis and trauma patients, and they provide further evidence for a shift from Th1- to Th2-biased cells.
TL;DR: Carefully titrated intravenous adrenaline combined with volume resuscitation is an effective strategy for treating sting anaphylaxis, however severe bradycardia may benefit from additional treatment with atropine.
Abstract: Objectives: To assess a protocol for treatment of sting anaphylaxis. Design: Prospective assessment of treatment with oxygen, intravenous infusion of adrenaline (epinephrine), and volume resuscitation with normal saline. Setting: Sub-study of a venom immunotherapy trial. Participants: 21 otherwise healthy adults with systemic allergic reactions to diagnostic sting challenge. Main outcome measures: Response to treatment, total adrenaline dose and infusion duration, recurrence of symptoms after stopping the infusion, and additional volume resuscitation. Results: 19 participants required intervention according to the protocol. All received adrenaline, and five received volume resuscitation. In nine cases, physical signs of anaphylaxis recurred after initial attempts at stopping adrenaline but resolved after recommencing the infusion. The median total dose and infusion duration were 590 μg and 115 minutes respectively, but were significantly higher for eight patients who had hypotensive reactions (762 μg and 169 minutes respectively). Hypotension was always accompanied by a relative bradycardia, which was severe and treated with atropine in two patients. Widespread T wave inversion occurred, before starting treatment with adrenaline, in one person with an otherwise mild reaction. All patients fully recovered and were fit for same day discharge, apart from the person with ECG changes who was observed overnight and discharged the following day. Conclusions: Carefully titrated intravenous adrenaline combined with volume resuscitation is an effective strategy for treating sting anaphylaxis, however severe bradycardia may benefit from additional treatment with atropine. Cardiac effects of anaphylaxis, perhaps including neurocardiogenic mechanisms, may be an important factor in some lethal reactions.
TL;DR: Long-term survival after MICU is mainly related to the underlying condition, whereas known factors for in-MICU survival do not influence long-term prognosis.
Abstract: Objective
To determine the prognostic indicators of long-term survival after admission to a medical intensive care unit (MICU) for patients aged 80 years and over.
TL;DR: In the trauma system, ETI confers no survival advantage over BVM and slightly increases prehospital time, when corrected for mechanism and severity of anatomic and physiologic injury.
Abstract: Background Few data exist supporting a survival benefit to prehospital endotracheal intubation (ETI) over bag-valve-mask ventilation (BVM) in trauma patients. Methods Data were reviewed from all trauma patients transported to our Level I trauma center receiving prehospital ETI or BVM. Mortality was adjusted by age, Revised Trauma Score, Injury Severity Score, and mechanism of injury (penetrating vs. blunt). Results Of 5,773 patients, 316 (5.5%) had ETI and 217 (3.8%) had BVM. Patients receiving ETI were significantly more like to die (88.9% vs. 30.9%, p Conclusion In our trauma system, when corrected for mechanism and severity of anatomic and physiologic injury, ETI confers no survival advantage over BVM and slightly increases prehospital time.
TL;DR: It is proposed that the acute administration of EPO on reperfusion and/or resuscitation will reduce the tissue injury caused by ischemia-reperfusion of the heart (and other organs) and hemorrhagic shock.
Abstract: Here we investigate the effects of erythropoietin (EPO) on the tissue/organ injury caused by hemorrhagic shock (HS), endotoxic shock, and regional myocardial ischemia and reperfusion in anesthetized rats. Male Wistar rats were anesthetized with thiopental sodium (85 mg/kg i.p.) and subjected
TL;DR: Fluid resuscitation of severe sepsis may consist of natural or artificial colloids or crystalloids and should be administered and repeated based on response and tolerance and evidence of intravascular volume overload.
Abstract: Objective In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for fluid resuscitation in severe sepsis and septic shock that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and improve outcome in severe sepsis Design The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee Methods The modified Delphi methodology used for grading recommendations built on a 2001 publication sponsored by the International Sepsis Forum We undertook a systematic review of the literature graded along five levels to create recommendation grades from A to E, with A being the highest grade Pediatric considerations to contrast adult and pediatric management are in the article by Parker et al on p S591 Conclusion Fluid resuscitation of severe sepsis may consist of natural or artificial colloids or crystalloids Fluid challenge should be administered and repeated based on response (increase in blood pressure and urine output) and tolerance (evidence of intravascular volume overload)
TL;DR: Burn shock resuscitation due to the Baxter formula leads to significant hypovolemia during the first 48 h following burn, which results in more aggressive therapeutic strategies and is associated with a significant increase in fluid administration.
TL;DR: This clinical practice guideline will focus on resuscitation after achieving hemostasis and will not address the issue of uncontrolled hemorrhage further, and evaluate the current state of the literature regarding use of potential markers and related goals of resuscitation, focusing on those that have been tested in human trauma victims.
Abstract: STATEMENT OF THE PROBLEM Severely injured trauma victims are at high risk of development of the multiple organ dysfunction syndrome (MODS) or death. To maximize chances for survival, treatment priorities must focus on resuscitation from shock (defined as inadequate tissue oxygenation to meet tissue O2 requirements), including appropriate fluid resuscitation and rapid hemostasis. Inadequate tissue oxygenation leads to anaerobic metabolism and resultant tissue acidosis. The depth and duration of shock leads to a cumulative oxygen debt. Resuscitation is complete when the oxygen debt has been repaid, tissue acidosis eliminated, and normal aerobic metabolism restored in all tissue beds. Many patients may appear to be adequately resuscitated based on normalization of vital signs, but have occult hypoperfusion and ongoing tissue acidosis (compensated shock), which may lead to organ dysfunction and death. Use of the endpoints discussed in this guideline may allow early detection and reversal of this state, with the potential to decrease morbidity and mortality from trauma. Without doubt, resuscitation from hemorrhagic shock is impossible without hemostasis. Fluid resuscitation strategies before obtaining hemostasis in patients with uncontrolled hemorrhage, usually victims of penetrating trauma, remain controversial. Withholding fluid resuscitation may lead to death from exsanguination, whereas aggressive fluid resuscitation may disrupt the clot and lead to more bleeding. “Limited,” “hypotensive,” and/or “delayed” fluid resuscitation may be beneficial, but clinical trials have yielded conflicting results. This clinical practice guideline will focus on resuscitation after achieving hemostasis and will not address the issue of uncontrolled hemorrhage further. Use of the traditional markers of successful resuscitation, including restoration of normal blood pressure, heart rate, and urine output, remain the standard of care per the Advanced Trauma Life Support Course. When these parameters remain abnormal, i.e., uncompensated shock, the need for additional resuscitation is clear. After normalization of these parameters, up to 85% of severely injured trauma victims still have evidence of inadequate tissue oxygenation based on findings of an ongoing metabolic acidosis or evidence of gastric mucosal ischemia. This condition has been described as compensated shock. Recognition of this state and its rapid reversal are critical to minimize risk of MODS or death. Consequently, better markers of adequate resuscitation for severely injured trauma victims are needed. This guideline committee sought to evaluate the current state of the literature regarding use of potential markers and related goals of resuscitation, focusing on those that have been tested in human trauma victims. This manuscript is part of an ongoing process of guideline development that includes periodic (every 3–4 years) review of the topic and the recommendations in light of new data. The goal is for these guidelines to assist clinicians in assuring adequate resuscitation of trauma patients, ultimately improving patient outcomes.
TL;DR: The beneficial effect of therapeutic hypothermia on neurologic outcome along with the recent approach to prognosticate long-term outcome by electrophysiologic techniques and molecular markers of brain injury are reviewed.
Abstract: Purpose of review In industrial countries the incidence of cardiac arrest is still increasing Almost 80% of cardiac arrest survivors remains in coma for varying lengths of time and full cerebral recovery is still a rare event After successful cardiopulmonary resuscitation, cerebral recirculation disturbances and complex metabolic postreflow derangements lead to death of vulnerable neurons with further deterioration of cerebral outcome This article discusses recent research efforts on the pathophysiology of brain injury caused by cardiac arrest and reviews the beneficial effect of therapeutic hypothermia on neurologic outcome along with the recent approach to prognosticate long-term outcome by electrophysiologic techniques and molecular markers of brain injury Recent findings Recent experimental studies have brought new insights to the pathophysiology of secondary postischemic anoxic encephalopathy demonstrating a time-dependent cerebral oxidative injury, increased neuronal expression, and activation of apoptosis-inducing death receptors and altered gene expression with long-term changes in the molecular phenotype of neurons Recently, nuclear MR imaging and MR spectroscopic studies assessing cerebral circulatory recovery demonstrated the precise time course of cerebral reperfusion after cardiac arrest Therapeutic hypothermia has been shown to improve brain function after resuscitation from cardiac arrest and has been introduced recently as beneficial therapy in ventricular fibrillation cardiac arrest Summary Electrophysiologic techniques and molecular markers of brain injury allow the accurate assessment and prognostication of long-term outcome in cardiac arrest survivors In particular, somatosensory evoked potentials have been identified as the method with the highest prognostic reliability A recent systematic review of 18 studies analyzed the predictive ability of somatosensory evoked potentials performed early after onset of coma and found that absence of cortical somatosensory evoked potentials identify patients not returning from anoxic coma with a specificity of 100%
TL;DR: The majority of survivors of OHCA with ventricular fibrillation as the initial rhythm are cognitively unimpaired, and long delays to ROSC are compatible with good cognitive outcome.
TL;DR: Applying PEEP during resuscitation of very premature infants might be advantageous and merits further investigation.
Abstract: Positive end expiratory pressure (PEEP) is important for neonatal ventilation but is not considered in guidelines for resuscitation. Our aim was to investigate the effects of PEEP on cardiorespiratory parameters during resuscitation of very premature lambs delivered by hysterotomy at approximately 125 d gestation (term approximately 147 d). Before delivery, they were intubated and lung fluid was drained. Immediately after delivery, they were ventilated with a Drager Babylog plus ventilator in volume guarantee mode with a tidal volume of 5 mL/kg. Lambs were randomized to receive 0, 4, 8, or 12 cm H(2)O of PEEP. They were ventilated for a 15-min resuscitation period followed by 2 h of stabilization at the same PEEP. Tidal volume, peak inspiratory pressure, PEEP, arterial pressure, oxygen saturation, and blood gases were measured regularly, and respiratory system compliance and alveolar/arterial oxygen differences were calculated. Lambs that received 12 cm H(2)O of PEEP died from pneumothoraces; all others survived without pneumothoraces. Oxygenation was significantly improved by 8 and 12 cm H(2)O of PEEP compared with 0 and 4 cm H(2)O of PEEP. Lambs with 0 PEEP did not oxygenate adequately. The compliance of the respiratory system was significantly higher at 4 and 8 cm H(2)O of PEEP than at 0 PEEP. There were no significant differences in partial pressure of carbon dioxide in arterial blood between groups. Arterial pressure was highest with 8 cm H(2)O of PEEP, and there was no cardiorespiratory compromise at any level of PEEP. Applying PEEP during resuscitation of very premature infants might be advantageous and merits further investigation.