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PubMed2005

Dedicated neonatal retrieval teams improve delivery room resuscitation of outborn premature infants.

BACKGROUND: Morbidity related to ineffective resuscitation and stabilization of premature infants is increased when delivery occurs outside tertiary perinatal centers. The regional neonatal transport team received extensive training to expand their scope of practice to include delivery room resuscitation allowing them to attend high-risk deliveries in community hospitals when maternal transfer was not possible. OBJECTIVE: Compare the resuscitation and stabilization of premature infants when a specialized neonatal retrieval team (SNRT) is in attendance at delivery with immediate resuscitation and stabilization performed by the referral hospital team (RHT). STUDY DESIGN: We assessed the impact of a specially trained neonatal transport team by comparing the initial resuscitation process, airway and vascular access skills, illness severity and patient stabilization in both groups. RESULTS: Neonates resuscitated by the RHT were more likely to receive oxygen, mask CPAP, bag and mask ventilation and cardiac compressions for a significantly longer time period. Neonates resuscitated by the SNRT were intubated more promptly (8.5 minutes {1 to 22} vs 16 minutes {1 to 90}, p=0.035) following a fewer number of attempts. The endotracheal tube was correctly positioned on radiological assessment in 72% of cases in the SNRT group vs 38.1% in the RHT group (p<0.001). Many neonates had no vascular access (31%) and were profoundly hypothermic (38.5%) on arrival of the SNRT. Although there was no significant difference in maximum FiO(2) or oxygenation index, babies with respiratory distress syndrome resuscitated by the RHT were less likely to receive surfactant therapy (76.6 vs 34.4%, p=0.001). There was no difference in transport-related mortality between the groups CONCLUSIONS: The presence of a highly skilled transport team at a high-risk preterm delivery improves the quality of neonatal resuscitation by increasing intubation success rates and achieving earlier vascular access. Neonates resuscitated by dedicated neonatal retrieval teams were less likely to become significantly hypothermic. Although the severity of RDS was similar neonates in the RHT were less likely to receive surfactant.

Analysis of Variance↗
PubMed2000

Attitudes of neonatal clinicians towards resuscitation of the extremely premature infant: an exploratory survey.

OBJECTIVE: This study aims to explore the current attitudes of Australian neonatologists and nurses towards the resuscitation of extremely preterm infants. METHODOLOGY: An anonymous questionnaire regarding resuscitation of infants of less than 28 weeks gestation was sent to all neonatologists and three registered nurses in each perinatal centre in Australia. RESULTS: One hundred and thirty-three questionnaires were sent. A return rate of 93% and 73% was obtained from neonatologists and nurses, respectively. Twenty-two per cent of neonatologists would 'occasionally' resuscitate at 22 weeks while none of the nurses would. A considerable proportion of neonatologists (23%) but only a few nurses (6%) would 'quite often' resuscitate 23-week infants. The majority of neonatologists (85%) and nurses (88%) would 'almost always' resuscitate 24 week infants. More than half of the respondents would 'occasionally' resuscitate a 400-499 g infant and most would resuscitate infants weighing more than 500 g. Clinicians were not as optimistic of long-term outcome as they were for survival. Typically, only 52% of neonatologists and 38% of nurses thought babies of 25 weeks gestation had a greater than 50% chance of survival without major handicap. Parental wishes and the presence of congenital abnormalities were major influences on decision to resuscitate. Hypothetically, most respondents, more doctors than nurses, would consider initiating resuscitation without parental consent at a median gestation of 25 weeks. CONCLUSIONS: The majority of Australian clinicians would resuscitate at a gestation of 24 weeks or greater or at a birth weight of over 500 g despite conservative estimates of intact survival. This survey has brought to light the importance of communication with parents prior to extreme premature birth.

Attitude↗
PubMed1991

Unsuccessful emergency medical resuscitation--are continued efforts in the emergency department justified?

BACKGROUND: The majority of attempts to resuscitate victims of prehospital cardiopulmonary arrest are unsuccessful, and patients are frequently transported to the emergency department for further resuscitation efforts. We evaluated the efficacy and costs of continued hospital resuscitation for patients in whom resuscitation efforts outside the hospital have failed. METHODS: We reviewed the records of 185 patients presenting to our emergency department after an initially unsuccessful, but ongoing, resuscitation for a prehospital arrest (cardiac, respiratory, or both) by an emergency medical team. Prehospital and hospital characteristics of treatment for the arrest were identified, and the patients' outcomes in the emergency room were ascertained. The hospital course and the hospital costs for the patients who were revived were determined. RESULTS: Over a 19-month period, only 16 of the 185 patients (9 percent) were successfully resuscitated in the emergency department and admitted to the hospital. A shorter duration of prehospital resuscitation was the only characteristic of the resuscitation associated with an improved outcome in the emergency department. No patient survived until hospital discharge, and all but one were comatose throughout hospitalization. The mean stay in the hospital was 12.6 days (range, 1 to 132), with an average of 2.3 days (range, 1 to 11) in an intensive care unit. The total hospital cost for the 16 patients admitted was $180,908 (range per patient, $1,984 to $95,144). CONCLUSIONS: In general, continued resuscitation efforts in the emergency department for victims of cardiopulmonary arrest in whom prehospital resuscitation has failed are not worthwhile, and they consume precious institutional and economic resources without gain.

Cardiopulmonary Resuscitation↗
PubMed2003

Family presence during cardiopulmonary resuscitation and invasive procedures: practices of critical care and emergency nurses.

BACKGROUND: Increasingly, patients' families are remaining with them during cardiopulmonary resuscitation and invasive procedures, but this practice remains controversial and little is known about the practices of critical care and emergency nurses related to family presence. OBJECTIVE: To identify the policies, preferences, and practices of critical care and emergency nurses for having patients' families present during resuscitation and invasive procedures. METHODS: A 30-item survey was mailed to a random sample of 1500 members of the American Association Of Critical-Care Nurses and 1500 members of the Emergency Nurses Association. RESULTS: Among the 984 respondents, 5% worked on units with written policies allowing family presence during both resuscitation and invasive procedures and 45% and 51%, respectively, worked on units that allowed it without written policies during resuscitation or during invasive procedures. Some respondents preferred written policies allowing family presence (37% for resuscitation, 35% for invasive procedures), whereas others preferred unwritten policies allowing it (39% for resuscitation, 41% for invasive procedures). Many respondents had taken family members to the bedside (36% for resuscitation, 44% for invasive procedures) or would do so in the future (21% for resuscitation, 18% for invasive procedures), and family members often asked to be present (31% for resuscitation, 61% for invasive procedures). CONCLUSIONS: Nearly all respondents have no written policies for family presence yet most have done (or would do) it, prefer it be allowed, and are confronted with requests from family members to be present. Written policies or guidelines for family presence during resuscitation and invasive procedures are recommended.

Adult↗
PubMed2003

Hypertonic resuscitation of hemorrhagic shock upregulates the anti-inflammatory response by alveolar macrophages.

BACKGROUND: Resuscitated hemorrhagic shock predisposes patients to the development of acute respiratory distress syndrome (ARDS). Hypertonic saline (HTS) has been shown to inhibit immune cell activation in response to lipopolysaccharide (LPS) in vitro and to reduce lung damage when used for resuscitation of hemorrhagic shock in vivo. We hypothesize that HTS resuscitation of hemorrhagic shock may exert this anti-inflammatory effect by modulating alveolar macrophage function leading to an altered balance between the proinflammatory and the counter-inflammatory response. METHODS: A 2-hit rat model of shock resuscitation was used. Alveolar macrophages were harvested by bronchoalveolar lavage (BAL), and tumor necrosis factor (TNF)-alpha and interleukin (IL)-10 were quantified in the cell culture supernatants by enzyme-linked immunosorbent assay (ELISA). Alternatively, 1 hour after resuscitation, animals received endotracheal LPS followed by endotracheal anti-IL-10 neutralizing antibody. Lung injury was determined by measuring BAL neutrophil counts 4 hours after LPS in vivo administration. RESULTS: Systemic administration of HTS significantly modulates the responsiveness of alveolar macrophages. Specifically, HTS resuscitation inhibited LPS-induced TNF-alpha production while enhancing IL-10 release in response to LPS administered ex vivo and in vivo. Anti-IL-10 antibody in vivo partially reversed the lung protective effect of HTS resuscitation. CONCLUSIONS: HTS resuscitation exerts an immunomodulatory effect on alveolar macrophages by shifting the balance of pro- and counter-inflammatory cytokine production in favor of an anti-inflammatory response. The in vivo data suggest a causal role for HTS-induced augmented IL-10 as protective. These findings suggest a novel mechanism for the in vivo salutary effect of HTS resuscitation on lung injury after resuscitated hemorrhagic shock.

Animals↗
PubMedDate not supplied

Termination of resuscitation in the prehospital setting for adult patients suffering nontraumatic cardiac arrest. National Association of EMS Physicians Standards and Clinical Practice Committee.

The National Association of EMS Physicians (NAEMSP) supports out-of-hospital termination of resuscitation for adult, nontraumatic cardiac arrest patients who have not responded to full resuscitative efforts. The following factors should be considered in establishing termination of resuscitation protocols: 1) Termination of resuscitation may be considered for any adult patient who suffers sudden cardiac death that is likely to be medical. 2) Unwitnessed cardiac arrest with delayed initiation of cardiopulmonary resuscitation (CPR) beyond 6 minutes and delayed defibrillation beyond 8 minutes has a poor prognosis. 3) In the absence of "do not resuscitate" or advanced directives, a full resuscitative effort including CPR, definitive airway management, medication administration, defibrillation if necessary, and at least 20 minutes of treatment following Advanced Cardiac Life Support (ACLS) guidelines should be performed prior to declaring the patient dead. 4) A patient whose rhythm changes to, or remains in, ventricular fibrillation or ventricular tachycardia should have continued resuscitative efforts. Patients in asystole or pulseless electrical activity should be strongly considered for out-of-hospital termination of resuscitation. 5) Logistic factors should be considered, such as collapse in a public place, family wishes, and safety of the crew and public. 6) Online medical direction should be established prior to termination of resuscitation. The decision to terminate efforts should be a consensus between the on-scene paramedic and the online physician. 7) The on-scene providers and family should have access to resources, such as clergy, crisis workers, and social workers. 8) Quality review is necessary to ensure appropriate application of the termination protocol, law enforcement notification, medical examiner or coroner involvement, and family counseling.

Adult↗
PubMed1986

Resuscitation from hemorrhagic shock. Alterations of the intracranial pressure after normal saline, 3% saline and dextran-40.

Resuscitation from hemorrhagic shock by infusion of isotonic (normal) saline (NS) is accompanied by a transient elevation in intracranial pressure (ICP), although cerebral edema, as measured by brain weights at 24 hours, is prevented by adequate volume resuscitation. The transient increase in ICP is not observed during hypertonic saline (HS) resuscitation. The effect of colloid resuscitation on ICP is unknown. Beagles were anesthetized, intubated, and ventilated, maintaining pCO2 between 30-45 torr. Femoral artery, pulmonary artery, and urethral catheters were positioned. ICP was measured with a subarachnoid bolt. Forty per cent of the dog's blood volume was shed and the shock state maintained for 1 hour. Resuscitation was done with shed blood and a volume of either NS (n = 5), 3% HS (n = 5), or 10% dextran-40 (D-40, n = 5) equal to the amount of shed blood. Intravascular volume was then maintained with NS. ICP fell from baseline values (4.7 +/- 3.13 mmHg) during the shock state and increased greatly during initial fluid resuscitation in NS and D-40 groups, to 16.0 +/- 5.83 mmHg and 16.2 +/- 2.68 mmHg, respectively. ICP returned to baseline values of 3.0 +/- 1.73 mmHg in the HS group with initial resuscitation and remained at baseline values throughout resuscitation. NS and D-40 ICP were greater than HS ICP at 1 hour (p less than .001) and 2 hours (p less than .05) after resuscitation. These results demonstrate that NS or colloid resuscitation from hemorrhagic shock elevates ICP and that HS prevents elevated ICP.

Animals↗
PubMed1997

Dopexamine improves liver oxygenation during crystalloid resuscitation from experimental hemorrhagic shock.

OBJECTIVE: To evaluate the effects of dopexamine administration on hemodynamic variables and tissue oxygen tensions during crystalloid resuscitation from hemorrhagic shock. DESIGN: Randomized, control trial. SETTING: An animal laboratory at a university center. SUBJECTS: Twelve piglets, mean weight 22 kg. INTERVENTIONS: The animals were anesthetized and bled to a state of hemorrhagic shock and resuscitated, using a crystalloid solution infused at a rate of approximately 2.6 mL/min/kg (total amount 208 mL/kg). Cardiac output and mean arterial pressure (MAP were measured as indicators of volume filling during the 20- to 30-min resuscitation period and during the follow-up period until 80 mins from the start of resuscitation. Dopexamine was administered by infusion at 6 micrograms/kg-min from the start of volume replacement (dopexamine group, n = 6). The rest of the animals (control group, n = 6) were given volume replacement only. MEASUREMENTS AND MAIN RESULTS: Systemic oxygen transport variables were calculated. Tissue oxygen tensions were continuously recorded from the liver, conjunctival layer, and via subcutaneous and transcutaneous electrodes in the abdominal region. MAP decreased from 119 +/- 2 (SEM) to 44 +/- 2 mm Hg and cardiac output decreased by 77% during the shock period. During resuscitation, cardiac output was restored in both groups. MAP increased close to the baseline during the early resuscitation period and decreased slowly during follow-up. Oxygen delivery remained at 46% of baseline, whereas systemic oxygen consumption was restored during resuscitation in both groups. Liver tissue oxygen tension increased well above baseline during resuscitation in the dopexamine group, and liver tissue oxygen tension was significantly higher than in the control group. After 60 mins of resuscitation, the liver oxygen tension decreased to control group values. None of the other tissue oxygen tensions showed any differences between groups. CONCLUSIONS: Dopexamine administration during crystalloid resuscitation from hemorrhagic shock was well tolerated and resulted in significant and specific, although transient, improvement in liver oxygenation.

Adrenergic beta-Agonists↗
PubMed1998

Resuscitation after hemorrhage using recombinant human hemoglobin (rHb1.1) in rats: effects on nitric oxide and prostanoid systems.

OBJECTIVES: Hemoglobin-based oxygen carriers are designed to replace blood volume and to increase oxygen delivery to tissues after blood loss. The goals of the present study were two-fold: a) to determine the systemic and regional vascular effects of resuscitation with recombinant human hemoglobin (rHb1.1) in rats during controlled hemorrhage; and b) to determine whether nitric oxide (NO) or prostaglandins were involved in the observed responses. DESIGN: Paralyzed, ventilated rats were hemorrhaged (18 mL blood/kg body weight) during halothane anesthesia and allowed to stabilize for 30 mins. Systemic and regional hemodynamics and oxygen delivery were monitored at three time points, using the radioactive microsphere method. Microspheres were first infused at the end of the hemorrhage stabilization period (t=0 min). rHb1.1 (1 g/kg body weight) or rHb1.1 diluent (phosphate buffered saline, 36 mL/kg body weight) were infused over 20 mins and microspheres were administered again, 30 mins later (t=50 mins). Saline (0.5 mL), indomethacin (5 mg/kg to inhibit cyclooxygenase), or NG-monomethyl-L-arginine (L-NMMA, 100 mg/kg, to inhibit NO synthase) were then infused in rHb1.1-treated rats and microspheres injected once more (t=80 mins). SETTING: Research laboratory. SUBJECTS: Male Wistar rats (n=37). INTERVENTIONS: Recombinant human hemoglobin (rHb1.1), rHb1.1 diluent (phosphate buffered saline) resuscitation of hemorrhaged rats. Saline, L-NMMA, or indomethacin treatment after resuscitation. MEASUREMENTS AND MAIN RESULTS: Resuscitation with rHb1.1 increased mean arterial pressure (MAP), cardiac output, and systemic oxygen delivery significantly when compared with diluent. After rHb1.1 resuscitation, regional blood flows were significantly increased in skin, kidney, spleen, and heart compared with diluent resuscitation. Compared with saline treatment after rHb1.1 resuscitation, L-NMMA increased MAP and regional resistances in virtually all tissues; indomethacin did not alter MAP, but increased resistance in the brain. CONCLUSIONS: These data indicate that rHb1.1 resuscitation was more effective than diluent in improving systemic and regional hemodynamics and oxygen delivery, suggesting that rHb1.1 may be of benefit in the treatment of acute blood loss. Increased resistance after L-NMMA in the presence of rHb1.1 indicated that rHb1.1 resuscitation did not eliminate NO dependent circulatory control. Increased resistance after indomethacin in brain indicated that vasodilator prostanoids were important in regulating vascular resistance in these tissues after rHb1.1 resuscitation.

Animals↗
PubMed1990

Hypertonic saline resuscitation of head injury: effects on cerebral water content.

UNLABELLED: Ideal resuscitation would simultaneously replete intravascular volume and minimize cerebral edema. We assessed the effects of hypertonic saline (HS) shock resuscitation on cerebral edema after head injury. Rats were subjected to hemorrhagic shock (40 mm Hg for 1 hour) in the presence or absence of mechanical brain injury, followed by 1 hour of resuscitation with either hypertonic saline (6.5%) or lactated Ringer's (LR). After resuscitation, animals were sacrificed and brain water contents determined. RESULTS: Less HS than LR was needed for resuscitation both in animals without brain injury (7 +/- 2 ml/kg vs. 97 +/- 16 ml/kg; p less than 0.0003) and with brain injury (10 +/- 1 ml/kg vs. 68 +/- 6 ml/kg; p less than 0.0001). Brain water content (ml H2O/gm dry wt) after HS resuscitation was decreased compared to LR resuscitation in animals without brain injury (3.36 +/- 0.12 vs. 3.74 +/- 0.08; p less than 0.025) and in the uninjured hemisphere of head-injured animals (3.29 +/- 0.11 vs. 3.78 +/- 0.09; p less than 0.025). Brain water content was increased in injured brain in both resuscitation groups, but the increase was the same (HS 4.10 +/- 0.13; LR 4.25 +/- 0.17; p greater than 0.05). CONCLUSIONS: HS resuscitation of hemorrhagic shock decreases brain water content in uninjured but not injured brain. HS may be useful in resuscitation of combined hemorrhagic shock and head injury.

Animals↗
PubMed1995

Limiting initial resuscitation of uncontrolled hemorrhage reduces internal bleeding and subsequent volume requirements.

We tested the hypothesis that full or "standard resuscitation" (SR) with lactated Ringer's solution (LRS) results in increased bleeding in uncontrolled hemorrhagic shock, compared with a "limited prehospital resuscitation" (LPR) regimen and a control group of "no resuscitation" (NR). Cardiac output was used as physiological endpoint for resuscitation. Twenty swine had 25 mL/kg of blood withdrawn during a 30-minute controlled hemorrhage, followed by a 20-minute "prehospital" resuscitation regimen was conducted in three groups: the SR group (n = 6), LRS infused as needed to restore cardiac index (CI) to 100% baseline; the LPR group (n = 8), with resuscitation using LRS to 60% of baseline CI, with volume limited to 10 mL/kg; and the NR group (n = 6). After aortotomy repair, intraoperative resuscitation was continued for 120 minutes using LRS to achieve and maintain 80% of baseline mean arterial pressure. Blood pressure and cardiac index were greatly reduced, to 34% and 39% of baseline, respectively, by hemorrhage. During prehospital resuscitation, the SR group required 48.8 +/- 6.5 mL/kg of LRS, whereas the LPR group received 9.4 +/- 0.6 mL/kg (p < 0.05). Mean arterial pressure increased in all three groups during prehospital resuscitation (p < 0.05). Pulse pressures increased in the SR and LPR groups only (p < 0.05). The increment in oxygen delivery was significantly greater in the SR group, compared with the LPR group (p < 0.05), which in turn was significantly greater than the NR group (p < 0.05). Peritoneal blood volume was significantly higher in the SR group (20.6 +/- 5.6 mL/kg), versus the LPR (7.3 +/- 1.3 mL/kg; p < 0.05) and NR groups (3.0 +/- 0.9 mL/kg; p < 0.05). Crystalloid and whole blood requirements during the intraoperative resuscitation phase were significantly higher in the SR group (193 +/- 16.0 and 9.0 +/- 2.5 mL/kg), than in LPR (111.8 +/- 15.6 and 4.5 +/- 1.8 mL/kg; p < 0.05) and NR groups (128.5 +/- 32.3 and 3.9 +/- 2.3 mL/kg; p < 0.05). In the presence of uncontrolled hemorrhagic shock, LPR and NR can significantly reduce internal hemorrhage and subsequent intraoperative crystalloid and blood requirements.

Animals↗
PubMed1996

Resuscitation of uncontrolled liver hemorrhage: effects on bleeding, oxygen delivery, and oxygen consumption.

Using a standardized liver injury model of uncontrolled hemorrhage, we tested the effect of different fluid resuscitation regimens on hemodynamics, oxygen delivery, oxygen consumption, bleeding volume, and fluid resuscitation requirements. Rats were randomized into three bolus resuscitation groups 15 minutes after liver injury: lactated Ringer's solution (LR, n = 10), hypertonic saline (HS, n = 10), and hypertonic sodium acetate (HA, n = 10). In all resuscitation groups, a 4 mL/kg bolus was first infused at a rate of 0.4 mL/min. Continuous supplemental LR infusion was then given for 90 minutes to maintain a mean arterial pressure of 80 mm Hg. An initial bolus of LR led to minimal changes in hemodynamics. Initial resuscitation with HS markedly increased blood pressure and cardiac index. The bolus of HA increased cardiac index but did not increase blood pressure; systemic vascular resistance was significantly decreased and bleeding significantly increased. Resuscitation with HS did not increase bleeding compared with LR and resulted in the smallest total resuscitation volume requirement. Resuscitation with HS and HA both resulted in a rapid increase in oxygen consumption; LR did not increase oxygen consumption. Animals in the HS group had significantly higher oxygen extraction ratios at the conclusion of the experiment. The use of different bolus fluids for the resuscitation of uncontrolled hemorrhage resulted in significant differences in hemodynamics, oxygen metabolism, and blood loss even when subsequent resuscitation was the same in all groups. Results from large vessel injury animal models and clinical studies of patients with penetrating trauma may not apply to solid parenchymal injuries.

Animals↗
PubMed1998

Lactated ringer's is superior to normal saline in a model of massive hemorrhage and resuscitation.

BACKGROUND: Previous models comparing normal saline (NS) with lactated Ringer's solution (LR) for resuscitation use only mild or moderate hemorrhage and do not address the clinical situation of massive hemorrhage and resuscitation (MHR). This work compares NS and LR by using a new rat model of MHR. METHODS: NS and LR were compared by using both a traditional model of moderate pressure-controlled hemorrhage and a model of MHR. Moderate hemorrhage animals were bled to mean arterial pressure (MAP) = 60 mm Hg x 2 hour then resuscitated with crystalloid (NS or LR) for 1 hour. MHR animals were bled at a rate of 1 estimated blood volume (EBV) per hour for 2 hours with simultaneous resuscitation by using washed red blood cells (B) and crystalloid (LR+B or NS+B). MAP was kept at 60 mm Hg during the 2 hours of hemorrhage. Bleeding was then stopped, and animals were resuscitated for 1 additional hour with blood and crystalloid to MAP more than 90 mm Hg or until 10x EBV was given. Group means were compared with Student's t test (p < 0.01 significant) and 2-week survival rates were compared by using Fisher's exact test (p < 0.05 significant). RESULTS: The moderate hemorrhage group was bled 36% of EBV. In this setting, resuscitation with NS and LR was equivalent. The final hematocrit, pH, and base excess were not different, and all animals survived in both groups. MHR animals were bled 218% of EBV. Animals resuscitated with NS+B were significantly more acidotic than animals resuscitated with equal volumes of LR+B (pH 7.14+/-.06 vs. 7.39+/-.04, respectively) and had significantly worse survival (50% vs. 100%, respectively). CONCLUSION: With moderate hemorrhage, NS and LR are equivalent, but in the setting of massive hemorrhage and resuscitation, significantly more physiologic derangement and mortality occurs with NS than LR. LR is superior to NS for use in massive resuscitation.

Animals↗
PubMed2000

Lactated ringer's solution and hetastarch but not plasma resuscitation after rat hemorrhagic shock is associated with immediate lung apoptosis by the up-regulation of the Bax protein.

BACKGROUND: We previously demonstrated that the type of resuscitation fluid used in hemorrhagic shock affects apoptosis. Unlike crystalloid, whole blood seems to attenuate programmed cell death. The purpose of this study was to determine whether the acellular components of whole blood (plasma, albumin) attenuated apoptosis and to determine whether this process involved the Bax protein pathway. METHODS: Rats were hemorrhaged 27.5 mL/kg, kept in hypovolemic shock for 75 minutes, then resuscitated over 1 hour (n = 44). Control animals underwent anesthesia only (sham, n = 7). Treatment animals were bled then randomly assigned to the following resuscitation groups: no resuscitation (n = 6), whole blood (n = 6), plasma (n = 6), 5% human albumin (n = 6), 6% hetastarch (n = 7), and lactated Ringer's solution (LR, n = 6). Hetastarch was used to control for any colloid effect. LR was used as positive control. Immediately after resuscitation, the lung was collected and evaluated for apoptosis by using two methods. TUNEL stain was used to determine general DNA damage, and Bax protein was used to specifically determine intrinsic pathway involvement. RESULTS: LR and hetastarch treatment resulted in significantly increased apoptosis in the lung as determined by both TUNEL and Bax expression (p < 0.05). Plasma infusion resulted in significantly less apoptosis than LR and hetastarch resuscitation. Multiple cell types (epithelium, endothelium, smooth muscle, monocytes) underwent apoptosis in the lung as demonstrated by the TUNEL stain, whereas Bax expression was limited to cells residing in the perivascular and peribronchial spaces. CONCLUSION: Apoptosis after volume resuscitation of hemorrhagic shock can be affected by the type of resuscitation fluid used. Manufactured fluids such as lactated Ringer's solution and 6% hetastarch resuscitation resulted in the highest degree of lung apoptosis. The plasma component of whole blood resulted in the least apoptosis. The process of apoptosis after hemorrhagic shock resuscitation involves the Bax protein.

Animals↗
PubMed2004

Neonatal resuscitation: raising the bar.

PURPOSE OF REVIEW: To provide an overview of neonatal resuscitation practices with an emphasis on interventions that are not currently accepted or adapted into existing resuscitation guidelines. RECENT FINDINGS: Current resuscitation guidelines do not contain specific guidelines for the approach to the extremely low birth weight infant. The differences in environment and management between the neonatal ICU and delivery room are striking and are magnified in the resuscitation of extremely low birth weight infants for whom maintenance of a neutral thermal environment is essential. The use of a polyethylene wrap applied at delivery has been shown to reduce the occurrence of hypothermia and decrease mortality. There is substantial evidence that term and near-term newborn infants can be effectively resuscitated with room air, and recent follow-up studies have demonstrated that this approach is not associated with increased significant differences in neurologic handicap, somatic growth, or developmental milestones when compared with the use of 100% oxygen. The safety and potential benefits of this approach require prospective evaluation in the premature and especially extremely low birth weight infant. There is preexisting evidence that demonstrates that the use of prolonged inflations and t-piece resuscitators may be advantageous during resuscitation, but not all guidelines support these interventions. Although regulated continuous positive airway pressure, pulse oximeters, and blenders are routinely used once an infant is admitted to the neonatal ICU, none of these interventions is recommended in the delivery area. Although prospective studies have demonstrated that the use of colorimetric CO2 detectors significantly decreases the time to recognize misplaced endotracheal tubes placed during resuscitation, their use is not required by current guidelines. The duration of an intubation attempt during resuscitation had never been prospectively evaluated, and our recent findings suggest that a limit of 30 seconds is well tolerated and provides adequate time for a successful attempt. SUMMARY: There is significant potential for improvement in current resuscitation environments and interventions that will only be realized through further prospective research.

Body Temperature↗
PubMed2002

Enalaprilat improves systemic cardiovascular parameters and mesenteric blood flow during hypotensive resuscitation from hemorrhagic shock in dogs.

Resuscitative interventions that improve mesenteric perfusion without causing instability in systemic arterial pressures may be helpful for improving trauma patient outcomes. Blocking angiotensin II formation with enalaprilat may be such an intervention. Two questions were addressed in this two-part study investigating resuscitation from hemorrhagic shock in dogs: Can systemic arterial pressures be maintained while administering a constant rate infusion of enalaprilat during resuscitation, and can enalaprilat improve cardiovascular status during resuscitation? Animals were hemorrhaged to a mean arterial pressure (MAP) of 40 to 45 mmHg for 30 min and then 30 to 35 mmHg for 30 min. Group I (n = 5) was resuscitated to a MAP 60 to 65 mmHg with enalaprilat (0.02 mg/kg/h). Group II was resuscitated to a MAP 40 to 45 mmHg with (n = 5) or without (n = 5) enalaprilat. Resuscitation in both groups consisted of intermittent intravenous lactated Ringer's solution (60 mL/kg/h) to reach and maintain the target MAPs. Systemic arterial pressures were unaffected by enalaprilat during resuscitation in Group I, allowing us to proceed to the second study. During severely hypotensive resuscitation (Group II), systemic arterial pressures were also stable and enalaprilat administration was associated with increases (P < or = 0.02) in cardiac index (+1.2 L/min/m2), stroke volume index (SVI) (+14.5 mL/m2), superior mesenteric artery flow (+80 mL/min), stroke work (+561 mmHg/mL/m2), and left ventricular power output (+55.7 mmHg/L/min/m2). Corresponding increases were not observed in controls. We conclude that administration of a constant rate infusion of enalaprilat during resuscitation can be accomplished without causing a hypotensive crisis. Since enalaprilat significantly improved cardiovascular status including mesenteric perfusion even during intentional hypotension, it has potential value for improving the treatment of trauma patients.

Animals↗
PubMed2002

The impact of television fiction on public expectations of survival following inhospital cardiopulmonary resuscitation by medical professionals.

RATIONALE: Research has shown that the public overestimates the survival chances of patients after cardiopulmonary resuscitation. Other studies have suggested that demonstrably exaggerated survival rates in medical television fiction might affect these estimates. Such studies were mostly conducted in the United States, dealt with cardiopulmonary resuscitation in general, and asked respondents to indicate their source of medical information, an unreliable survey technique. OBJECTIVE: To examine whether public perceptions of survival after inhospital cardiopulmonary resuscitation by physicians and nurses is related to the consumption of medical drama, without relying on respondents' self-reports of what influences them. To examine whether training in basic cardiopulmonary resuscitation techniques mediates this relationship. METHODS: A random sample of 820 third and fifth year secondary school students completed a questionnaire in which they indicated their consumption of medical television fiction, their practical knowledge of cardiopulmonary resuscitation techniques, and their estimates of the survival rate after inhospital cardiopulmonary resuscitation. RESULTS: A relationship was found between the consumption of medical television drama and higher estimates of cardiopulmonary resuscitation survival. Practical knowledge of cardiopulmonary resuscitation also resulted in increased estimated survival rates. An interaction effect of drama and practical knowledge was found. Respondents with practical knowledge were less affected by television. CONCLUSIONS: The consumption of medical television drama is related to overestimating survival chances after inhospital resuscitation by physicians and nurses following cardiopulmonary arrest. A practical knowledge of basic cardiopulmonary resuscitation techniques moderates but does not eliminate the television effect.

Adolescent↗
PubMed2004

The influence of timing of elective cesarean section on neonatal resuscitation risk.

OBJECTIVE: Cesarean section has negative effects on the physiologic responses to birth, including the development of lung volumes, pulmonary vascular resistance, and biochemical responses. The objective of this study was to examine the association between the timing of delivery between 37 and 42 wks gestation and neonatal resuscitation risk in elective cesarean section. DESIGN: Observational, cohort study. SETTING: Maternity Department of Padua University, Italy. SUBJECTS: All pregnant women who delivered by elective cesarean section at term during a 3-yr period were identified from a perinatal database and compared retrospectively with pregnant women who delivered vaginally and matched for week of gestation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Comparative neonatal resuscitation risk (odds ratio, OR; confidence interval, CI) was analyzed. During this time, 1,284 (13%) elective cesarean section deliveries occurred at or after 37 wks of gestation. Forty-four (3.4%) newborns delivered by elective cesarean section and 18 (1.4%) newborns vaginally delivered needed positive pressure ventilation resuscitation by laryngeal mask airway or tracheal tube. Positive pressure ventilation resuscitation risk was significantly higher in the infant group delivered by elective cesarean section compared with vaginal delivery (OR, 2.05; CI, 1.25-5.67; p < .01) and involved both laryngeal mask airway and tracheal tube resuscitation maneuvers (OR, 2.77 CI, 1.26-5.8; p < .01 and OR, 2.9; CI, 1.02-7.81; p < .01, respectively). In the period of weeks 37(+0) to 38(+6), positive pressure ventilation resuscitation risk and single laryngeal mask airway and tracheal tube resuscitation maneuver risk were significantly greatly increased (OR, 4.25; CI, 1.46-16.12; p < .01; OR, 2.25; CI, 1.46-6.12; p < .01; and OR, 11.3; CI, 2.15-16.0; p < .01, respectively). After 38(+6) weeks, there was no significant difference in positive pressure ventilation resuscitation risk. CONCLUSIONS: Elective cesarean section at term, in an obstetric population without prenatally identified risk factors, remains associated with increased resuscitation risk with related implications for the neonate compared with vaginal delivery. A significant reduction in neonatal resuscitation risk would be obtained by waiting until week 39(+0) before performing elective cesarean section.

Adult↗