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PubMed1994

Survival after failed out-of-hospital resuscitation. Are further therapeutic efforts in the emergency department futile?

BACKGROUND: Because of extremely poor outcomes, the practice of continuing cardiopulmonary resuscitation in hospital emergency departments after unsuccessful out-of-hospital cardiopulmonary resuscitation has been strongly questioned. Before revising our institutional guidelines according to previous pessimistic reports we wished to review our own experience with this practice. METHODS: The case histories of 141 consecutive victims of witnessed cardiac arrest brought to the emergency department with ongoing cardiopulmonary resuscitation were reviewed. The emergency medical system was two-tiered and was based on the emergency department of a single university hospital. The first tier, staffed with emergency medical technicians, provided only basic cardiac life support. The second, physician-staffed tier provided advanced cardiac life support and was allowed to terminate resuscitation in the field. Rates of successful resuscitation, survival to discharge and after 1 year, and the cerebral performance of resuscitated and surviving patients were determined. RESULTS: Ninety-one patients (65%) died in the emergency department; 50 (35%) were resuscitated and admitted. Thirty-two patients (23%) died in the hospital, 18 (13%; 95% confidence interval, 8% to 20%) survived to discharge. Sixteen survivors showed no or only mild neurologic impairment at discharge. Seventeen patients were alive 1 year later. Bystander resuscitation, short intervals to initiation of resuscitation, and ventricular fibrillation at emergency department entry were significantly associated with survival. CONCLUSIONS: Institutional guidelines for the decision whether to continue resuscitation after failed out-of-hospital efforts should be based on an analysis of the characteristics and results of the local emergency medical system. Continuing efforts in the hospital may not be inevitably futile.

Aged↗
PubMed1997

A histopathological study of anoxic-resuscitated liver allografts.

The possibility of resuscitating livers after warm ischaemia has been recently suggested. The aim of the present investigation was to analyse the effects of anoxia on the morphology of hepatic cells, to determine whether these effects are reversible after providing a resuscitation period between warm ischaemia (WI) and cooling, and to study the behaviour of the resuscitated liver in the recipient organism. Ten female, Large-White pigs acted as donors for 10 recipient animals of the same kind who received an orthotopic liver graft. Recipients were divided into two groups depending on whether the livers they received had undergone a resuscitation period (Group I (n=5) where animal livers were subjected to 5 min warm ischaemia (WI) without resuscitation, and Group II (n=5) where the livers were subjected to 5 min WI followed by 5 min resuscitation). Morphological and ultrastructural studies of liver cells were performed using light and electron microscopy. ATP, ADP and AMP levels were determined in liver biopsies by high performance liquid chromatography (HPLC). Plasma AST and bilirubin levels in the two groups were compared 24 h after transplantation. After 5 min of anoxia, hepatocytes showed two morphological patterns in response to WI. Some were appreciably condensed with dark mitochondria, peroxisomes and some cytoplasmic vacuoles. Others showed electronlucent organelles, inflamed mitochondria with broken cristae and disorganized endoplasmic reticulum. Hepatocytes showed globular microvilli and bleb formation with migration towards the sinusoids. One hour after the revascularisation of the resuscitated livers, the hepatocytes showed nearly normal morphological characteristics. However, the hepatocytes of non-resuscitated organs continued to show alterations. Kupffer cells were activated in the livers of both experimental groups. Ultrastructural changes and total tissue adenine nucleotide (TAN) levels recovered completely in resuscitated livers soon after transplant. These results suggest that when short WI periods are followed by equivalent periods of resuscitation, the hepatocytes of transplanted livers recover from the effects of anoxia.

Animals↗
PubMed1998

Absorption of intubation-related lidocaine from the trachea during prolonged cardiopulmonary resuscitation.

The purpose of this study was to determine whether lidocaine is absorbed from the trachea during the artificial circulation of cardiopulmonary resuscitation. The tissue distribution of lidocaine was investigated in eight individuals (Cases 1-8) who underwent cardiopulmonary resuscitation before being pronounced dead. In Cases 1-4, there was no restoration of heart beat during cardiopulmonary resuscitation. Heart massage had been continued for 5 min in Cases 1 and 2, and for 60 min in Cases 3 and 4. Relatively high concentrations of lidocaine (more than 0.1 mg/L) were detected in the blood left in the heart and/or in the large thoracic vessels in the four cases. In Cases 1-3, a large proportion of the lidocaine detected in these blood samples may have diffused from the trachea after cessation of cardiopulmonary resuscitation since no lidocaine was detected in the cerebrospinal fluid, cerebrum, liver, right kidney, and/or right femoral muscle. In Case 4, however, tracheal lidocaine was thought to have been absorbed during cardiopulmonary resuscitation because 0.167-0.340 mg/L or mg/kg lidocaine was detected in the cerebrospinal fluid, liver, right kidney, and right femoral muscle. This was substantiated in experiments performed in rabbit carcasses given 50 microL/kg Xylocaine jelly (a 2% lidocaine hydrochloride preparation) intratracheally, followed by rhythmical thoracic compressions (100-150 times per minute) for 60 min. A possible reason for lack of absorption of lidocaine from the trachea of Case 3 during a 60-min cardiopulmonary resuscitation procedure may have been that effective blood circulation was not obtained during cardiopulmonary resuscitation because of bleeding and pulmonary collapse. Cases 5-8 survived for 3 h to 10 days after successful cardiopulmonary resuscitation; it was obvious that lidocaine was distributed to the tissues under the influence of the natural circulation. The kidney to liver lidocaine ratio in Case 4 (0.8) was much lower than that in Cases 5-8 (1.3-4.6), although the lidocaine ratio in the blood in the left ventricle when compared to blood in the right ventricle was similar in the five cases. The kidney to liver lidocaine ratio may be helpful in judging whether the lidocaine detected was absorbed during the artificial circulation of cardiopulmonary resuscitation or naturally. Additionally, postmortem diffusion of tracheal lidocaine into the blood in the left ventricle was much greater than into the blood in the right ventricle due to their anatomical location during a supine position. The pattern of tissue distribution of lidocaine gives useful information on the state of decedents during cardiopulmonary resuscitation.

Absorption↗
PubMed1998

On resuscitation from the dormant state of Micrococcus luteus.

It has been found previously that a significant number of Micrococcus luteus cells starved in a prolonged stationary phase (up to 2 months) and then held on the bench at room temperature without agitation for periods of up to a further 2-7 months can be resuscitated in liquid media which contained (statistically) no initially-viable (colony-forming) cells but which were fortified with sterile supernatant from the late logarithmic phase of batch growth. Here it was found that such resuscitation can be done only within a defined time period after taking the first sample from such cultures, necessarily involving agitation of the cells. The duration of this period depends on the age of the starved culture: cells kept on the bench for 3 months possess a 2 month period of resuscitability while cells starved for 6 months can be resuscitated only within 10 days after the beginning of sampling. It is suggested that the input of oxygen to the starved cultures while they are agitated may exert a negative influence on the cells, since cultures stored in anaerobic conditions (under nitrogen) had a more prolonged 'survival' time. The cells which experienced between 10 and 60 days of starvation on the bench could be resuscitated, although the number of resuscitable cells depended strongly on the concentration of yeast extract in the resuscitation medium. This concentration for cells stored on the bench for more than 2 months was 0.05% while '1-month-old' cells displayed a maximum resuscitability in the presence of 0.01% of yeast extract. Application of the fluorescent probe propidium iodide revealed the formation of cells with a damaged permeability barrier if resuscitation was performed by using concentrations of yeast extract of 0.1% and above. Thus the successful resuscitation of bacterial cultures under laboratory conditions may need rather strictly defined parameters if it is to be successfully performed for the majority of cells in a population.

Adaptation, Physiological↗
PubMed2006

Effects of Diaspirin Crosslinked Hemoglobin (DCLHb) on microcirculation and local tissue pO2 of striated skin muscle following resuscitation from hemorrhagic shock.

The hemoglobin based oxygen carrier (HBOC) Diaspirin Crosslinked Hemoglobin (DCLHb) has been developed to substitute not only the blood volume, but also to restore the oxygen-carrying properties of blood during hemorrhagic shock. However, it has been suggested that HBOCs may enhance the formation of free oxygen radicals through the release of free iron ions via the Haber-Weiss reaction. The aim of this study was to investigate the effects of DCLHb on the microcirculation, leukocyte-endothelial cell interaction and local tissue oxygenation in striated skin muscle of Syrian golden hamsters during and after resuscitation from hemorrhagic shock. In particular we focused on the local tissue oxygenation after resuscitation with DCLHb (hemoglobin content 10 g%) compared to resuscitation using autologous blood diluted to a hemoglobin content of 10 g%. Hemorrhagic shock was induced for 45 minutes by bleeding the animals at a rate of 33 ml/kg BW maintaining a mean arterial pressure of 30 +/- 5 mmHg. Animals were resuscitated either with 33 ml/kg BW 6% Dextran-60.000 or with 10 g% DCLHb. The control group received shed blood diluted with Ringers to a hemoglobin content of 10 g%. Intravital microscopy was used for investigation of the microcirculatory parameters and a multiwire platinum surface electrode for measurement of local tissue pO2 in striated skin muscle in the dorsal skinfold chamber of Syrian golden hamsters. Resuscitation from hemorrhagic shock with 10 g% AUB revealed significant increase of leukocytes rolling in postcapillary venules at 30 to 120 minutes after resuscitation compared to baseline values. DCLHb turned out to reduce the number of firmly adherent leukocytes after resuscitation compared to 10 g% AUB. Microvascular permeability as an indicator for functional endothelial integrity revealed no significant differences between the groups. DCLHb and 10 g% AUB led to a significant increase in local tissue oxygenation after resuscitation from hemorrhagic shock. However, 10 g% AUB turned out to be most effective to restore the local tissue pO2 compared to Dx-60. Our findings indicate that DCLHb restores microvascular perfusion after critical hemorrhagic shock as efficient as Dx-60 and 10 g% AUB. The absence of enhanced leukocyte-endothelium interaction after resuscitation with DCLHb implies that this HBOC does not exacerbate formation of oxygen free radicals during reperfusion. DCLHb effectively increases local tissue pO2 after resuscitation from hemorrhagic shock; however, not as effectively as 10 g% AUB.

Animals↗
PubMed2003

Should do-not-resuscitate orders be suspended for surgical cases?

PURPOSE OF REVIEW: There are significant misunderstandings about the management of perioperative do-not-resuscitate orders. This paper reviews some of the difficulties generated by the halting acceptance and inconsistent implementation of an ethically appropriate perioperative do-not-resuscitate policy that mandates reconsideration of existing do-not-resuscitate orders. It also offers strategies for empowerment of such a policy. RECENT FINDINGS: Recent advances in the ethical practice of anesthesiology have centered on determining and correcting why perioperative do-not-resuscitate policies are poorly accepted, and how to establish a hospital-wide adherence to such policies. Barriers to ethically appropriate application of perioperative do-not-resuscitate orders include differing values and misunderstandings between physicians and their patients - and also between anesthesiologists and other physicians - as well as medicolegal concerns. Policies should be designed and implemented at the level of the healthcare institution, and they must be sufficiently flexible to permit the tailoring of the perioperative do-not-resuscitate order to the autonomous choice of the patient. Such policies should state unambiguously that existing do-not-resuscitate orders are to be reevaluated, delineate responsibilities for reconsidering the do-not-resuscitate order, state available options, define necessary documentation, and list resources for help. SUMMARY: A well written perioperative do-not-resuscitate policy is essential for surmounting obstacles to a well functioning perioperative do-not-resuscitate system.

Journal Article↗
PubMed1991

Interaction of sodium and volume in fluid resuscitation after hemorrhage.

Some measures of the efficacy of fluid resuscitation after hemorrhage are blood volume restitution (BVR) and attenuation of the neuroendocrine response. We compared the effectiveness of resuscitation with 0.9% NaCl and 3.0% NaCl in chronically prepared awake dogs after 30% hemorrhage. Each dog was bled on four occasions and resuscitated by four protocols: 1) full resuscitation (infusion to return and maintain mean arterial pressure (MAP) at control +/- 10 mm Hg) with 3.0% NaCl (HS); 2) full resuscitation with 0.9% NaCl (NS); 3) under-resuscitation with a volume of 0.9% NaCl equal to the subject's previous 3.0% NaCl requirement (SV); and 4) no fluid therapy (NR). Approximately three times more volume was needed to restore MAP with NS vs. HS, and thus the amount of Na administered was not different in these groups. Net volume balance was positive in the NS and SV groups but negative in the HS group due to marked saline diuresis. Net Na balance was positive in all three fluid-treated groups, but significantly higher in the HS group (p less than 0.01). MAP remained below baseline in the SV and NR groups (p less than 0.05). BVR exceeded 100% in NS and HS early in resuscitation, but BVR was not sustained in the HS group. Total plasma protein increased in all three fluid treated groups. Responses of all hormones were completely attenuated in the NS group. ACTH, cortisol, and AVP responses were promptly attenuated in the HS group, but remained greater than control. In the SV group, all hormone levels except renin returned to control values, but more slowly than the other groups. ACTH and cortisol correlated best with BVR; AVP, PRA, and aldosterone correlated with MAP restoration. In summary, resuscitation with either HS or NS can achieve similar MAP restoration. Hypertonic saline produces a more rapid increase in BVR and MAP, but the BVR improvement is transient. Resuscitation with HS incurs an intracellular water debt which is aggravated by a saline diuresis. Hormonal attenuation is linked either to BVR (ACTH, cortisol) or to MAP restoration (renin, AVP). Thus the optimal resuscitation regimen may consist of initial infusion of hypertonic saline followed by sufficient hypotonic solution to restore interstitial fluid volume and normal cellular hydration.

Adrenocorticotropic Hormone↗
PubMed1999

Do different rates of fluid resuscitation adversely or beneficially influence immune responses after trauma-hemorrhage?

BACKGROUND: Although rapid fluid resuscitation continues to be an important component of the initial therapy for trauma patients, it remains unknown whether the rate of fluid administration after trauma-hemorrhage has any deleterious or beneficial effects on immunity. METHODS: Male C3H/HeN mice were subjected to sham operation or soft-tissue trauma (midline laparotomy) and hemorrhagic shock (mean arterial blood pressure of 35+/-5 mm Hg for 90 minutes) followed by resuscitation with four times the volume of shed blood in the form of lactated Ringer's solution over 30 minutes (rapid rate), 60 minutes (moderate rate), or 120 minutes (slow rate). The animals were killed at either 4 hours or 4 days after the end of trauma-hemorrhage. Spleens were harvested and splenocyte interleukin (IL)-3 and interferon-gamma (IFN-gamma) release as well as splenic macrophage IL-1beta and IL-6 release were determined. RESULTS: The results indicate that at 4 hours after trauma-hemorrhage, splenocyte IL-3 and IFN-gamma release were significantly depressed in all animals subjected to trauma-hemorrhage compared with sham-operated animals. At 4 days after trauma-hemorrhage, splenocyte IL-3 and IFN-gamma release were restored in mice resuscitated with the slow rate of resuscitation; however, the release of these cytokines remained significantly depressed in animals resuscitated with the moderate or rapid rates. Splenic macrophage IL-1beta and IL-6 release were significantly depressed at 4 hours after trauma-hemorrhage. At 4 days after trauma-hemorrhage, the release of these proinflammatory cytokines was still depressed in animals resuscitated with the rapid rate. In contrast, splenic macrophage IL-1beta and IL-6 release were restored in mice receiving the slow rate of resuscitation. CONCLUSION: These results suggest that a slower rate of fluid resuscitation after trauma-hemorrhage leads to a faster restoration of the depressed cell-mediated immunity, whereas rapid fluid resuscitation produces a prolonged depression of immune responses. In view of this, we propose that a prospective clinical study of this type must be performed in a select group of trauma patients to determine whether or not a slower rate of fluid resuscitation also improves immune responses in trauma patients.

Animals↗
PubMed2006

HSPTX protects against hemorrhagic shock resuscitation-induced tissue injury: an attractive alternative to Ringer's lactate.

BACKGROUND: Conventional fluid resuscitation with Ringer's lactated (RL) activates neutrophils and causes end-organ damage. We have previously shown that HSPTX, a combination of small volume hypertonic saline (HS) and pentoxifylline (PTX), a phosphodiesterase-inhibitor, downregulates in vitro neutrophil activation and proinflammatory mediator synthesis. Herein, we hypothesized that HSPTX decreases end-organ injury when compared with RL in an animal model of hemorrhagic shock. METHODS: Sprague-Dawley rats were bled to a mean arterial pressure of 35 mm Hg for 1 hour. Animals were divided into 3 groups: sham (no shock, no resuscitation, n = 7), RL (32 mL/kg, n = 7), and HSPTX (7.5% NaCl 4 mL/kg + PTX 25 mg/kg; n = 7). Shed blood was infused after fluid resuscitation. Blood pressure was monitored until the end of resuscitation. Animals were sacrificed at 24 hour after resuscitation. Bronchoalveolar lavage fluid (BALF) was obtained for white cell count (total and differential) and TNF-alpha and IL-1beta levels were measured by ELISA. Lung and intestinal injury at 24 hour were evaluated by histopathology. Organ damage was graded by a pathologist and a score was created (0 = no injury; 3 = severe). Lung neutrophil infiltration was evaluated by MPO immune staining. RESULTS: There were no differences in mean arterial pressure between groups. At 24 hours, BALF leukocyte count was decreased by 30% in HSPTX animals (p < 0.01). TNF-alpha and IL-1beta levels were markedly decreased in HSPTX-resuscitated animals compared with their RL counterparts (p < 0.01). HSPTX-resuscitated animals (lung injury score = 1.0 +/- 0.4) had markedly decreased acute lung injury compared with RL-treated animals (2.5 +/- 0.3) (p < 0.01). RL resuscitation led to a two-fold increase in lung neutrophil infiltration whereas in HSPTX-treated animals, the number of MPO + cells was similar to sham animals (p < 0.001). Intestinal injury was markedly attenuated by HSPTX (1.1 +/- 0.3) compared with RL animals (2.6 +/- 0.4) (p < 0.001). CONCLUSIONS: HSPTX, a small volume resuscitation strategy with marked immunomodulatory potential led to a marked decrease in end-organ damage. HSPTX is an attractive alternative to RL in hemorrhagic shock resuscitation.

Animals↗
PubMed2005

The ethics of neonatal resuscitation at the margins of viability: informed consent and outcomes.

OBJECTIVES: To determine the adequacy of records of parental counseling in mothers with threatened preterm delivery before 27 weeks gestation, whether interventions performed at birth were consistent with recorded antenatal decisions and whether extent of resuscitation affected the occurrence of serious short-term morbidity. STUDY DESIGN: Antenatal consultation records and records of resuscitation and short-term outcomes were analyzed of 65 mothers with threatened delivery at 21 weeks to 26 weeks and 6 days gestation, and their 61 infants who delivered before 27 weeks. RESULTS: Discussions about survival rates and the frequency of handicap were more likely to be recorded before 25 weeks gestation than after; the adequacy of the records varied among individuals. A decision not to resuscitate was present in 6 of the 13 consultations performed before 23 weeks gestation, and in none of the 52 at 23 weeks or above. A decision to resuscitate only if the infant's condition at birth was good was found in 7 consultations, 6 of which were at less than 24 weeks gestation. All infants born at 23 weeks and above were resuscitated, including the infants with conditional resuscitation decisions. Three of the 6 infants receiving heart massage were discharged alive without major short-term morbidity (severe intracranial hemorrhage, periventricular leukomalacia, or threshold retinopathy). All 8 infants of less than 25 weeks gestation with a heart rate at 3 minutes that was still less than 100 beats/min, in spite of active resuscitation, either died or had major short-term morbidity. CONCLUSIONS: Records of antenatal consultations were often lacking important information. Variations in physician documentation practices are substantial and affect the care offered to infants at the threshold of viability. Even extensive resuscitation can be followed by intact survival if the resuscitation required is brief.

Adult↗
PubMed1993

Cessation of unsuccessful pediatric resuscitation--how long is too long?

Emergency teams asked to provide cardiopulmonary resuscitation for pediatric patients often consist of nurses and physicians from various pediatric and nonpediatric specialties. Team members should agree on the timing of termination of unsuccessful resuscitative efforts; however, no firm guidelines about such timing have been established. The purposes of this study were to determine (1) whether a consensus exists among health-care professionals about the optimal duration of unsuccessful resuscitation for pediatric patients and (2) whether attitudes are influenced by individual case prognosis, medical specialty, level of training, or certification in pediatric advanced life support (PALS). By random selection, 140 physicians, nurses, and medical students were asked to specify the duration that they would continue unsuccessful resuscitative efforts for each of two hypothetical cases: one patient with a good prognosis for survival and one with a poor prognosis. Although no clear consensus existed, all groups of health-care providers chose significantly briefer durations of resuscitation for the case with a poorer prognosis (P < 0.01). The specified durations of resuscitation were briefer for those who had PALS certification than for those who did not and for pediatricians than for nonpediatric physicians (P < 0.01). Furthermore, PALS certification (P < 0.01) and pediatric specialty (P < 0.05) contributed as independent variables in influencing the study participants' attitudes about duration of resuscitation, whereas level of training did not. We conclude that no consensus exists among the groups studied on the optimal duration of unsuccessful resuscitative efforts in pediatric patients. We speculate that the opinions might be more uniform if resuscitation of pediatric patients was provided primarily by pediatricians or PALS-certified physicians.

Attitude of Health Personnel↗
PubMed2003

Resuscitation teaching in New Zealand schools.

AIMS: Resuscitation skills such as cardiopulmonary resuscitation (CPR) are taught as an optional component of the New Zealand school curriculum. This study was conducted to determine the frequency of, and factors influencing, CPR teaching in New Zealand primary and secondary schools. METHODS: At the end of the 2001 school year, we surveyed by questionnaire every school in New Zealand asking which schools taught CPR skills during 2001, what other resuscitation skills were taught, and what the barriers to greater teaching of resuscitation were. RESULTS: Seven hundred and fifty four of 2205 (34.9%) primary schools and 173 of 456 (38.6%) secondary schools returned the survey. Of primary schools, 37.5% taught resuscitation skills during 2001, as did 81% of secondary schools. In secondary schools, resuscitation was most commonly taught during year 12 (pupil age 16-17 years), but then only as an elective subject to 10-30% of students. For both primary and secondary schools there was a positive correlation between school size (number of pupils) and the teaching of resuscitation (p = 0.0001). The most significant barriers to resuscitation teaching were identified as funding, an overfull curriculum and, in primary schools, the question of the suitability of teaching resuscitation to young children. CONCLUSIONS: This survey indicates that the majority of primary schools are not teaching CPR skills, or other life-saving first aid, and that the majority of secondary schools are treating these subjects as optional, taught only to a small proportion of students. If New Zealand is to achieve widespread community CPR knowledge, it is suggested that greater funding needs to be available to schools for resuscitation/first-aid training and the subject must become a compulsory, rather than optional, component of the school curriculum.

Adolescent↗
PubMed2005

Laryngeal mask airway versus bag-mask ventilation or endotracheal intubation for neonatal resuscitation.

BACKGROUND: Providing effective positive pressure ventilation is the single most important component of successful neonatal resuscitation. Ventilation is frequently initiated with a manual resuscitation bag and face-mask (BMV) followed by endotracheal intubation (ETT) if depression continues. These techniques may be difficult to perform successfully resulting in prolonged resuscitation or severe neonatal depression. The laryngeal mask airway (LMA) may achieve initial ventilation and successful resuscitation faster than a bag-mask device or endotracheal intubation. OBJECTIVES: Among newborns requiring positive pressure ventilation for resuscitation, is effective ventilation and successful resuscitation achieved faster with the LMA compared with either BMV or ETT? SEARCH STRATEGY: The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2004), MEDLINE (1966-November 2004), Pre-MEDLINE (November 15, 2004), CINAHL 1982-November 2004), reference lists of published trials, and Society for Pediatric Research abstracts were searched. Experts were contacted for additional references. SELECTION CRITERIA: Randomised and quasi-randomised trials DATA COLLECTION AND ANALYSIS: Two reviewers independently evaluated studies, assessed methodologic quality, and extracted data using the Cochrane Neonatal Review Group criteria. Categorical treatment effects were described as relative risks and risk differences and continuous treatment effects were described as the mean difference. There were insufficient data to perform pooled analyses. MAIN RESULTS: No eligible studies compared the LMA with BMV. One small randomised controlled trial comparing the LMA with ETT when BMV had been unsuccessful was included. There was no statistically significant difference between the LMA and ETT with the exception of a clinically insignificant difference in time to complete insertion of the device favouring the ETT. AUTHORS' CONCLUSIONS: The LMA can achieve effective ventilation during neonatal resuscitation in a time-frame consistent with current guidelines. There is no evidence to evaluate the relative efficacy and safety of the LMA compared with BMV as the primary airway device. A single, small randomised controlled trial found no clinically significant difference between the LMA and ETT when BMV was unsuccessful. Case series and case reports suggest that the LMA can provide an effective rescue airway during resuscitation if both BMV and ETT have been unsuccessful. A well-designed randomised controlled trial comparing the LMA with BMV during neonatal resuscitation is warranted.

Humans↗
PubMed1991

Two-stage resuscitation of the cat brain after prolonged cardiac arrest.

Following prolonged cardiac arrest, reperfusion of the brain is endangered by the low blood perfusion pressure during the early resuscitation phase. In order to avoid low perfusion brain injury, a two-stage resuscitation protocol was applied to cats submitted to 30 min potassium chloride induced cardiac arrest: first, the heart was resuscitated, followed--after stabilisation of blood pressure--by recirculation of the brain. During cardiac resuscitation the brain was disconnected from the general circulation by inflating a pneumatic cuff around the neck. The results were compared with the outcome of conventional one-stage resuscitation following 15 min cardiac arrest. Cardiac resuscitation was successful in 5 out of 8 animals with 15 min and in 6 out of 13 animals with 30 min cardiac arrest. In successfully resuscitated animals of both groups, brain energy metabolism recovered to normal within 3 h although two-stage resuscitation increased brain ischemia time to 37-61 min. Two-stage resuscitation, in consequence, is a promising approach for revival of the brain after prolonged cardiac arrest.

Adenosine Triphosphate↗
PubMed1991

Pentoxifylline but not saralasin restores hepatic blood flow after resuscitation from hemorrhagic shock.

After determining that hepatic blood flow remains impaired after resuscitation from hemorrhagic shock, we used the angiotensin II receptor antagonist saralasin and pentoxifylline to investigate their respective effects on hepatic blood flow responses after resuscitation from hemorrhagic shock. Rats were bled to 50% of baseline blood pressure for 60 min and resuscitated with shed blood and an equal volume of lactated Ringer's solution. Saralasin [10 micrograms/kg per min (n = 6)], pentoxifylline [25 mg/kg bolus and 12.5 mg/kg per hr (n = 7)], or saline (n = 11) were started with the onset of resuscitation. Total hepatic blood flow measured by ultrasonic transit time flow meter, effective nutrient hepatic blood flow measured by galactose clearance, mean arterial pressure, and cardiac output were recorded at 15-min intervals for 2 hr after resuscitation. Hemorrhage decreased cardiac output 57% below baseline and decreased total hepatic blood flow 64% below baseline. Resuscitation restored cardiac output to baseline levels in all three groups. Despite restoration of cardiac output, total hepatic and effective hepatic blood flow remained significantly below baseline in the saline control and saralasin groups but was restored to baseline levels in the pentoxifylline group. These data indicate that angiotensin II does not contribute significantly to the hepatic blood flow impairment after resuscitation from hemorrhagic shock. Improvement in flow with pentoxifylline implies that hemorrhage and resuscitation impair hepatic microvascular hemorrheology and that addition of pentoxifylline to standard resuscitation corrects the impairment.

Angiotensin II↗
PubMed1975

Resuscitation of patients with ischaemic heart disease before admission to hospital.

This paper provides data about the efficacy of resuscitation before hospital admission of 139 patients with myocardial infarction. Successful resuscitation was effected in 43 (30.9 percent) patients, of whom 29 (20.9 percent) survived and were discharged from hospital. An organizational scheme is given for resuscitation measures before admission, in which the following teams participate: premedical, general first-aid ambulance team and specialized first-aid cardiological team (Mobile Coronary Care Unit, MCCU - definition of World Health Organization). The effectiveness of resuscitation depends upon the patient's age, and the presence and degree of circulatory insufficiency before clinical death. It proved possible to revive successfully patients of advanced age and with proceding mild or moderate acute circulatory insufficiency. Resuscitation was not successful in patients with preceding severe circulatory insufficiency. Blood electrolytes were studied in the post-resuscitation period. There was a statistically significant decline in plasma potassium ion concentration. Potassium salts should be introduced in the form of a polarizing mixture, especially to patients with an irregular cardiac rhythm in the post-resuscitation period. Problems of intracardiac injections of drugs, intubation, and pervenous electric pacing in patients with myocardial infarction during resuscitation are discussed. It has been concluded that the optimum form of resuscitation before admission of patients with myocardial infarction involves rendering maximal aid at the place of occurrence of the infarction.

Adult↗
PubMed2004

Trends in burn resuscitation: shifting the focus from fluids to adequate endpoint monitoring, edema control, and adjuvant therapies.

Bum shock is a complex process involving a series of intertwined physiologic responses to injury that require more rigorous intervention than simply a change in fluid tonicity, fluid composition, or fluid resuscitation volume. Controversy ensues over monitoring techniques and resuscitation goals, in part because the identification of true markers of perfusion is clouded by intradependence of endpoints on other metabolic processes. The persistence of cellular hypoperfusion in patients who have been deemed adequately resuscitated by global indices supports the growing realization that failure of conventional endpoint-monitoring strategies to detect compensated bum shock can lead to significant organ injury from SIRS or MODS. Current endpoints should be interpreted in the aggregate, because none have yet been demonstrated to reflect tissue perfusion status independently and accurately. Numerous technologically advanced endpoints to predict patient outcome, which may be useful in determining futility of treatment or end-of-life decisions, are now available. Still lack-ing, however, is a reliable tool proven to improve outcome that can guide bum shock resuscitation therapies successfully. Exciting new research in tissue oxygenation and perfusion has revealed that damaging mediator cascades and irreversible microvascular changes may preclude complete resolution of bum shock solely through restoration of oxygen delivery. Because bum patients now frequently survive the early resuscitation phase. the focus should be on controlling derangements in oxygen use and correcting occult hypoperfusion to reduce later adverse patient outcomes from SIRS, sepsis, and MODS. Bum-specific research on resuscitation endpoints and monitoring strategies lags behind research in other patient populations. Present standards and monitoring guidelines for bum shock resuscitation should be critically evaluated and based on true, scientifically validated data rather than on observational studies or personal beliefs. Thus the continuing challenge for clinicians and researchers:burn centers must collaborate to perform large, multi-center studies to evaluate critically and to prove resuscitation endpoints and therapies. Future technologies targeted at microcirculatory perfusion and cellular oxygenation offer an exciting promise for less invasive, easily accessible, more accurate endpoints and treatments for bum shock resuscitation.

Abdomen↗
PubMed2006

Paediatric critical care nurses' attitudes and experiences of parental presence during cardiopulmonary resuscitation: a European survey.

BACKGROUND: Although recent resuscitation guidelines are supportive of family presence during cardiopulmonary resuscitation literature from the last decade suggests that it is often discouraged, and the subject remains a controversial issue. OBJECTIVES: To determine the experiences and attitudes of European paediatric critical care nurses about parental presence during the resuscitation of a child. DESIGN: A survey design was employed. PARTICIPANTS: A convenience sample of European paediatric critical care nurses was used. METHODS: A structured questionnaire was used, which incorporated a series of attitude statements that were rated using a 5-point Likert scale. Differences in attitudes were explored in three areas: decision-making, processes and outcomes of resuscitation. RESULTS: The results from this survey suggest that European paediatric nurses are very supportive of parental presence during cardiopulmonary resuscitation. Only a few nurses reported that their unit had a policy that covered parental presence during cardiopulmonary resuscitation and most nurses did not support the use of a dedicated nurse to look after the parents during resuscitation. CONCLUSIONS: Compared with previous studies relating to adult cardiopulmonary resuscitation, paediatric nurses experience family member presence more frequently than adult critical care nurses and appear to be more supportive of relatives' presence. It is recommended that paediatric intensive care units establish local policies that cover parental presence during cardiopulmonary resuscitation.

Adult↗