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PubMed2005

Cardio-pulmonary resuscitation training, knowledge and attitudes of newly-qualified doctors in New Zealand in 2003.

OBJECTIVE: To assess the resuscitation knowledge and confidence of newly-qualified doctors in New Zealand (NZ) in 2003. DESIGN: Anonymous questionnaires were distributed to all newly-qualified doctors in NZ (n=279). PARTICIPANTS: Two hundred and thirty-three respondents from hospitals throughout NZ (84% response rate). MAIN OUTCOME MEASURES: Resuscitation training received during medical school and use of recommended text (Level 7 of NZ resuscitation manual), confidence in resuscitation skills and core knowledge of basic and advanced resuscitation. RESULTS: 98.3% of doctors received advanced resuscitation training during their final year of medical school, of these 64.6% had received training in the previous 6 months. The mean knowledge score was 56.6% and 45% of doctors made 'fatal errors'. Eighty-four percentage of doctors had read the Level 7 manual and 72.6% found it very or extremely useful. Those who had read the manual had higher scores and were less likely to make a 'fatal error'. Having attended a cardiac arrest and having received training within the last 6 months improved doctor confidence in resuscitation. CONCLUSIONS: The resuscitation knowledge and confidence of newly-qualified doctors in NZ are sub-optimal, with some doctors displaying dangerous deficiencies. Our results suggest mandatory attainment of an advanced resuscitation certificate, six-monthly practical resuscitation sessions and increased exposure to real resuscitation situations should be implemented to improve undergraduate resuscitation training.

Adult↗
PubMed2002

cDNA array analysis of gene expression following hemorrhagic shock and resuscitation in rats.

UNLABELLED: The aim of this study was to characterize gene expression following hemorrhagic shock and resuscitation with emphasis on the differences between various resuscitation strategies. METHODS: Male Sprague Dawley rats (n = 25; 5/group) were subjected to a three stage hemorrhage and resuscitated as follows: (1) sham hemorrhage; (2) sham resuscitation; (3) lactated Ringer's solution (LR), 3:1 volume; (4) 7.5% hypertonic saline (HTS) 9.7 ml/kg; (5) plasma, 1:1 volume. Liver, spleen, lung and muscle were collected 3 h post resuscitation and cDNA array analysis was performed on the total RNA. RESULTS: Expression of 1,176 genes was analyzed. Following resuscitation, 82 of the genes studied (7%) displayed an altered expression of at least 2-fold compared to the sham hemorrhage group. Depending on organ system under study and resuscitation conditions, expression of these 82 genes was down- or up-regulated, bringing the total number of expression alterations to 167. Largest number of organ-specific changes in gene expression was noted in liver (63/167), followed by lung (57), muscle (25), and spleen (22). Most of the resuscitation strategy specific changes were caused by plasma resuscitation (68/167), followed by LR (51), and HTS (48). In every organ studied, gene expression profile was dependent upon the fluid used for resuscitation. CONCLUSION: Cellular response to hemorrhagic shock, even at the level of gene expression, is dependent on the resuscitation strategy. We have discovered altered expression of genes not previously implicated in the physiology of hemorrhagic shock and resuscitation. Gene array technology provides a rapid and efficient means of dissecting the complex genetic regulation of cellular response to shock.

Animals↗
PubMed2003

Prehospital resuscitation practices: a survey of prehospital providers.

Numerous factors affect decision making in the prehospital provision of resuscitative care. This study was undertaken to determine current practices involved in the initiation, continuation and termination of resuscitative efforts, and the impact of advance directives, in the prehospital resuscitation setting. This cross-sectional mailed questionnaire surveyed 3807 members of the National Association of Emergency Medical Technicians. The study instrument included questions regarding the termination and withholding of resuscitative efforts in the prehospital setting, as well as survival rates, local protocols and compliance with advance directives. Of 1546 respondents (41% response rate), with a mean 9.0 years of experience, most (89%) indicated that they would withhold resuscitative efforts in the presence of an official state-approved advance directive. However, very few providers would withhold resuscitative efforts if only an unofficial document (4%) or verbal report of an advance directive (10%) were available. Providers with more than 10 years experience were more likely to withhold resuscitation attempts in the presence of only a verbal report of an advance directive (p = 0.02, Chi-square), and were more likely to withhold resuscitation attempts in situations they considered futile (p = 0.001, Chi-square). Most (77%) respondents have local EMS guidelines for termination of resuscitation in the prehospital setting, but 23% of those consider existing guidelines to be inadequate. The majority of prehospital providers stated that they honor official state-approved advance directives, but do not follow directives from unofficial documents or verbal reports of advance directives. More experienced providers stated that they withhold resuscitative efforts more often in futile situations, or in the presence of unofficial advance directives. Advance directives should be utilized more uniformly among patients who wish to forgo resuscitative efforts in the event of cardiac arrest. Because many local protocols are judged to be inadequate, we support the institution of improved clinical guidelines regarding the prehospital termination of resuscitative efforts.

Advance Directives↗
PubMed1996

Coupling between local cerebral blood flow and metabolism after hypertonic/hyperoncotic fluid resuscitation from hemorrhage in conscious rats.

The effects of small volume hypertonic/hyperoncotic fluid resuscitation from hemorrhage on brain metabolism and blood flow were evaluated by autoradiographic techniques with high spatial resolution. The data were compared to fluid resuscitation with a volume equal to shed blood of isotonic 6% hydroxyethyl starch solution (HES) and a control group without hemorrhage and fluid resuscitation (n = 6 in each group). In conscious rats, volume-controlled hemorrhage for 30 min (30 mL/kg body weight, resulting in a blood loss of approximately 50% of the circulating blood volume) was followed by intravenous infusion of a hypertonic/hyperoncotic saline hydroxyethyl starch solution (HTHO; 7.5% saline/10% hydroxyethyl starch, 4.0 mL/kg body weight). Local cerebral blood flow (LCBF) and local cerebral glucose utilization (LCGU) were measured in 34 brain structures 2 h after fluid resuscitation by means of the quantitative autoradiographic iodo [14C]antipyrine and 2-[14C]-deoxy-D-glucose methods. Compared to the untreated control group, LCBF increased significantly in all brain regions analyzed after fluid resuscitation with HTHO (mean, +63%) or HES (mean, +56%). The increases in LCBF after fluid resuscitation were sufficient to restore cerebral oxygen delivery to the level calculated for the untreated control group. LCGU was unchanged after fluid resuscitation. The close relationship between LCGU and LCBF observed in the control group (r = 0.95) was preserved after hemorrhage and fluid resuscitation with HTHO (r = 0.97) and HES (r = 0.96), although the LCBF-to-LCGU ratio was reset to a higher level (1.5 mL/mumol in the control group and 2.7 mL/mumol after fluid resuscitation with HTHO and HES, P < 0.05). We conclude that the increase in LCBF compensates for the reduction of arterial oxygen content to maintain cerebral oxygen delivery. Therefore, "small volume resuscitation" appears to be as effective as resuscitation with large volumes of isotonic HES in meeting the circulatory and metabolic demands of the brain tissue within the first 2 h after fluid resuscitation from hemorrhage.

Animals↗
PubMed1995

Hypertonic sodium resuscitation is associated with renal failure and death.

OBJECTIVE: The use of hypertonic sodium solutions (HSS) and lactated Ringer's (LR) solution in the resuscitation of patients with major burns was compared. SUMMARY BACKGROUND DATA: Hypertonic sodium solutions have been recommended for burn resuscitation to reduce the large total volumes required with isotonic LR solution and their attendant complications. METHODS: To evaluate the efficacy of this therapy in our adult burn center, we resuscitated 65 consecutive patients with HSS (290 mEq/L Na) between July 1991 and June 1993 and compared them with 109 burn patients resuscitated with LR (130 mEq/L Na) between July 1986 and June 1988 (LR-1). A subsequent 39 patients were resuscitated with LR between September 1993 and August 1994 (LR-2). RESULTS: Patients receiving hypertonic sodium solutions versus LR-1 were similar with respect to age (46.0 vs. 43.6 years), total burn size (39.2% vs. 39.9%), incidence of inhalation injury (41.5% vs. 47.7%), and predicted mortality (34.6% vs. 30.2%). Total resuscitation volumes during the first 24 hours were lower among patients treated with HSS than those in the LR-1 group (3.9 +/- 0.3 vs. 5.3 +/- 0.2 mL/kg/% body surface area [BSA], p < 0.05). After 48 hours, however, cumulative fluid loads were similar (6.6 +/- 0.6 vs. 7.5 +/- 0.3 mL/kg/%BSA), and total sodium load was greater with the HSS group (1.3 +/- 0.1 vs. 0.9 +/- 0.1 mEq/kg/%BSA, p < 0.002). During the first 3 days after burn, serum sodium concentrations were moderately elevated in the HSS patients (153 +/- 2 vs. 135 +/- 1 mEq/L, p < 0.001). Patients resuscitated with HSS had a fourfold increase in renal failure (40.0 vs. 10.1%, p < 0.001) and twice the mortality of LR-1 patients (53.8 vs. 26.6%, p < 0.001). In patients resuscitated with HSS, renal failure was an independent risk factor (p < 0.001, by logistic regression). Analysis of these results prompted a return to LR resuscitation (LR-2). Age (41.6 +/- 2.9 years), burn size (37.8 +/- 3.9 %BSA), and incidence of inhalation injury (51.3%) were similar to the earlier groups. Total sodium load was less among LR-2 patients than the HSS group (0.7 +/- 0.1 mEq/kg/%BSA, p < 0.01), but similar to the LR-1 patients. Renal failure developed in only 15.4%, and 33.3% died, similar to the LR-1 group and significantly lower than patients treated with HSS (p < 0.001 and p < 0.05, respectively). CONCLUSION: Hypertonic sodium solution resuscitation of burn patients did not reduce the total resuscitation volume required. Furthermore, it was associated with an increased incidence of renal failure and death. The use of HSS for burn resuscitation may be ill advised.

Acute Kidney Injury↗
PubMed1988

Video recording trauma resuscitations: an effective teaching technique.

Since the initial hour after injury is the most crucial time for trauma patients, resuscitation technique is of vital importance. Standardized courses for first-hour management (ATLAS) have been widely accepted. A teaching format based upon video recording of every resuscitation has been developed. Tapes are reviewed by the staff and by the individuals involved in a particular resuscitation. In a weekly resuscitation review conference, actual footage is presented to the trauma team members, specific aspects of a resuscitation are critiqued, and supplemental didactic information is presented. Legal problems have been avoided by making the review and conference a part of the quality assurance process. Patient anonymity is preserved by positioning the video camera at the foot of the resuscitation bed. Tapes are erased after each conference. Video recording allows analysis of: 1) priorities during the resuscitation; 2) cognitive integration of the workup by the team leader; 3) physical integration of the workup by the team leader; 4) team member adherence to assigned responsibilities, resuscitation time, errors or breaks in technique; and 5) behavior change over time. In 3 1/2 years, more than 2,500 resuscitations have been recorded. Over a 3-month period, average resuscitation time to definitive care decreased for age- and injury severity-matched patient groups cared for by one team. Resuscitations have become more efficient and adherence to assigned responsibilities better. Weekly review of resuscitation contributes to improved technique and trauma care.

Critical Care↗
PubMed1995

Liver injury as a model of uncontrolled hemorrhagic shock: resuscitation with different hypertonic regimens.

Using a standardized liver injury model of uncontrolled hemorrhage, we tested the effect of different hypertonic solutions on mortality, blood pressure, intra-abdominal bleeding, and circulating blood volume. After liver injury, rats were randomized to 4 groups: lactated Ringer's (LR, n = 10), Isosal (ISO, n = 10), hypertonic saline (HS, n = 10), and hypertonic sodium acetate (HA, n = 10). In all resuscitation groups, 4 mL/kg was infused at a rate of 0.4 mL/min. Blood volume was evaluated both directly and by estimation. Mortality was highest after HA resuscitation (40%) and lowest after HS resuscitation (0%), but this difference was not significant. Blood pressure was significantly higher after HS resuscitation, and this difference was sustained for 4 hours. The HA resuscitation did not increase blood pressure compared with LR resuscitation. Intraperitoneal blood volume was significantly higher with HS (25.5 +/- 0.7 mL/kg) and HA (26.8 +/- 1.2 mL/kg) than with LR (22.5 +/- 0.4 mL/kg). The HA resuscitation led to a significantly larger drop from baseline values of estimated terminal circulating blood volume than LR resuscitation. Nonparametric analysis combining survival time and directly measured change in blood volume demonstrated a significant advantage to HS, compared with LR. HA and HS resuscitations increased bleeding from uncontrolled solid viscus injury. The HS resuscitation restored blood pressure better than the other hypertonic solutions and maintained circulating blood volume in spite of increased bleeding. The HA and ISO resuscitations did not exhibit any advantage over LR in resuscitation of solid viscus injury.

Acetates↗
PubMed2003

Goal-oriented shock resuscitation for major torso trauma: what are we learning?

Shock resuscitation is an obligatory intervention for severely injured patients who present in shock. During the past 15 years, with widespread acceptance of "damage control" surgery and early triage to the intensive care unit (ICU) to optimize resuscitation, the lives of many major trauma victims have been saved, and much has been learned about shock resuscitation. Due largely to the work of Shoemaker et al., a resuscitation strategy based on a standardized process using O(2) delivery index (DO(2)I) as an endpoint and physiologic performance goal for interventions has been developed, studied, and refined for resuscitation of shock caused by major trauma. DO(2)I >or=600 mL O(2)/min-m2 is the only resuscitation endpoint variable that has been tested in prospective randomized trials (PRTs) of trauma patient outcome. These PRTs are limited, and their results are not conclusive. Results from other investigators, including our group, using similar process and endpoints, are indicating similar performance and outcomes. We believe that DO(2)I is a useful endpoint because it integrates three important variables, ie, hemoglobin concentration [Hb], arterial hemoglobin O(2) saturation, and cardiac output. We have found DO(2)I >or=500 mL O(2)/min-m2 to be an endpoint with more general applicability, but we believe that the standardized process is more important than the specific endpoint. To standardize our process, we have developed a computerized decision support tool for shock resuscitation. This technology has provided novel data collection and has permitted refinement of the bedside process. Our data analysis indicates that the next challenge will be to develop a similar pre ICU resuscitation process that will use less invasive monitors and different endpoints. Identification of the high-risk resuscitation nonresponders early in the resuscitation process will be needed to redirect their clinical trajectories. As an endpoint for interventions for goal-directed resuscitation in the critically injured trauma patient, systemic O(2) delivery is the current state of the art and the basis for near future development of clinical processes for resuscitation of shock due to major trauma.

Clinical Protocols↗
PubMed2005

Endothelial dysfunction after lactated Ringer's solution resuscitation for hemorrhagic shock.

BACKGROUND: Endothelial dysfunction is presumed to occur after hemorrhagic shock and resuscitation. This study uses a novel large-animal model to evaluate the effects of diverse resuscitation regimens on endothelial function. METHODS: Twenty-seven adult domestic pigs (Sus scrofa) were used in this study. Control pigs (n = 3) underwent instrumentation alone. The remaining pigs experienced controlled hemorrhagic shock to a mean arterial blood pressure of 30 +/- 5 mm Hg for 45 minutes. Pigs were resuscitated to their baseline mean arterial blood pressure +/-5 mm Hg with either shed blood (SB; n = 8), lactated Ringers solution (40 mL/kg) followed by shed blood (LRSB; n = 8), or lactated Ringers solution alone (LR; n = 8). At baseline, 1 and 4 hours after resuscitation, acetylcholine (5, 10, and 15 microg/min) was infused into the proximal iliac artery to measure endothelial dependent relaxation (EDR). Sodium nitroprusside was infused to determine endothelial independent relaxation at the end of the study to insure smooth muscle vasomotor integrity. External iliac artery luminal diameter was measured using motion-mode ultrasonography. Statistical analysis was performed using repeated-measures analysis of variance with Tukey's post-hoc analysis. RESULTS: All pigs survived the experiment. Pigs required ninefold more resuscitation with LR (370.58 +/- 29 mL/kg) versus SB (41.45 +/- 3.5 mL/kg) or LRSB (76.4 +/- 1.1 mL/kg) (p < 0.05). EDR for LR pigs 1 hour after initiation of resuscitation (R1) was 70.4 +/- 14.4% compared with 94.2 +/- 13.4% for SB and 106.1 +/- 8.2% for LRSB (p < 0.05). At 4 hours after resuscitation (R4), systolic luminal diameters were larger in the SB (0.45 +/- 0.01 cm) and LRSB (0.51 +/- 0.02 cm) groups compared with LR (0.41 +/- 0.03 cm) (LRSB versus LR; p = 0.01). At R4, EDR for the LR group was 78.3 +/- 10.7% compared with SB (101.4 +/- 8.3%) and LRSB (106.4 +/- 7.4%) (p < 0.05). Infusion of sodium nitroprusside confirmed integrity of smooth muscle vasorelaxation. Analysis of serum nitric oxide levels revealed decreased values after resuscitation with LR (9.44 +/- 0.76 mol/L) compared with SB (26.3 +/- 7.8 mol/L) and LRSB (16.3 +/- 1.0 mol/L) (p = not significant). CONCLUSION: This is the first description of a large-animal model to evaluate EDR after hemorrhagic shock. Resuscitation with LR requires significantly larger volumes than SB or LRSB. LR resuscitation leads to endothelial dysfunction, as determined by decreased EDR, versus SB or LRSB. Resuscitation with blood products may preserve nitric oxide bioactivity when compared with crystalloid resuscitation in the setting of hemorrhagic shock.

Animals↗
PubMed2005

Energy substrate-supplemented resuscitation affects brain monocarboxylate transporter levels and gliosis in a rat model of hemorrhagic shock.

BACKGROUND: Monocarboxylate (MC)-supplemented resuscitation has been shown to attenuate cellular injury after hemorrhagic shock. However, little is known about its effect on the central nervous system. The brain can use MCs such as lactate, pyruvate, and beta-hydroxybutyrate as energy substrates. The transit of MCs into the central nervous system is facilitated by the monocarboxylate transporters (MCTs), and their blockage can exacerbate neuronal damage. We examined the expression of MCT1 and markers specific for activation of astroglia and microglia in the brains of rats subjected to hemorrhagic shock and resuscitation. The hypothesis was that resuscitation with MC-based fluids would be accompanied by MCT1 up-regulation and glial response. METHODS: Rats (n = 30) were subjected to volume-controlled hemorrhage. Test groups included: sham, no resuscitation, resuscitation with normal saline, resuscitation with racemic lactated Ringer's solution, resuscitation with pyruvate Ringer's solution, and resuscitation with beta-hydroxybutyrate-containing ketone Ringer's solution. Plasma levels of MC were measured serially. The brains were investigated using GFAP, CD11b, CD43, MCT1, and GLUT1 immunohistochemistry. RESULTS: Rats resuscitated with MC-containing fluids had increased levels of MCT1 in brain endothelial cells and neuropil compared with sham rats. Enhanced staining was localized to the choroid plexus, astrocytic end feet, and white matter structures. None of the resuscitation treatment induced astrocytic hyperplasia, and pyruvate Ringer's solution and ketone Ringer's solution resuscitation led to hypertrophy of astrocytes. CONCLUSION: In hemorrhagic shock, resuscitation with MC-based fluids increased brain MCT1 level and led to activation of astrocytes. Enhanced MC trafficking could be an essential route for energy supply to neurons under adverse circulatory conditions.

Animals↗
PubMed1998

Effects of colloidal resuscitation fluids on reticuloendothelial function and resistance to infection after hemorrhage.

The effects of three resuscitation fluids, hydroxyethyl starch (HES), Haemaccel, and fresh autologous blood, on reticuloendothelial system phagocytic and catabolic functions and resistance to infection after 40% hemorrhages in BALB/c mice were studied. The mice, anesthetized with isoflurane, were bled over a 10-min period, left hypovolemic for 30 min, and then resuscitated with their shed blood or the same volume of asanguineous fluid. Normothermia was maintained throughout the experiments. The uptake and catabolism of intravenously injected double-labelled sheep erythrocytes (51Cr-125I-SRBC) in liver and spleen were determined at 1 and 48 h after hemorrhage. No significant changes in the uptake or catabolism of SRBC in liver or spleen were found at 1 h after hemorrhage and resuscitation with any of the fluids. However, at 48 h a significant increase in liver uptake of SRBC was seen in animals resuscitated with either Haemaccel or HES compared to that in animals resuscitated with shed blood or in animals subjected to a sham operation. The increase in liver uptake was accompanied by a small decrease in spleen uptake in animals resuscitated with Haemaccel but not with HES. No great changes in catabolic activity were seen at 48 h, although activity levels tended to be higher in animals resuscitated with Haemaccel. Separate groups of animals were challenged by an intraperitoneal injection with live Escherichia coli at 1 or 48 h after hemorrhage and resuscitation. Sixty-four percent of the animals resuscitated with shed blood survived the challenge with E. coli at 1 h after hemorrhage, whereas only 10 and 0% survival was seen for animals resuscitated with Haemaccel and HES, respectively. At 48 h survival was 80% for shed-blood-resuscitated animals and 60 and 70% for Haemaccel- and HES-resuscitated animals, respectively.

Animals↗
PubMed1996

Comparison of cardiopulmonary resuscitation techniques using video camera recordings.

OBJECTIVE: To use video recordings to compare the performance of resuscitation teams in relation to their previous training in cardiac resuscitation. METHODS: Over a 10 month period all cardiopulmonary resuscitations carried out in an accident and emergency (A&E) resuscitation room were videotaped. The following variables were monitored: (1) time to perform three defibrillatory shocks; (2) time to give intravenous adrenaline (centrally or peripherally); (3) the numbers and grade of medical and nursing staff involved in the resuscitation; (4) the experience and training of these personnel. RESULTS: Of 101 resuscitations recorded, 69 were carried out by the A&E team alone and 32 by the hospital cardiac arrest team. Resuscitation procedures were carried out significantly more rapidly by the former. Skills and protocols were most effectively used when the resuscitation team was led by an experienced doctor who had received specific training in cardiopulmonary resuscitation, that is, Advanced Life Support course (ALS) or Advanced Cardiac Life Support course (ACLS). Such an individual was always present at A&E team resuscitations but in only 6% of cardiac arrest team resuscitations. CONCLUSIONS: ALS course completion should be regarded as a vital part of the training of any doctor involved in cardiopulmonary resuscitation.

Cardiopulmonary Resuscitation↗
PubMed2005

Functional significance of inflammatory mediators in a murine model of resuscitated hemorrhagic shock.

The mechanisms that underlie the development of myocardial dysfunction after resuscitated hemorrhagic shock (HS) are not known. Recent studies suggest that systemic activation of inflammatory mediators may contribute to cellular dysfunction and/or cell death in various organs, including the heart. However, the precise role that inflammatory mediators play in the heart in the setting of resuscitated HS is not known. Accordingly, the purpose of the present study was to use a well-defined murine model of resuscitated HS to characterize the functional significance of inflammatory mediators in the heart in vivo. Mice were subjected to sham operation or resuscitated HS. Left ventricular (LV) function was assessed by two-dimensional echocardiography 6 h after resuscitation. Myocardial TNF, IL-1beta, and IL-6 proteins were measured 1 and 6 h after resuscitation. To determine the role of TNF in HS-induced LV dysfunction, mice were treated with a soluble TNF receptor antagonist (etanercept) before HS or at the time of resuscitation. LV fractional shortening was significantly depressed (P < 0.05) in resuscitated HS mice (28 +/- 1.5%) compared with sham controls (35.8 +/- 1.0%). TNF and IL-1beta levels were significantly increased (P < 0.05) in resuscitated HS mice. Pretreatment with etanercept abrogated resuscitated HS-induced LV dysfunction, whereas treatment at the time of resuscitation significantly attenuated, but did not abrogate, LV dysfunction. Together, these data suggest that TNF plays a critical upstream role in resuscitated HS-induced LV dysfunction; however, once the deleterious consequences of reperfusion injury are initiated, TNF contributes to, but is not necessary for, the development of LV dysfunction.

Animals↗
PubMed1999

Effect of allopurinol on venous endothelial dysfunction after resuscitated hemorrhagic shock.

BACKGROUND: Blood flow deficits contribute to organ dysfunction in patients resuscitated from hemorrhage. AIM: To determine the contribution of xanthine oxidase mediated reperfusion injury to venous endothelial function after resuscitated hemorrhagic shock. METHODS: Rats were prepared for intravital microscopic study then bled to 50% of baseline blood pressure for 60 min. Treatment animals received a 50mg/kg bolus and a 25mg/kg/h infusion of the xanthine oxidase inhibitor allopurinol (allo) after shock but before resuscitation with shed blood and an equal volume of Ringer's lactate. A similarly resuscitated group (Std) and a non-hemorrhage group (No HS) served as control. Endothelial function was quantified at baseline, 30 min (R30) and 90 min (R90) post resuscitation as a change in mesenteric vessel diameter after topical application of acetylcholine (Ach), an endothelial dependent vasodilator. RESULTS: Resuscitation restored cardiac output and blood pressure in both hemorrhage groups. First order venules (V1) demonstrated a 39% and a 36% reduction in ability to dilate to Ach at R30 and R90 after resuscitation with shed blood and Ringer's lactate (Std). Second order venules (V2) demonstrated a 20% and a 25% reduction in ability to dilate to Ach at R30 and R90 after resuscitation with shed blood and Ringer's lactate (Std). Addition of allopurinol to standard resuscitation attenuated this response resulting in the preservation of endothelial dependent venous vasodilation. CONCLUSIONS: These data suggest that xanthine oxidase mediated ischemia-reperfusion injury contributes to venous endothelial dysfunction in the mesenteric microcirculation after resuscitated hemorrhagic shock. Endothelial function can be preserved by the addition of the xanthine oxidase inhibitor allopurinol to standard resuscitation lending support for its inclusion as an adjunct to resuscitation after hemorrhagic shock.

Allopurinol↗
PubMed1989

End-tidal carbon dioxide monitoring during cardiopulmonary resuscitation. A prognostic indicator for survival.

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

Blood Gas Monitoring, Transcutaneous↗
PubMed1996

The effect of preservation temperature and period on resuscitation of the ischemically damaged canine pancreas during preservation by the two-layer (University of Wisconsin solution/perfluorochemical) method.

We have shown that 24 to 48 hour-preservation by the two-layer (University of Wisconsin solution (UW)/perfluorochemical (PFC)) method at 4 degrees C resuscitates a canine pancreas subjected to 90 min of warm ischemia. However, it is necessary to shorten preservation period for resuscitation of the ischemically damaged pancreas in a clinical simultaneous pancreas-kidney transplantation. The purpose of this study was to clarify the effect of preservation temperature and period on the resuscitation of the ischemically damaged pancreas during preservation by the two-layer method. First of all, we examined the possibility of resuscitation of the ischemically damaged pancreas during short-term preservation by the two-layer method. After 90 minutes of warm ischemia, canine pancreases were preserved by the two-layer method at 4, 20, or 37 degrees C. In control group, the pancreas graft was autotransplanted without preservation. Graft viability was judged by graft survival after autotransplantation. Pancreas grafts subjected to 90 min of warm ischemia were not viable (0/5). At 4 degrees C, 5 to 12 hr-preservation did not resuscitate the grafts (0/3 and 0/3 respectively). At 20 degrees C, 3 and 5 hr-preservation resuscitated the grafts (3/5 and 5/5 respectively), although 1 and 8 hr-preservation were not successful (0/3 and 0/3 respectively). At 37 degrees C, all the grafts were not resuscitated irrespective of preservation period. It was clear that the ischemically damaged pancreas was resuscitated during shot-term preservation by the two-layer method only at 20 degrees C. Secondly, we measured tissue adenine nucleotide levels by high performance liquid chromatography and pancreatic tissue perfusions using H2 clearance technique on reperfusion and examined the viability of vascular endothelium by nuclear trypan blue staining to make clear the necessary conditions for resuscitation of the ischemically damaged pancreas at 20 degrees C. ATP tissue levels in one hr-preserved grafts were 2.55 +/- 0.38 mumol/g dry weight and were significantly lower compared with the levels in 5 and 8 hr-preserved grafts, 9.40 +/- 2.09 (P < 0.01) and 7.37 +/- 1.06 mumol/g dry weight (P < 0.01) respectively. On the other hand, nuclear trypan blue uptakes of endothelial cells in 8 hr-preserved grafts were 37.6 +/- 11.6% and were significantly higher than 1 hr- and 5 hr-preserved grafts 5.6 +/- 4.5 (P < 0.01) and 5.0 +/- 3.0% (P < 0.01) respectively. As a consequence, pancreatic tissue perfusions in 8 hr-preserved grafts, 31.0 +/- 3.5 ml/min/g, were significantly lower than 1 hr- and 5 hr-preserved graft 72.0 +/- 11.6 (P < 0.01), 63.9 +/- 13.3 ml/min/g (P < 0.01) respectively. However, thromboxane A2 synthesis inhibitor (OKY046 0.1 mM/L) decreased the percentage of trypan blue uptake (8.2 +/- 3.6%) without interfering ATP synthesis (8.44 +/- 0.92 mumol/g dry weight) in 8 hr-preserved pancreas and tissue perfusions after reperfusion were dramatically improved (99.6 +/- 11.8 ml/min/g). As a result the ischemically damaged pancreas was resuscitated (4/5, 80%). It was suggested that 1 hr-preservation was not enough to synthesize ATP, which was essential to repair damaged cells, although vascular endothelial cells were maintained. Eight hr-preservation incurs endothelial cell damage although ATP tissue levels were maintained and consequently microcirculation was disturbed at reperfusion but OKY046 protects endothelial cells against preservation/reperfusion injury. As a consequence, the ischemically damaged pancreas was resuscitated. We conclude that short-term (3 to 8 hr) preservation at 20 degrees C by the two-layer method with OKY046 accelerates ATP synthesis, which is essential for repairing damaged cells and protects microvascular endothelial cells. This makes it possible to resuscitate the canine pancreas graft subjected to 90 min warm ischemia. This method holds promise for pancreas-kidney transplantation from cardiac arrest donors.

Animals↗
PubMed1997

Health care professionals' willingness to do mouth-to-mouth resuscitation.

To assess the willingness of physicians and nurses with training in basic cardiac life support to provide mouth-to-mouth resuscitation in both hospital and out-of-hospital settings, we surveyed all attendees at a monthly advanced life support course over a 1-year period. Of 622 attendees, 379 (61%) responded to our survey describing a variety of cardiac arrest scenarios. Less than half of the participants surveyed were willing to do mouth-to-mouth resuscitation on an unknown adult, male or female, who had collapsed in a supermarket. Overall, the group was willing to do mouth-to-mouth resuscitation on victims known to them: their neighbors (84%), children at a pool (88%), spouses (94%), and parents (93%). In the hospital setting, knowing a patient's human immunodeficiency virus (HIV) status greatly influenced the willingness to do mouth-to-mouth rescue. If a patient's HIV status was unknown, only a third of providers would do mouth-to-mouth resuscitation; if the HIV status was known to be negative, two thirds would do mouth-to-mouth resuscitation (P < 0.002), Children in the hospital whose HIV status was unknown would receive mouth-to-mouth resuscitation by 57% of the respondents. Children known to be HIV-negative would be resuscitated by 79% of the respondents. Co-workers were more willing to resuscitate a known physician or nurse than an unknown co-worker, with physicians more willing than nurses to do mouth-to-mouth resuscitation on an unknown co-worker. A third of the group has performed mouth-to-mouth resuscitation previously. Although an increased percentage of this subgroup was willing to provide mouth-to-mouth in all adult hospital scenarios, experienced providers of mouth-to-mouth wanted to receive mouth-to-mouth resuscitation less frequently (75%) than inexperienced providers (84%) (P = 0.02). The self-reported willingness to provide mouth-to-mouth resuscitation is influenced by patient characteristics; as the level of familiarity with the victim decreased, so did the willingness of the health care professional to do mouth-to-mouth.

Adult↗
PubMed1994

Resuscitation in cancer. Comparison of patient and health staff preferences.

One hundred oncology patients from a major teaching hospital and their treating health staff were studied in the second phase of research examining attitudes towards cardiopulmonary resuscitation (CPR). A descriptive approach was used incorporating semistructured interviews of patients and established questionnaire measures, examining knowledge of and attitude towards disease and treatment, psychological functioning, and current and projected attitude toward resuscitation. Health staff also participated in a semistructured interview. This phase of the project focused particularly on a direct comparison of patient and staff assessments. In current circumstances, 10% of patients refused resuscitation. This was associated with disease of good prognosis. In a future hypothetical deteriorated scenario presented to patients, 39% declined resuscitation. This was associated with a past history of suicidal behavior. In current circumstances, health staff designated 14% of patients "Do-Not-Resuscitate" (DNR)--this was associated with a number of variables considered to predict poor outcome in resuscitation. In the future scenario, staff designated 54% of patients DNR--this was associated again with poor resuscitation outcome variables, but also independently, with a past psychiatric history. Comparison of patient and health staff preferences for resuscitation showed moderate yet significant concordance in current circumstances but not in the future scenario. The findings indicate firstly the feasibility of discussing resuscitation preferences with seriously ill patients and secondly an urgent need to improve patient and staff discussions regarding resuscitation, as staff and patients' attitudes to resuscitation differ.

Adult↗