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PubMed2005

Parent resuscitation preferences for young people with severe developmental disabilities.

OBJECTIVE: To determine the relationship of providing explanatory information regarding resuscitation to DNR status for parents and guardians of young people who reside in a pediatric skilled nursing facility. DESIGN: Retrospective, quasi-experimental study of policy change, with each individual serving as his or her own control. Interval comparisons were made between resuscitation choices before and after information was provided to families. For those who were originally in the full resuscitation group, comparisons were also made between those who changed to DNR and those who did not. SETTING: Pediatric skilled nursing facility in Massachusetts. PARTICIPANTS: Sixty individuals with severe mental retardation and complex medical problems, between the ages of approximately 2 and 32 years. MEASUREMENTS: Review of records regarding resuscitation choices and changes, with each person serving as his or her own control. Both univariate and multivariate analyses were performed on individuals who were in the full resuscitation group at the initiation of the study to determine distinguishing characteristics between those who remained in that group from those who changed to DNR. RESULTS: The families of 11 (18%) of 60 patients had requested DNR orders prior to requirement of written preference for resuscitation or DNR in the event of cardiopulmonary arrest. After provision of informative material, there was an increase to 26 patients (43%) who were designated DNR (P < . 001). There was no significant difference in characteristics between the groups that changed to DNR and those that remained full resuscitation, although there was a marginal trend of children in the group with an acquired etiology for their developmental disabilities were more apt to have their resuscitation status changed than those with congenital diagnoses (P = .053). CONCLUSION: When families are provided with explanatory information regarding resuscitation in a nonacute, pediatric skilled nursing home setting, there is a significant increase in request for DNR.

Adolescent↗
PubMed2005

An alternative approach to advancing resuscitation science.

Stagnant survival rates in out-of-hospital cardiac arrest remain a great impetus for advancing resuscitation science. International resuscitation guidelines, with all their advantages for standardizing resuscitation therapeutic protocols, can be difficult to change. A formalized evidence-based process has been adopted by the International Liason Committee on Resuscitation (ILCOR) in formulating such guidelines. Currently, randomized clinical trials are considered optimal evidence, and very few major changes in the Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care are made without such. An alternative approach is to allow externally controlled clinical trials more weight in Guideline formulation and resuscitation protocol adoption. In Tucson, Arizona (USA), the Fire Department cardiac arrest database has revealed a number of resuscitation issues. These include a poor bystander CPR rate, a lack of response to initial defibrillation after prolonged ventricular fibrillation, and substantial time without chest compressions during the resuscitation effort. A local change in our previous resuscitation protocols had been instituted based upon this historical database information.

Cardiopulmonary Resuscitation↗
PubMed1987

Neurologic benefits from the use of early cardiopulmonary resuscitation.

The efficacy of bystander CPR in resuscitation from cardiac arrest when defibrillation is available within five to six minutes has been questioned. Epidemiologic studies from different cities have shown conflicting results. We conducted a study to determine the effect of early CPR versus no CPR on resuscitability, 24-hour survival, and neurologic deficit in an animal model of cardiac arrest. Twenty-two mongrel dogs were subjected to five minutes of electrically induced ventricular fibrillation. In 11 dogs, closed-chest massage and ventilation with room air was begun immediately and was continued for five minutes. The other 11 dogs received no CPR. At five minutes defibrillation was attempted and advanced cardiac life support (ACLS) protocols were followed until the animal was resuscitated or died. No statistical difference in resuscitability or 24-hour survival between the two groups was demonstrated. Eight of 11 "early CPR" animals were resuscitated and survived 24 hours; six of 11 "no CPR" dogs were resuscitated, and five lived for 24 hours. A significant difference was demonstrated by the Student t test in neurologic deficit and ease of resuscitation. "Early CPR" dogs had no neurologic deficit, while "no CPR" dogs had a 41% deficit (P less than .01). "Early CPR" dogs were resuscitated in significantly less time once ACLS was started (29 versus 317 seconds), and required less electrical energy (100 versus 560 J), fewer countershocks (1.3 versus 4.0), and less epinephrine (0.1 versus 1.7 mg) than did "no CPR" animals. In this animal model of cardiac arrest, early CPR was shown to be beneficial to neurologic function and ease of resuscitation, even when ACLS was provided within five minutes.

Animals↗
PubMed1996

Traumatic hypothermia is related to hypotension, not resuscitation.

STUDY OBJECTIVE: To determine whether posttraumatic hypothermia is associated with hemorrhage or with resuscitation. METHODS: We used a sequential hemorrhage-resuscitation rat model. Rats were subjected to hemorrhage (30 mL/kg), then 1 hour of shock, followed by 2:1 crystalloid/blood resuscitation (60 mL/kg) at ambient temperature. A control group underwent neither hemorrhage nor resuscitation. RESULTS: We recorded core temperature and blood pressure every 10 minutes. Temperature drop averaged 3.4 degrees C and was fastest during hypotensive shock. Rate of temperature change correlated with blood pressure (beta = .0102, P < .001), shock phase (beta = .4504, P = .041), and blood pressure during shock phase (beta = .0116, P < .001), but not with resuscitation phase or with duration of shock or resuscitation. Three of 14 rats died during shock, none during resuscitation. An increase in temperature was noted in 1 of 14 rats during shock and in 7 of 11 rats during resuscitation. CONCLUSION: Hemorrhage-associated hypothermia occurs during hypotensive shock, not during fluid resuscitation.

Animals↗
PubMed1998

Do advanced cardiac life support drugs increase resuscitation rates from in-hospital cardiac arrest? The OTAC Study Group.

STUDY OBJECTIVE: The benefit of Advanced Cardiac Life Support (ACLS) medications during cardiac resuscitation is uncertain. The objective of this study was to determine whether the use of these medications increased resuscitation from in-hospital cardiac arrest. METHODS: A prospective cohort of patients undergoing cardiac arrest in 1 of 5 academic hospitals was studied. Patient and arrest factors related to resuscitation outcome were recorded. We determined the association of the administration of ACLS drugs (epinephrine, atropine, bicarbonate, calcium, lidocaine, and bretylium) with survival at 1 hour after resuscitation. RESULTS: Seven hundred seventy-three patients underwent cardiac resuscitation, with 269 (34. 8%) surviving for 1 hour. Use of epinephrine, atropine, bicarbonate, calcium, and lidocaine was associated with a decreased chance of successful resuscitation (P <.001 for all except lidocaine, P <.01). While controlling for significant patient factors (age, gender, and previous cardiac or respiratory disease) and arrest factors (initial cardiac rhythm, and cause of arrest), multivariate logistic regression demonstrated a significant association between unsuccessful resuscitation and the use of epinephrine (odds ratio . 08 [95% confidence interval .04-.14]), atropine (.24 [.17-.35]), bicarbonate (.31 [.21-.44]), calcium (.32 [.18-.55]), and lidocaine (.48 [.33-.71]). Drug effects did not improve when patients were grouped by their initial cardiac rhythm. Cox proportional hazards models that controlled for significant confounders demonstrated that survivors were significantly less likely to receive epinephrine (P <. 001) or atropine (P <.001) throughout the arrest. CONCLUSION: We found no association between standard ACLS medications and improved resuscitation from in-hospital cardiac arrest. Randomized clinical trials are needed to determine whether other therapies can improve resuscitation from cardiac arrest when compared with the presently used ACLS drugs.

Aged↗
PubMed1998

From reviving the living to raising the dead; the making of cardiac resuscitation.

Cardiac arrest (the process of the heart ceasing to beat) and cardiac resuscitation (the attempt to restart the heart) were created in the surgical theatres of the early to middle twentieth century, in response to the cardiac arrests which were being caused by the "theatre" doctors themselves. These patients were young and healthy (a consequence of the preselection surgery involves), cardiac resuscitation was trying to revive the living. The paper explores the intimate relationship between cardiac arrest and cardiac resuscitation. By the use of historical and Latourian sociological analysis the paper also reveals how cardiac resuscitation was made into the emblematic medical event it is today, a process which has been so complete that it has become, in many senses, an "obligatory passage point to death", that is, in order to die one must pass through cardiac resuscitation. The outcome of this is the changed nature of cardiac resuscitation, no longer attempting to revive the living, cardiac resuscitation now attempts to raise the dead and dying, and at this it fails. Despite the remarkable success of cardiac resuscitation as a fact, the paper argues that it is a failure as a technique, paradoxically the more successful a fact it became, the more it failed as a procedure. The paper explains this apparent contradiction and the resistance to anomalies, by showing how cardiac resuscitation was created simultaneously inside and outside medical science, from its very start being a social and scientific fact with a vast network of stabilising allies.

Attitude to Death↗
PubMed2002

Neonatal resuscitation: toward improved performance.

BACKGROUND: As part of a continuous quality assurance process which we instituted in 1999, we review videotapes of selected high-risk deliveries at our hospital. We utilized our reviews to evaluate the occurrence of errors, and to evaluate team and leader functions during neonatal resuscitation. METHODS: We established accepted behavior for members of resuscitation teams and the team leader. The actual conduct of the resuscitation was judged against the standard of the guidelines of the Neonatal Resuscitations Program of the American Heart Association, and the American Academy of Pediatrics. The videotapes of resuscitations were reviewed, and significant deviations from accepted practices were noted, and discussed by a specifically developed quality assurance committee, including, whenever possible, the actual resuscitators. RESULTS: We were able to detect a number of problems, which included inappropriate leader and team member activities, inappropriate preparation, communication, and coordination, and made a number of changes to our practice. CONCLUSIONS: We believe that neonatal resuscitation may be improved by the provision of teaching about team and leader functions, encouraging debriefing following complicated resuscitations, developing a minimal form to be completed for any patient requiring compressions or epinephrine within the delivery room, and providing more direct observations regarding the actual conduct of resuscitation.

Asphyxia Neonatorum↗
PubMed2002

Treatment of post resuscitation myocardial dysfunction: aortic counterpulsation versus dobutamine.

BACKGROUND: Post resuscitation myocardial stunning is well described and recognized as a significant contributor to poor long-term outcome following cardiac arrest. Optimal strategies for treatment have not been determined. METHODS: Ten domestic swine (49+/-3 kg) underwent 15 min of untreated ventricular fibrillation before being successfully resuscitated. Left ventricular systolic and diastolic function was measured at pre-arrest baseline, at 30 min and at 6 h post resuscitation. Five animals were treated immediately after resuscitation with intra-aortic balloon counterpulsation (IABP) and five were given dobutamine (5 mcg/kg per min). RESULTS: No baseline differences were found. At 30 min post resuscitation pulmonary capillary wedge pressure and LVEDP were significantly higher (16+/-3 vs. 7+/-1 and 20+/-2 vs. 11+/-1 mmHg) while LV isovolumic relaxation ('Tau') was significantly longer (34+/-2 vs. 20+/-2 ms) in the IABP treated versus the dobutamine treated animals. Likewise, at 6 h post resuscitation LV ejection fraction was significantly less (21+/-6 vs. 39+/-4%), and LVEDP significantly higher (18 vs. 10 mmHg) in the IABP group. Heart rate was not different between the groups at any time post resuscitation. CONCLUSION: Dobutamine was superior to IABP for treatment of post resuscitation left ventricular systolic and diastolic dysfunction. The hypothesized advantage of IABP for treatment of post resuscitation myocardial stunning without excessively raising the heart rate like dobutamine was not realized.

Animals↗
PubMed2002

Post-resuscitation right ventricular dysfunction: delineation and treatment with dobutamine.

BACKGROUND: Left ventricular dysfunction after resuscitation from cardiac arrest has been well described. Treatment with dobutamine improves post-resuscitation left ventricular function. Right ventricular function following resuscitation has not been investigated. The purposes of this study were to examine right ventricular function following resuscitation and determine whether dobutamine would improve post-resuscitation right ventricular function. METHODS AND RESULTS: Right ventricular function was measured in 28 swine (29+/-1 kg) before and after resuscitation from 15 min of untreated ventricular fibrillation. Twelve animals received dobutamine at 10 mcg/kg/min while 16 animals served as untreated controls. Among controls, right ventricular dysfunction post-resuscitation was demonstrated by a decrease in right ventricular ejection fraction and an increase in right ventricular end-diastolic pressure. Among animals treated with dobutamine, there was a significant improvement in right ventricular function post-resuscitation compared to untreated controls. CONCLUSIONS: This study establishes that right ventricular systolic and diastolic dysfunction does occur after prolonged cardiac arrest from ventricular fibrillation. Dobutamine can ameliorate post-resuscitation right ventricular dysfunction.

Animals↗
PubMed1999

The place of general practitioners in the management of out-of-hospital cardiopulmonary resuscitation.

BACKGROUND: The involvement of general practitioners in community based resuscitation of out-of-hospital cardiac arrest has been found to be effective in improving survival rates. The aim of the study was to assess the potential for including general practitioners in Nottinghamshire in the resuscitation of out-of-hospital cardiac arrest victims by first determining whether they had the skill, experience and equipment to provide cardio-pulmonary resuscitation in the community; and second to ascertain what proportion of them would be prepared to establish a 'rapid response' scheme for patients requiring resuscitation. METHODS: A postal questionnaire survey, between March and April 1997, of all 738 general practitioners in Nottinghamshire who serve, in total, a population of 1 million. RESULTS: A total of 592 general practitioners (80%) responded to our survey. The majority worked in a predominantly urban environment and carried out their own out-of-hours on-call duties. Of them 93% had previous experience in cardiopulmonary resuscitation (median of 3 years), while 72.1% had experience of advanced life support, including use of a defibrillator but not recently (median of 8 years). General practitioners in rural practices were more likely to be trained in advanced life support (ALS), had more recent experience in cardiopulmonary resuscitation (including defibrillation) and were more willing to be involved in any proposed local resuscitation scheme. Only 9% of general practitioners carried a defibrillator when on-call and only 13% had access to a defibrillator within their practice premises. Of the general practitioners surveyed 349 (59%) reported a willingness to participate in a 'rapid response cardiac arrest' scheme and general practitioners who had no formal advanced life support training were as willing to become involved in such a scheme as those who were trained in ALS. CONCLUSIONS: General practitioners may have an important role to play in improving the survival outcome of out-of-hospital cardiac arrest as many are ALS trained and have recent experience in resuscitation. However, few have access to a defibrillator and many do not have recent experience of defibrillation. Any proposed local resuscitation scheme would be particularly applicable to rural general practitioners as many have recent training in ALS, recent experience in advanced life support and most of all, are more willing to participate in such a scheme.

Attitude of Health Personnel↗
PubMed1985

Importance of the duration of inadequate coronary perfusion pressure on resuscitation from cardiac arrest.

The effect of the duration of inadequate coronary perfusion pressure on resuscitation from cardiac arrest was examined in 32 mongrel dogs with a mean weight of 22 +/- 5 kg. In all dogs, the heart was electrically fibrillated and closed chest compression with assisted ventilation was performed for 15 minutes. At this time, all dogs had an inadequate coronary perfusion pressure (mean 7 +/- 9 mm Hg) and were randomized to a control group (group 1) with continued closed chest compression or to one of the three groups with open chest cardiac massage. These three groups differed only in the duration of continued closed chest compression before initiation of open chest massage (15, 20 and 25 minutes, respectively, in groups 2, 3 and 4). The control group (group 1) had no significant increase in coronary perfusion pressure, and only one of the eight dogs could be resuscitated. The three groups with open chest cardiac massage had a significant increase in coronary perfusion pressure (from 5 +/- 9 to 51 +/- 26 mm Hg, p less than 0.05), but the rate of successful resuscitation depended on the duration of inadequate coronary perfusion pressure before cardiac open chest massage. In group 2, six of eight dogs were resuscitated (p less than 0.05 compared with the control group); in group 3, three of eight dogs were resuscitated and in group 4 none of the eight dogs was resuscitated. The resuscitation rate was significantly (p less than 0.05) greater in group 2 than in group 4. These findings indicate that techniques that improve coronary perfusion pressure during cardiopulmonary resuscitation must be applied before extensive myocardial cellular dysfunction occurs if the probability of successful resuscitation is to be improved.

Animals↗
PubMed1986

Twenty-four hour survival in a canine model of cardiac arrest comparing three methods of manual cardiopulmonary resuscitation.

Two new modifications of manual cardiopulmonary resuscitation, high impulse compression at a rate of 120/min and interposed abdominal compression at a rate of 60/min, have been reported to produce better hemodynamic responses than standard cardiopulmonary resuscitation at 60/min. However, the effect of these two new methods on initial resuscitation success and 24 hour survival is unknown. In this study, 30 mongrel dogs were divided into three equal groups, each treated with one of three types of manual cardiopulmonary resuscitation. Ventricular fibrillation was induced electrically in morphinized, endotracheally intubated dogs emerging from halothane anesthesia. After 3 minutes of circulatory arrest without intervention, one of the three techniques of manual cardiopulmonary resuscitation was begun, and continued for 17 minutes. Defibrillation was performed at 20 minutes. Successful resuscitation was defined as a mean arterial blood pressure of at least 60 mm Hg, without chest compressions, 10 minutes after the initial defibrillation attempt. Intensive care was provided for 2 hours, including hemodynamic and respiratory monitoring, and drug intervention when required. Twenty-four hour survival and neurologic deficit were used as critical measures of outcome. Ten of 30 animals survived 24 hours with a mean neurologic deficit score of 5% (normal = 0, brain dead = 100). There was no difference in initial resuscitation success, 24 hour survival or neurologic deficit of the survivors among the three manual cardiopulmonary resuscitation methods. Aortic diastolic and calculated coronary perfusion pressures were similar for all three methods. Well performed standard manual cardiopulmonary resuscitation is as effective as these modified versions (high impulse compression and interposed abdominal compression) when compared in the same animal model.

Animals↗
PubMed1987

Serum potassium, calcium and magnesium after resuscitation from ventricular fibrillation: a canine study.

Serum electrolytes were measured before and sequentially for 3 hours after resuscitation from ventricular fibrillation in a canine model that was designed to approximate the human cardiac arrest and resuscitation process. Twenty anesthetized dogs were resuscitated from ventricular fibrillation; 7 required epinephrine during resuscitation and 13 did not. To control for the effects of anesthesia, 10 dogs were anesthetized and instrumented, but ventricular fibrillation was not induced. Serum potassium decreased from 3.7 +/- 0.3 mmol/liter at baseline to 3.2 +/- 0.4 mmol/liter 45 minutes after resuscitation in the experimental dogs resuscitated without epinephrine, as compared with 3.6 +/- 0.3 to 3.4 +/- 0.2 mmol/liter in control dogs (p = 0.07 versus control dogs by two-way analysis of variance) and returned toward baseline at the end of 3 hours. Serum calcium decreased from 9.6 +/- 0.6 mg/dl at baseline to 8.9 +/- 0.9 mg/dl at 5 minutes after resuscitation as compared with 9.4 +/- 0.7 to 9.5 +/- 0.7 mg/dl in control dogs (p less than 0.05 versus control dogs) and returned to baseline by 3 hours. Serum magnesium decreased from 1.5 +/- 0.1 to 1.3 +/- 0.2 mEq/dl by 3 hours in resuscitated dogs as compared with 1.6 +/- 0.2 to 1.5 +/- 0.2 mEq/dl in control dogs (p = 0.06 versus control dogs). These changes in serum potassium, calcium and magnesium were independent of the administration of epinephrine during the resuscitation process. Changes in potassium were independent of arterial pH or bicarbonate therapy. Serum glucose increased after ventricular fibrillation but not in control dogs (p less than 0.0005 versus control). No changes in other electrolytes were observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed2003

Organ-specific changes in high-energy phosphates after hemorrhagic shock and resuscitation in the rat.

BACKGROUND: Adenosine nucleotides provide energy for many essential cellular functions. Liver and intestinal ATP and energy charge are known to decrease during hemorrhagic shock, and the ability to regenerate high-energy phosphates may have important implications for recovery. We measured organ-specific changes in energy charge after hemorrhagic shock and after shock followed by resuscitation. STUDY DESIGN: Anesthetized Sprague-Dawley rats were bled and maintained at a mean arterial pressure (MAP) of 40 mmHg for 1, 2, 3, or 4 hours. Some animals were resuscitated with normal saline and shed blood (1:1) to a mean arterial pressure of 80 to 90 mmHg for 1 hour. Control animals were anesthetized, but not hemorrhaged. At the conclusion, blood gases and adenine nucleotides were measured. RESULTS: Arterial pO2 and pCO2 were normal in all groups. Unresuscitated hemorrhage caused metabolic acidosis, but bicarbonate was normal in controls and after hemorrhage followed by resuscitation. Energy charge (EC) in the gastrocnemius was unaffected by hemorrhage or resuscitation. Liver EC decreased after hemorrhage (p = 0.0001), but recovered partially after resuscitation. Kidney EC was decreased after only 3 hours of hemorrhage and 1 hour of resuscitation (p = 0.005), but not with shorter periods of hemorrhage. Lung EC decreased with shock, but was substantially worse after resuscitation (p < 0.05). CONCLUSIONS: After hemorrhage and resuscitation, EC decreased in lung, liver, kidney, and intestine, but the time course, extent of decline, and ability to recover after resuscitation varied from organ to organ. Inability to regenerate high-energy phosphates after hemorrhagic shock may be a marker for more severe cellular damage.

Adenosine Diphosphate↗
PubMed1984

Choices about cardiopulmonary resuscitation in the hospital. When do physicians talk with patients?

We studied the extent to which 82 private physicians and 75 house officers talked with hospitalized patients or their families (or both) about whether they would desire cardiopulmonary resuscitation if it became necessary. During the period of study (1981), 154 patients were resuscitated at our university teaching hospital. In 68 per cent of the cases, physicians had formed an opinion about the patient's attitude toward cardiopulmonary resuscitation. However, only 30 (19 per cent) of the patients had discussed resuscitation before the arrest with either their private physician or a house officer (or both); 51 (33 per cent) of the families were consulted. These percentages did not differ significantly according to the underlying disease, whether the patient was on the general wards or in the intensive-care unit, the physician's estimate of the probability of arrest, or the physician's level of training. Even the 151 physicians who believed that patients should participate in decisions about resuscitation, actually discussed the issue with their patients only rarely. We interviewed the 24 competent patients who survived cardiopulmonary resuscitation, to compare their actual attitudes about resuscitation with their physicians' opinions about their attitudes. The physician's opinion about a patient's desire for resuscitation correlated only weakly with the preference expressed by the patient. We suggest that physicians and patients consider the benefit of open discussion about cardiopulmonary resuscitation.

Adolescent↗
PubMed2003

Public education regarding resuscitation: effects of a multimedia intervention.

STUDY OBJECTIVE: Previous studies have demonstrated inaccuracies in knowledge and perceptions regarding cardiopulmonary resuscitation (CPR) among the general public. This study was undertaken to determine the effect of a multimedia educational intervention on knowledge base and resuscitation preferences among the lay public. METHODS: In this prospective interventional study with preintervention and postintervention measurements, a validated multisite survey was administered to 310 volunteer lay participants in community-based settings during 2001 and 2002. The survey was piloted and validated (percentage of agreement index 98.6%; 95% confidence interval [CI] 0.9810 to 0.9900). An original 8-minute multimedia educational video was written and produced by physicians to provide educational information about cardiac resuscitation to the lay public. RESULTS: Among 310 participants, the mean age was 40 years (range 17 to 92 years), 67% were female, and 57% reported household incomes of more than 30,000 US dollars. Participants' median estimates of predicted postcardiac arrest survival rate before and after the educational intervention were 50% and 16%, respectively (median change 30%; 95% CI 25% to 35%). Median estimated durations of resuscitative efforts in the emergency department before and after the educational intervention were 30 minutes and 19 minutes, respectively (median change 10 minutes; 95% CI 5 to 15 minutes). For a series of hypothetical scenarios, significantly more participants indicated that they would refuse resuscitative efforts in scenarios involving terminally ill patients after the educational intervention. CONCLUSION: Inaccurate perceptions regarding cardiac resuscitation and postarrest survival exist among the lay public. A novel educational intervention demonstrated effective improvements in knowledge base regarding resuscitation, resulting in significant effects on resuscitation preferences among the lay public. Improved public education regarding resuscitation is needed to improve knowledge regarding CPR among the lay public.

Adolescent↗
PubMed2003

Ketone and pyruvate Ringer's solutions decrease pulmonary apoptosis in a rat model of severe hemorrhagic shock and resuscitation.

BACKGROUND: Resuscitation fluids containing beta-hydroxybutyrate (BHB) have been shown to decrease cellular injury after hemorrhagic shock and resuscitation through an unknown mechanism. We tested whether this effect was related to BHB-induced metabolic modulations. METHODS: Male Sprague Dawley rats (n=30) were subjected to volume-controlled hemorrhage (27 mL/kg during 10 minutes followed by 75 minutes of shock during which another 8 mL/kg of blood was withdrawn). Experimental groups included the following: (1) sham, (2) no resuscitation (NR), (3) racemic lactated Ringer's (DL-LR) solution, (4) LR containing L-isomer only (L-LR), (5) ketone Ringer's solution with lactate substituted by BHB (KR), and (6) pyruvate Ringer's solution with lactate substituted by pyruvate (PR). The resuscitation fluids were infused during 45 minutes simultaneously with additional hemorrhage of 8 mL/kg. Hemodynamic and physiologic parameters and the plasma levels of BHB were serially measured. The animals were killed 2 hours after resuscitation, and tissues were frozen instantaneously for cellular adenylate extraction and adenosine triphosphate (ATP) and adenosine diphosphate analysis. Pulmonary apoptosis was studied using Western blotting, immunohistochemistry, and reverse transcriptase-polymerase chain reaction. Expression of enzymes involved in ketogenesis and ketolysis was analyzed by reverse transcriptase-polymerase chain reaction. RESULTS: NR and resuscitation with DL-LR increased the expression of apoptotic markers, whereas resuscitation with KR and PR significantly decreased the expression of apoptotic markers in rat lungs. Resuscitation with KR was followed by a profound increase in plasma BHB levels; however, the expression levels of ketolytic enzymes were essentially unaffected. KR infusion did not induce significant improvements in tissue ATP levels. CONCLUSIONS: Resuscitation with KR and PR protects against pulmonary apoptosis without improving tissue ATP content. Therefore, metabolic modulation is unlikely to be the major mechanism by which BHB exerts its protective effects during reperfusion.

3-Hydroxybutyric Acid↗
PubMed1993

Are retinal hemorrhages found after resuscitation attempts? A study of the eyes of 169 children.

Resuscitation attempts have been hypothecated to explain retinal hemorrhages in infants who are suspected victims of child abuse. This study was undertaken to test that hypothesis by postmortem ocular examinations following unsuccessful resuscitation attempts on a sample of 169 children selected by 19 prosectors willing to contribute to the study. Cardiopulmonary resuscitation had been attempted for a minimum of 30 min in 131 of the children, whereas 38 controls did not have such protracted attempts; 70 children with prolonged resuscitation attempts had no retinal hemorrhages, including eight children whose fatal blunt force injuries of the trunk represented extremes of the forces used in resuscitation attempts. Children who died of asphyxia, respiratory illnesses, sudden infant death syndrome, and various other causes had no hemorrhages; neither did 21 children who died of head injury or central nervous system (CNS) diseases, nor did 29 controls. Retinal hemorrhages were present in 70 children, 61 with prolonged resuscitation attempts and nine controls. Among those with attempted resuscitation, 56 had head injuries, and four had CNS diseases and sepsis, all recognized causes of retinal hemorrhages. The other death that involved a resuscitation attempt and retinal hemorrhages was an officially "undetermined" death. The child had come from a household with two prior child deaths and documented abuse. No case is found in this study to support the hypothesis that retinal hemorrhages are caused by resuscitation attempts.

Child↗