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PubMed2005

Ethical considerations behind the limitation of cardiopulmonary resuscitation in Hungary--the role of education and training.

INTRODUCTION: Although the long term success of cardiopulmonary resuscitation (CPR) is still less than hoped for, its value cannot be questioned when carried out appropriately in selected cases. Resuscitation frequently brings only short-term success, and several patients suffer severe consequences also causing an economic, medical and ethical burden to society. The issue of limitation of resuscitation, including Do Not Attempt Resuscitation (DNAR) and the termination of resuscitation has been surveyed in many European countries using a structured questionnaire. In Hungary no such comprehensive study has been conducted yet. The goal of this investigation was to recognise the ethical factors limiting resuscitation in Hungary. METHODS: We contacted 72 doctors personally during 2003, who were working actively at an intensive care unit (ICU) and asked them to answer a structured questionnaire in strict anonymity. We investigated the role of different ethical issues in beginning and suspending resuscitation efforts in conjunction with medical experience, sex, ideology, and education using a five point visual analogue scale. The answers given were categorised to autonomy, futility, obtainable quality of life, resource utilization, and to "another" category detailed later on. The questionnaire and the plan of this investigation was approved by the Semmelweis Medical University's Ethical Committee (SE-TUKEB 109/2003). RESULTS: The decision not to attempt resuscitation was mostly dictated by the opinion of the head of department and the doctor in charge of the patient (3.53 +/- 1.30), and after this the presumed obtainable quality of life (3.13 +/- 1.40), objective futility (3.11 +/- 0.94), and patient autonomy (2.02 +/- 1.63). The other objective (0.57 +/- 1.59), and subjective (1.04 +/- 1.21) factors, as well as resource utilization (0.29 +/- 0.66) played a less important role. The decision to terminate resuscitation efforts was mostly dictated by the objective futility criteria (3.39 +/- 0.88), obtainable quality of life (3.31 +/- 1.50), subjective futility (3.19 +/- 1.47), and autonomy (1.57 +/- 1.67) to a smaller extent. Among the doctors who participated in an appropriate-an internationally accredited (ERC/RC(UK)/AHA)-Advanced Life Support (ALS) training-the frequency of the appearance of the principle of modern bioethics-such as autonomy-was significantly higher and the same tendency could be observed in those who completed their studies at the medical university in the last 5 years. CONCLUSIONS: The results underline the original presumption that the Hungarian resuscitation practice is at first influenced by professional (or "thought to be professional") standpoints. The quality of life, and patient autonomy plays an important role in the decision making about limitation of resuscitation efforts. Current CPR education emphasizes the importance of ethical considerations, and this could be observed clearly in the answers.

Attitude of Health Personnel↗
PubMed2000

Restoration of body temperature to normothermia during resuscitation following trauma-hemorrhage improves the depressed cardiovascular and hepatocellular functions.

HYPOTHESIS: Rewarming the body to 37 degrees C during resuscitation following trauma-hemorrhage has salutary effects on cardiovascular and hepatocellular functions. DESIGN, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Male rats underwent laparotomy (trauma induced) and were then bled to and maintained at a mean arterial pressure of 40 mm Hg until 40% of the maximum shed blood volume was returned in the form of Ringer lactate solution. Rats were exposed to ambient temperature and allowed to become hypothermic during hemorrhage. The animals were then resuscitated with 4 times the volume of shed blood with Ringer lactate solution for 60 minutes. In 1 group, the body temperature was rewarmed to 37 degrees C during resuscitation. In another group, the body temperature was maintained at hypothermia (32 degrees C) for 4 hours after resuscitation. In an additional group, the body temperature was kept at 37 degrees C during hemorrhage and resuscitation. At 4 hours after resuscitation, the rats were returned to a room with ambient temperature. Various in vivo heart performance variables (maximal rate of pressure increase and decrease), cardiac output, hepatocellular function, and plasma IL-6 level were determined at 24 hours after resuscitation. RESULTS: Either maintenance of normothermia during hemorrhage or prolonged hypothermia following resuscitation had deleterious effects on cardiovascular variables and hepatocellular function and up-regulated plasma IL-6 levels. In contrast, rewarming the body to 37 degrees C during resuscitation improved cardiac contractility, cardiac output, and hepatocellular function and reduced plasma IL-6 level. CONCLUSION: Since rewarming the body temperature to normothermia during resuscitation improved depressed cardiovascular and hepatocellular functions, this should be considered as a useful adjunct to fluid resuscitation after trauma-hemorrhage.

Animals↗
PubMed2004

Changes of tumor necrosis factor-alpha and the effects of ulinastatin injection during cardiopulmonary cerebral resuscitation.

The changes of tumor necrosis factor-alpha (TNF-alpha) and brain ultrastructure during cardiopulmonary resuscitation and the effects of ulinastation injection were observed, and the mechanism was investigated. Twenty-four adult healthy Sprague-Dawley rats were randomly divided into control group (8 rats), resuscitation group (8 rats) and ulinastatin (UTI) group (8 rats). Rats in control group underwent tracheotomy without clipping the trachea to induce circulatory and respiratory standstill. Rats in resuscitation and ulinastatin group were subjected to the procedure of establishing the model of cardiopulmonary cerebral resuscitation (CPCR). Rats in ulinastatin group were given with UTI 104 U/kg once after CPCR. In the control group, the plasma was collected immediate, 30 min, 2 h, 4 h, and 6 h after tracheotomy. In resuscitation group and UTI group, plasma was collected immediate after tracheotomy, 30 min, 2 h, 4 h and 6 h after successful resuscitation. The plasma levels of TNF-alpha were determined by radioimmunoassay (RIA). At the end of the experiment, 2 rats were randomly selected from each group and were decapitated. The cortex of the brain was taken out immediately to observe the ultrastructure changes. In control group, there were no significant differences in the level of TNF-alpha among different time points (P>0.05). In resuscitation group, the level of TNF-alpha was increased obviously after resuscitation (P<0.01) and reached its peak 2 h later after resuscitation. An increasing trend of TNF-alpha showed in UTI group. There were no differences in TNF-alpha among each sample taken after successful resuscitation and that after tracheotomy. The utrastructure of brains showed the injury in UTI group was ameliorated as compared with that in resuscitation group. In early period of CPCR, TNF-alpha was expressed rapidly and kept increasing. It indicated that TNF-alpha might take part in the tissue injury after CPCR. The administration of UTI during CACR could depress TNF-alpha and ameliorate brain injury. By regulating the expression of damaging mediator, UTI might provide a protective effect on the tissue injury after CPCR.

Animals↗
PubMed2002

[Thrombolysis during cardiopulmonary resuscitation].

Between 40 and 90 cardiopulmonary resuscitations are performed per 100,000 inhabitants each year in western industrialised nations. In 50-70% of these patients, either fulminant pulmonary embolism or acute myocardial infarction is the underlying cause of cardiac arrest. Based on this fact, thrombolysis may represent a new and effective causal therapeutic strategy in patients suffering from cardiac arrest due to acute myocardial infarction or fulminant pulmonary embolism. In the past, thrombolysis was contraindicated during cardiopulmonary resuscitation due to great fears of severe bleeding complications (resuscitation-mediated or lysis-induced intracerebral bleeding). For a long time, only clinical case reports or small clinical case series were reported in the literature, however, recently, the first clinical studies focusing on the safety and efficacy of thrombolytic therapy during out-of-hospital cardiopulmonary resuscitation have been published. Besides a specific therapeutic causal effect on pulmonary artery emboli and coronary artery thrombosis, experimental data strongly indicate that thrombolysis might also have an impact on cerebral microcirculatory reperfusion during and after cardiopulmonary resuscitation. This effect might be responsible for the exceptionally good neurological outcome observed in patients treated with thrombolytic agents during cardiopulmonary resuscitation and might be a result of the proven imbalance of the endogenous coagulation system in patients suffering from cardiac arrest. This coagulation imbalance is thought to be responsible for postresuscitation cerebral microcirculatory reperfusion disorders in patients after cardiac arrest and cardiopulmonary resuscitation. In summary, recent clinical and experimental data focusing on thrombolysis during cardiopulmonary resuscitation strongly indicate, that thrombolysis may represent a new and relatively safe therapeutic option during resuscitation after cardiac arrest due to acute myocardial infarction or fulminant pulmonary embolism. If the results of an international randomised, controlled clinical multicentre trial presently underway confirm the previous clinical findings, thrombolysis during cardiopulmonary resuscitation could become an important part of future cardiopulmonary resuscitation algorithms.

Animals↗
PubMed2005

When minutes count--the fallacy of accurate time documentation during in-hospital resuscitation.

UNLABELLED: The purpose of this study is to examine the commonly held assumption that time is measured and documented accurately during resuscitation from cardiac arrest in the hospital. METHODS: A two-pronged approach was used to evaluate the accuracy of time documentation and measurement. First, two existing databases-the National Registry of Cardiopulmonary Resuscitation (NRCPR) and a 240-bed hospital's repository of cardiac arrest records-were evaluated for completeness and accuracy of documentation on resuscitation records of times required for calculating the Utstein gold-standard process intervals-recognition of pulselessness to starting cardiopulmonary resuscitation (CPR), delivery of first defibrillation shock, successful intubation, and epinephrine (adrenaline) administration. Second, nurses from a 900-bed hospital were interviewed to determine timepieces used during resuscitations, and timepieces were assessed for coherence and precision. RESULTS: : From the NRCPR database that included 10,689 pulseless cardiac arrests submitted by 176 hospitals, time data for calculating the Utstein intervals were missing for 10.9% of the interventions; negative intervals were calculated for 4%. From 232 consecutive resuscitation records from the 240-bed hospital, 85 records were identified from non-monitored units with staff who provided only CPR. Defibrillation, intubation and epinephrine administration were delayed until after arrival of advanced life support (ALS) responders; unlikely intervals of 0 min from event recognition to these ALS interventions were calculated for 11.5%. Sixty-seven nurses from the 900-bed hospital were interviewed; when documenting information during resuscitations, 21 (31.3%) reported using only patient room clocks, 30 (44.8%) only their watches, and 16 (23.9%) several timepieces. In all in-patient units in the same hospital, 241 timepieces (nurses' and physicians' watches, clocks in patient rooms, defibrillator clocks, central station monitors, and nursing station clocks) were compared to atomic time. The mean absolute time difference from atomic clock was 2.83 min (S.D. +/-5.9 min), median 1.88 min, and range 52.1 min slow to 72.85 min fast. There was no difference among timepieces (P = 0.35). CONCLUSIONS: Missing time data, negative calculated Utstein gold-standard process intervals, unlikely intervals of 0 min from arrest recognition to ALS interventions in units with CPR providers only, use of multiple timepieces for recording time data during the same event, and wide variation in coherence and precision of timepieces bring into question the ability to use time intervals to evaluate resuscitation practice in the hospital. Practitioners, researchers and manufacturers of resuscitation equipment must come together to create a method to collect and document accurately essential resuscitation time elements. Our ability to enhance the resuscitation process and improve patient outcomes requires that this be done.

Documentation↗
PubMed1983

Resuscitation time in ventricular fibrillation--a prognostic indicator.

Length of resuscitation in prehospital ventricular fibrillation patients was studied to define its relationship to survival. Five hundred sixty-five patients presenting with the initial rhythm of ventricular fibrillation to the Milwaukee County Paramedic System between January 1978 and April 1982 were resuscitated successfully. Pediatric patients and patients with trauma, poisoning, and drowning were excluded. Of the 565 resuscitated patients, 262 (46%) were discharged alive and 303 (54%) died during hospitalization. For all 565 patients the resuscitation time and times from arrival of paramedics until the first sustained pulse were plotted against survival to define a curve. The curve demonstrated rapidly declining survival rates for resuscitation time up to 20 minutes; thereafter, survival declined more gradually with respect to resuscitation time. The mean resuscitation time for those eventually discharged alive was 12.6 minutes, which was statistically shorter (P less than .0001) than the mean resuscitation time of 23.9 minutes for those who eventually died. The overall survival curve of witnessed arrest patients was not statistically different from that of unwitnessed patients. The survival curve of those patients receiving bystander cardiopulmonary resuscitation (CPR) was similar to the curve of those who received no CPR. We conclude that resuscitation time is a heretofore undefined significant predictor of survival of resuscitated prehospital ventricular fibrillation patients.

Aged↗
PubMed2000

Cardiopulmonary resuscitation skills in nurses and nursing students.

The purpose of this study is to describe the basic cardiac life-support (BLS) skills of nurses and nursing students in southern Finland and Hungary, and to assess the influence of resuscitation teaching and other group characteristics on performance. The data for the study were collected in the spring and autumn of 1997. The study group consisted of 75 nurses from Helsinki University Central Hospital's medical outcome unit, 188 final term students in four nursing institutes in Uusimaa county and 35 final term students in a Hungarian institute of nursing. A total of 298 people (34 men and 264 women) participated in the study. Background information was collected using a structured questionnaire devised specifically for this study. Resuscitation skills were measured using the Skillmeter Anne manikin. The manikin was placed supine during the test. After completing the questionnaire, every participant attempted resuscitation on the manikin - which was supplied with a printer - for 4 min. The results were printed out and attached to the questionnaires. The data were analysed using two-way frequency tables and logistic regression. Statistical differences were calculated using the chi(2)-test. The results showed that 53% of the participants had studied resuscitation during the last 6 months, but 7% had never participated in resuscitation teaching. Before testing, 55% of the participants estimated that their resuscitation skills were good. The results showed that 36% first assessed the patient's response, 67% opened the airway but only 3% determined pulselessness before starting to resuscitate. Twenty-one percent of the participants compressed correctly for at least half of the test and 33% ventilated correctly at least half of the time. Logistic regression showed that the best predictors for good response assessment skills went to those who were nursing students who had studied resuscitation skills sometime during the previous 6 months. The best predictor of the skill to open the airway was a positive attitude towards personal cardiopulmonary resuscitation (CPR) skills, i.e. self-confidence. The predictor for adequate skills in artificial ventilation was that they belonged in the group of nursing students who had benefited from recent resuscitation training (<6 months). In conclusion, the skills of the participants of the study can not be considered adequate in terms of an adequate and prompt assessment of the need for resuscitation, and a 50% success rate in artificial ventilation and chest compression.

Adult↗
PubMed2001

Continuous resuscitation after hemorrhage and acute fluid replacement improves cardiovascular responses.

BACKGROUND: Although acute fluid replacement after trauma and severe hemorrhage remains the cornerstone in the management of trauma victims, it remains unknown whether continuous resuscitation after trauma-hemorrhage and acute fluid replacement produces salutary effects on cardiovascular function and reduces proinflammatory cytokine release. METHODS: Adult male rats underwent laparotomy (ie, soft tissue trauma) and were bled to and maintained at a mean arterial pressure of 40 mm Hg until 40% of the shed blood volume was returned in the form of Ringer's lactate (RL). The animals were then resuscitated with 4 times the volume of shed blood with RL for 60 minutes, followed by continuous resuscitation with RL at 5 mL/h/kg for 48 hours after the acute fluid replacement. At 48 hours after hemorrhage, mean arterial pressure, cardiac output, and left ventricular contractility parameters, such as the maximal rates of ventricular pressure increase (+dP/dt(max)) and decrease (-dP/dt(max)), were determined. Microvascular blood flow in the intestine and kidney was assessed by laser Doppler flowmetry. In addition, plasma levels of TNF-alpha were assayed by enzyme-linked immunosorbent assay. RESULTS: The mean arterial pressure and cardiac output were decreased by 34% and 18%, respectively, at 48 hours after hemorrhage and acute resuscitation. Continuous resuscitation, however, markedly improved these parameters. Similarly, +dP/dt(max) and -dP/dt(max) decreased significantly after hemorrhage and acute fluid replacement but was restored to sham values after continuous resuscitation. Microvascular blood flow in the gut and kidneys was decreased after hemorrhage and acute resuscitation by 34% and 35%, respectively. However, intestinal and renal perfusion was maintained at the sham levels at 48 hours after continuous resuscitation. In addition, the upregulated TNF-alpha after acute resuscitation alone was reduced after continuous resuscitation. CONCLUSIONS: Continuous resuscitation after acute fluid replacement appears to be a useful approach for restoring and maintaining cardiovascular function and organ perfusion after trauma and severe hemorrhage.

Acute Disease↗
PubMed2001

Effect of methylene blue on resuscitation after haemorrhagic shock.

OBJECTIVE: To compare prehospital hypotensive resuscitation with volume resuscitation, and find out whether reagents that inhibit free-oxygen radical formation, such as methylene blue, can improve resuscitation and survival. DESIGN: Randomised controlled trial. SETTING: Animal laboratory, Israel. ANIMALS: 48 adult male Wistar rats. INTERVENTIONS: After 30 minutes of controlled haemorrhage, rats were subjected to 60 minutes of uncontrolled haemorrhage with simultaneous resuscitation. Hartmann's solution alone, or with blood or with a bolus of methylene blue were infused to maintain the mean arterial pressure (MAP) at 80 or 40 mm Hg. Then haemorrhage was stopped and Hartmann's solution plus whole blood were infused to obtain a MAP that was within normal limits. MAIN OUTCOME MEASURES: Volumes of shed blood and resuscitation fluids, MAP, packed cell volume, blood pH and base deficit, and survival. RESULTS: During uncontrolled haemorrhage. a MAP of 80 mm Hg could not be reached in animals resuscitated with Hartmann's solution alone, and all died. All the rats given Hartmann's solution with a bolus of methylene blue or with whole blood achieved a higher MAP. MAP of 40 mm Hg was attained in all animals regardless of the resuscitation fluid. Only 15 of 24 animals resuscitated to a MAP of 80 mm Hg survived, compared with 22 survivors of the 24 rats resuscitated to a MAP of 40 mm Hg (p <0.04). Methylene blue or whole blood drastically reduced the volumes of shed blood and of fluids required, and moderated the reduction in packed cell volume, particularly during hypotensive resuscitation. CONCLUSION: Hypotensive protocols should be used to improve survival. Methylene blue given with the electrolyte solutions could negate their detrimental effects during resuscitation.

Analysis of Variance↗
PubMed2004

Temporal effect of hemoglobin resuscitation on sepsis survival.

Hemoglobin (Hb)-based oxygen carriers are promising resuscitation fluids for hemorrhagic shock. However, infusion of large amounts of Hb-based material could interfere with reticuloendothelial function potentiating postresuscitation sepsis mortality. We investigated the temporal relationship between hemorrhage-resuscitation and sepsis survival. Male SD rats were subjected to hemorrhage and resuscitated with shed blood volumes of purified human hemoglobin solution (HS). Sepsis was induced by cecal ligation and puncture (CLP) 24 h before, 0, 24, or 72 h after hemorrhage/resuscitation (H/R) and survival was monitored. In additional animals with or without Hb resuscitation, hepatic heme oxygenase-1 (HO-1) gene expression and HO activity were assessed. Seven-day survival for animals resuscitated with HS prior to sepsis induction was significantly higher than other groups. Animals resuscitated with HS showed hepatic HO-1 gene expression while non-HS resuscitated animals did not. In addition, hepatic HO activity levels were significantly higher in HS resuscitated animals than non-HS resuscitated animals. In conclusion, HS resuscitation does not appear to enhance postresuscitation sepsis mortality. Rather, when conducted concomitantly or prior to sepsis, HS resuscitation appears to improve survival from a subsequent sepsis challenge.

Animals↗
PubMed1996

Liver function and morphology after resuscitation from severe hemorrhagic shock with hemoglobin solutions or autologous blood.

OBJECTIVE: To test the effects of three hemoglobin solutions on liver function and hepatic morphology after resuscitation from severe hemorrhagic shock. DESIGN: Prospective study. SETTING: Laboratory. SUBJECTS: Thirty-three beagle dogs. INTERVENTION: Hemorrhagic shock was induced in anesthetized dogs by removal of blood at a rate of 2 mL/kg/min until systolic blood pressure (BP) reached 50 mm Hg. BP was maintained at this level 2 hrs by further withdrawing 5 to 10 mL aliquots whenever BP increased > 50 mm Hg. Resuscitation was then initiated with autologous whole blood (n = 7), 4% pyridoxalated-hemoglobin-polyoxyethylene conjugate (4% PHP [n = 6]), 8% pyridoxalated-hemoglobin-polyoxyethylene conjugate (8% PHP [n = 9], or 8% stroma-free hemoglobin (n = 7). Four dogs were managed identically but were not resuscitated. Gross necropsy and histologic examination of the liver were performed on all dogs after 7 days, or earlier if death occurred. MEASUREMENTS AND MAIN RESULTS: In vitro interferences of PHP and stroma-free hemoglobin with liver function tests were determined and recommendations for interpretation of results from blood samples containing PHP and stroma-free hemoglobin were made. Blood was collected before, during, and after resuscitation from hemorrhagic shock. The dogs were then awakened and survivors were monitored daily with blood sampling until they were killed and necropsy was performed. After 7 days, the survival rate following hemorrhagic shock was 100% for whole blood and 4% PHP, 86% for stroma-free hemoglobin, and 33% for 8% PHP. Of the resuscitated dogs not surviving 7 days, all but one died within 27 hrs from coagulopathy. All dogs not resuscitated died within 1.75 hrs after 2 hrs of shock. Bilirubin, alkaline phosphatase, and lactic dehydrogenase concentrations could not be measured due to interferences of stroma-free hemoglobin and PHP. Aspartate (AST) and alanine (ALT) aminotransferase concentrations could be measured after dilution to overcome the interferences. Significant increases in AST and ALT values in all groups 24 hrs after resuscitation were attributed to hypoxic hepatocellular damage associated with the severity of the shock model rather than to the resuscitation fluid. Liver histology showed no changes attributed to toxic damage of hepatocytes in dogs resuscitated with stroma-free hemoglobin or PHP. However, changes, were less severe in dogs resuscitated with 4% PHP than in other groups. CONCLUSION: Morphologic studies at necropsy and liver function tests in dogs receiving hemoglobin solutions, compared with autologous blood, support the conclusion that the PHP and stroma-free hemoglobin solutions tested did not produce hepatic toxicity when used as resuscitation fluids in this model of severe shock.

Acute Disease↗
PubMed1988

NMR monitoring of phosphate metabolism of rat skeletal muscle during hemorrhage and resuscitation.

Phosphorus nuclear magnetic resonance (NMR) spectroscopy allows noninvasive monitoring of intracellular high-energy metabolites. In the present study we used topical NMR to monitor intracellular levels of ATP, creatine phosphate (CrP), inorganic phosphate (Pi), and pH in the biceps femoris muscle of rats during hemorrhagic shock and resuscitation. Twelve rats weighing 300-500 gm were anesthetized and bled to a mean arterial pressure (MAP) of 50-55 mm Hg for 90 minutes. Then they were resuscitated with lactated Ringers' until MAP returned to normal or resuscitation fluid equaled four times the shed blood volume. During resuscitation, the rats fell into one of two groups: survivor group (n = 5) which could be successfully resuscitated for 60 minutes or longer; or nonsurvivor group (n = 7) which died during resuscitation. In both groups, ATP levels were maintained during hemorrhage and resuscitation. Intramuscular pH dropped about 0.2 pH units in both groups at the end of hemorrhage; however, pH was restored back toward baseline in the survivor group. CrP levels were lower in the nonsurvivor group at the end of hemorrhage. After resuscitation, CrP returned to nearly baseline levels in the survivor group; in the nonsurvivor group, CrP was further depleted after resuscitation. Pi levels were increased in both groups at the end of hemorrhage, but in the survivor group Pi decreased during the first 15 minutes of resuscitation; in the nonsurvivor group Pi increased further to four times baseline levels. This study demonstrated that topical NMR can quantitate a metabolic deficit in skeletal muscle during hemorrhage and resuscitation. The results show that improvement of intracellular Pi and CrP levels correlated with survival.

Adenosine Triphosphate↗
PubMed2003

Hypertonic saline resuscitation limits neutrophil activation after trauma-hemorrhagic shock.

There is evidence suggesting that the ischemic gut is a major source of factors that lead to neutrophil activation, and that neutrophil activation can be reduced by hypertonic saline resuscitation. Thus, we tested whether trauma-hemorrhagic shock-induced neutrophil activation can be reduced by hypertonic saline resuscitation, as well as whether hypertonic saline reduces the ability of mesenteric lymph from shocked animals to activate neutrophils. Male Sprague-Dawley rats subjected to trauma (laparotomy), plus 90 min of shock [mean arterial pressure (MAP) MAP = 30 mmHg] or sham shock were resuscitated with Ringer's lactate or 7.5% hypertonic saline at an equivalent sodium load. Whole blood samples were collected before shock as well as at 1 and 2 h after the end of the shock period for neutrophil CD11b and CD18 expression measurements. In a second set of experiments, mesenteric lymph samples collected from rats subjected to trauma plus hemorrhagic shock (T/HS) or trauma plus sham-shock (T/SS) and resuscitated with Ringer's lactate or hypertonic saline were tested for their ability to modulate PMN CD11b, CD18, or L-selectin expression, as well as prime PMN for an augmented respiratory burst. To avoid confounding results due to interspecies differences, while at the same time looking at potential human responses, both naive rat and human PMN were tested. Both CD11b and CD18 expression were increased in PMN harvested from rats subjected to T/HS and resuscitated with Ringer's lactate solution, but not in T/HS rats resuscitated with hypertonic saline. These results indicate that PMN activation is increased to a greater extent in Ringer's lactate-resuscitated than hypertonic saline-resuscitated animals. Likewise, mesenteric lymph from the T/HS rats resuscitated with Ringer's lactate increased naive rat and human PMN CD11b and CD18 expression to a greater extent than did T/HS lymph from the hypertonic saline-treated rats. Additionally, T/HS lymph from the Ringer's lactate- but not the hypertonic saline-treated rats induced PMN L-selectin shedding. Lastly, T/HS lymph from the Ringer's lactate-treated rats induced the greatest PMN respiratory burst. These results indicate that resuscitation from T/HS with hypertonic saline is associated with less PMN activation than resuscitation with Ringer's lactate, and that factors produced or released by the postischemic intestine and carried in the mesenteric lymph contribute to neutrophil activation after an episode of T/HS.

Animals↗
PubMed2004

The effect of different volumes of fluid resuscitation on traumatic-hemorrhagic shock at high altitude in the unacclimated rat.

The effects of different volumes of fluid resuscitation on traumatic hemorrhagic shock in unacclimated rats to high altitude were investigated. Seventy-eight Wistar rats were transported to LaSa, Tibet, 3760 meters above sea level, and traumatic hemorrhagic shock was induced by right-femur fracture plus bleeding to 45 mmHg of mean arterial pressure (MAP) for 1 h under the anesthesia of sodium pentobarbital (40 mg/kg, i.p.). Experiments were conducted in two series. In series I, 36 rats were equally divided into six groups: sham-operated, untreated (traumatic shock without fluid infusion), and with lactated Ringer's resuscitation (LR) of 1.0, 1.5, 2.0 or 3.0 times the shed blood (1, 1.5, 2, 3 vol LR group). MAP, left intraventricular systolic pressure, the maximal change rate of intraventricular pressure rise or decline (+/-dp/dtmax), the maximal physiological velocity of contractile element shortening, and the area of left intraventricular pressure-dp/dt vector loop (Lo) were observed at 30, 60, 90, and 120 min and the blood gases were determined at 30 and 120 min after resuscitation. Meanwhile the survival time was observed after the observation period. In series II, 42 rats were used to observe the effects of different volumes of fluid resuscitation on water content of lung and brain and hematocrit. One and 1.5 vol LR resuscitation significantly lifted MAP, left intraventricular systolic pressure, +dp/dtmax, and Lo, partially improved the blood gases and significantly prolonged the survival time. Although 2 and 3 vol of LR resuscitation caused apparent hemodilution and lung edema, they only partially improved hemodynamic parameters. Meanwhile 2 and 3 vol of LR resuscitation decreased the survival time. These results suggest that 1 and 1.5 vol of LR resuscitation can effectively resuscitate traumatic hemorrhagic shock at high altitude. More than two volumes of LR resuscitation would deteriorate the resuscitation outcome.

Altitude↗
PubMed2003

Tissue oxygen monitoring during hemorrhagic shock and resuscitation: a comparison of lactated Ringer's solution, hypertonic saline dextran, and HBOC-201.

BACKGROUND: The ideal resuscitation fluid for the trauma patient would be readily available to prehospital personnel, universally compatible, effective when given in small volumes, and capable of reversing tissue hypoxia in critical organ beds. Recently developed hemoglobin-based oxygen-carrying solutions possess many of these properties, but their ability to restore tissue oxygen after hemorrhagic shock has not been established. We postulated that a small-volume resuscitation with HBOC-201 (Biopure) would be more effective than either lactated Ringer's (LR) solution or hypertonic saline dextran (HSD) in restoring baseline tissue oxygen tension levels in selected tissue beds after hemorrhagic shock. We further hypothesized that changes in tissue oxygen tension measurements in the deltoid muscle would reflect the changes seen in the liver and could thus be used as a monitor of splanchnic resuscitation. METHODS: This study was a prospective, blinded, randomized resuscitation protocol using anesthetized swine (n = 30), and was modeled to approximate an urban prehospital clinical time course. After instrumentation and splenectomy, polarographic tissue oxygen probes were placed into the liver (liver PO2) and deltoid muscle (muscle PO2) for continuous tissue oxygen monitoring. Swine were hemorrhaged to a mean arterial pressure (MAP) of 40 mm Hg over 20 minutes, shock was maintained for another 20 minutes, and then 100% oxygen was administered. Animals were then randomized to receive one of three solutions: LR (12 mL/kg), HSD (4 mL/kg), or HBOC-201 (6 mL/kg). Physiologic variables were monitored continuously during all phases of the experiment and for 2 hours postresuscitation. RESULTS: At a MAP of 40 mm Hg, tissue PO2 was 20 mm Hg or less in both the liver and muscle beds. There were no significant differences in measured liver or muscle PO2 values after resuscitation with any of the three solutions in this model of hemorrhagic shock. When comparing the hemodynamic effects of resuscitation, the cardiac output was increased from shock values in all three animal groups with resuscitation, but was significantly higher in the animals resuscitated with HSD. Similarly, MAP was increased by all solutions during resuscitation, but remained significantly below baseline except in the group of animals receiving HBOC-201 (p < 0.01). HBOC-201 was most effective in both restoring and sustaining MAP and systolic blood pressure. There was excellent correlation between liver and deltoid muscle tissue oxygen values (r = 0.8, p < 0.0001). CONCLUSION: HBOC-201 can be administered safely in small doses and compared favorably to resuscitation with HSD and LR solution in this prehospital model of hemorrhagic shock. HBOC-201 is significantly more effective than HSD and LR solution in restoring MAP and systolic blood pressure to normal values. Deltoid muscle PO2 reflects liver PO2 and thus may serve as an index of the adequacy of resuscitation in critical tissue beds.

Animals↗
PubMed2005

Nurses' knowledge and skill retention following cardiopulmonary resuscitation training: a review of the literature.

AIM: This paper reports a literature review examining factors that enhance retention of knowledge and skills during and after resuscitation training, in order to identify educational strategies that will optimize survival for victims of cardiopulmonary arrest. BACKGROUND: Poor knowledge and skill retention following cardiopulmonary resuscitation training for nursing and medical staff has been documented over the past 20 years. Cardiopulmonary resuscitation training is mandatory for nursing staff and is important as nurses often discover the victims of in-hospital cardiac arrest. Many different methods of improving this retention have been devised and evaluated. However, the content and style of this training lack standardization. METHOD: A literature review was undertaken using the Cumulative Index to Nursing and Allied Health Literature, MEDLINE and British Nursing Index databases and the keywords 'cardiopulmonary resuscitation', 'basic life support', 'advanced life support' and 'training'. Papers published between 1992 and 2002 were obtained and their reference lists scrutinized to identify secondary references, of these the ones published within the same 10-year period were also included. Those published in the English language that identified strategies to enhance the acquisition or retention of Cardiopulmonary resuscitation skills and knowledge were included in the review. RESULTS: One hundred and five primary and 157 secondary references were identified. Of these, 24 met the criteria and were included in the final literature sample. Four studies were found pertaining to cardiac arrest simulation, three to peer tuition, four to video self-instruction, three to the use of different resuscitation guidelines, three to computer-based learning programmes, two to voice-activated manikins, two to automated external defibrillators, one to self-instruction, one to gaming and the one to the use of action cards. CONCLUSIONS: Resuscitation training should be based on in-hospital scenarios and current evidence-based guidelines, including recognition of sick patients, and should be taught using simulations of a variety of cardiac arrest scenarios. This will ensure that the training reflects the potential situations that nurses may face in practice. Nurses in clinical areas, who rarely see cardiac arrests, should receive automated external defibrillation training and have access to defibrillators to prevent delays in resuscitation. Staff should be formally assessed using a manikin with a feedback mechanism or an expert instructor to ensure that chest compressions and ventilations are adequate at the time of training. Remedial training must be provided as often as required. Resuscitation training equipment should be made available at ward/unit level to allow self-study and practice to prevent deterioration between updates. Video self-instruction has been shown to improve competence in resuscitation. An in-hospital scenario-based video should be devised and tested to assess the efficacy of this medium in resuscitation training for nurses.

Cardiopulmonary Resuscitation↗
PubMed1991

Survey of "do not resuscitate" orders in a district general hospital.

OBJECTIVE: To evaluate the local use of written "Do not resuscitate" orders to designate inpatients unsuitable for cardiopulmonary resuscitation in the event of cardiac arrest. DESIGN: Point prevalence questionnaire survey of inpatients' medical and nursing records. SETTING: 10 acute medical and six acute surgical wards of a district general hospital. PARTICIPANTS: Questionnaires were filled in anonymously by nurses and doctors working on the wards surveyed. MAIN OUTCOME MEASURES: Responses to questionnaire items concerning details about each patient, written orders not to resuscitate in the medical case notes and nursing records, whether prognosis had been discussed with patients' relatives, whether a "crash call" was perceived as appropriate for each patient, and whether the "crash team" would be called in the event of arrest. RESULTS: Information was obtained on 297 (93.7%) of 317 eligible patients. Prognosis had been discussed with the relatives of 32 of 88 patients perceived by doctors as unsuitable for resuscitation. Of these 88 patients, 24 had orders not to resuscitate in their medical notes, and only eight of these had similar orders in their nursing notes. CONCLUSIONS: In the absence of guidelines on decisions about resuscitation, orders not to resuscitate are rarely included in the notes of patients for whom cardiopulmonary resuscitation is thought to be inappropriate. Elective decisions not to resuscitate are not effectively communicated to nurses. There should be more discussion of patients' suitability for resuscitation between doctors, nurses, patients, and patients' relatives. Suitability for resuscitation should be reviewed on every consultant ward round.

Age Factors↗
PubMed1995

Active decompression improves the haemodynamic state during cardiopulmonary resuscitation.

OBJECTIVE: To examine whether use of the active compression-decompression device improves the haemodynamics of cardiopulmonary resuscitation compared with those of conventional cardiopulmonary resuscitation. DESIGN: Prospective crossover study. SETTING: The accident and emergency department of a university teaching hospital. PATIENTS: 36 adult patients with non-traumatic, normothermic, out of hospital cardiac arrest. INTERVENTIONS: Cardiopulmonary resuscitation was performed during resuscitation in alternating 3 min cycles of conventional and active compression-decompression cardiopulmonary resuscitation. MAIN OUTCOME MEASURES: The end tidal carbon dioxide (ETCO2), femoral arterial pressure, and acid-base analysis of central venous blood measured during the last 30 s of each 3 minute cardiopulmonary resuscitation cycle. RESULTS: ETCO2 was monitored in 36 patients during conventional and active compression-decompression cardiopulmonary resuscitation. Active compression-decompression cardiopulmonary resuscitation caused a significant increase in ETCO2 (P < 0.0002), indicating improved cardiac output. Arterial pressure measurement was carried out in 10 patients. Systolic pressure was significantly greater with active compression-decompression than conventional cardiopulmonary resuscitation (P < 0.007). Central venous blood was taken for acid-base analysis in 11 patients. There was a significant increase in the central venous hydrogen ion concentration (P = 0.025) with rises in the partial pressures of carbon dioxide and oxygen, suggesting improved venous return. CONCLUSIONS: This study confirms that active compression-decompression cardiopulmonary resuscitation is associated with better haemodynamic status than conventional resuscitation.

Acid-Base Equilibrium↗