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PubMed1990

Calcium-entry blockers during porcine cardiopulmonary resuscitation.

1. Calcium-entry blockers increase the intramyocardial pH and decrease the intramyocardial Pco2 of ischaemic canine myocardium. However, the evidence documenting improvements in myocardial acidosis and in myocardial resuscitability after administration of calcium-entry blockers during cardiac arrest is incomplete. We therefore compared the effects of verapamil (0.05 mg/kg) and diltiazem (0.075 mg/kg) with those of saline placebo in an established porcine model of cardiac arrest and cardiopulmonary resuscitation. 2. After verapamil, six of 11 animals were successfully resuscitated; after diltiazem, five of 10; and after saline placebo, six of 10. Coronary perfusion and mean aortic pressures together with end-tidal CO2 concentration during precordial compression were predictive of resuscitation, independently of the drug or placebo. 3. Coronary vein pH decreased to 6.91 +/- 0.06 units (mean +/- SEM) with concurrent increases in PCO2 to levels exceeding 100 mmHg. Coronary vein lactate increased to a maximum of 7.5 +/- 0.6 mmol/l. Coronary vein acidaemia was accompanied by decreases in intramyocardial pH to 6.64 +/- 0.06 units. However, each of these differences between success and failure of resuscitation was unrelated to treatment with calcium-entry blockers. 4. Accordingly, neither verapamil nor diltiazem selectively altered coronary perfusion pressure, attenuated intramyocardial acidosis or improved resuscitability after porcine cardiac arrest and cardiopulmonary resuscitation.

Animals↗
PubMed1999

Resuscitations in an observation unit.

The outcome of all resuscitations in a 20-bed observation unit of a large teaching hospital over a 25-month period was reviewed. Resuscitation was defined as a patient receiving one or more of the following: external chest compressions; defibrillation, assisted ventilation (e.g. intubation); and/or advanced cardiac life support drug therapy such as atropine or lidocaine for life threatening dysrhythmias including ventricular tachycardia, ventricular fibrillation, or asystole. There were nine patients out of 10,245 patients admitted to the observation unit (9/10,245 = 0.088% or approximately 0.09%) over the 26-month period from May 1994 to July 1996 who needed resuscitation. Each patient was initially successfully resuscitated. There was only one death (1/10,245 = 0.0098% or approximately 0.01%) in the observation unit. This patient was resuscitated with return of a spontaneous pulse and blood pressure only to expire while awaiting transfer to the Intensive Care Unit (ICU). Eight of the nine patients were admitted to the ICU, four of whom later died, making a total of five deaths (5/10,245 = 0.049% or approximately 0.05%). The other four patients were discharged neurologically intact and at 1 year follow-up were alive and doing well. Compared with resuscitation rates for the prehospital setting, the emergency department, the hospital medical/surgical floors, or the intensive care units, there is a higher successful resuscitation rate for the observation unit.

Admitting Department, Hospital↗
PubMed1998

Survival after in-hospital cardiopulmonary resuscitation. A meta-analysis.

OBJECTIVE: To determine the rates of immediate survival and survival to discharge for adult patients undergoing in-hospital cardiopulmonary resuscitation, and to identify demographic and clinical variables associated with these outcomes. MEASUREMENTS AND MAIN RESULTS: The MEDLARS database of the National Library of Medicine was searched. In addition, the authors' extensive personal files and the bibliography of each identified study were searched for further studies. Two sets of inclusion criteria were used, minimal (any study of adults undergoing in-hospital cardiopulmonary resuscitation) and strict (included only patients from general ward and intensive care units, and adequately defined cardiopulmonary arrest and resuscitation). Each study was independently reviewed and abstracted in a nonblinded fashion by two reviewers. The data abstracted were compared, and any discrepancies were resolved by consensus discussion. For the subset of studies meeting the strict criteria, the overall rate of immediate survival was 40.7% and the rate of survival to discharge was 13.4%. The following variables were associated with failure to survive to discharge: sepsis on the day prior to resuscitation (odds ratio [OR] 31.3; 95% confidence interval [CI] 1.9, 515), metastatic cancer (OR 3.9; 95% CI 1.2, 12. 6), dementia (OR 3.1; 95% CI 1.1, 8.8), African-American race (OR 2. 8; 95% CI 1.4, 5.6), serum creatinine level at a cutpoint of 1.5 mg/dL (OR 2.2; 95% CI 1.2, 3.8), cancer (OR 1.9; 95% CI 1.2, 3.0), coronary artery disease (OR 0.55; 95% CI 0.4, 0.8), and location of resuscitation in the intensive care unit (OR 0.51; 95% CI 0.4, 0.8). CONCLUSIONS: When talking with patients, physicians can describe the overall likelihood of surviving discharge as 1 in 8 for patients who undergo cardiopulmonary resuscitation and 1 in 3 for patients who survive cardiopulmonary resuscitation.

Adult↗
PubMed2000

The capacity of different infusion fluids to lower the prooxidant activity of plasma iron: an important factor in resuscitation?

BACKGROUND: Prooxidant activity of non-protein-bound iron (NPBI) is an important contributor to reactive oxygen species-induced injury after the resuscitation of critically ill patients. Plasma NPBI occurs in critically ill adults, children, and newborn babies, who often require resuscitation. The ability of the resuscitation fluids to bind iron and lower the patients' NPBI levels in vitro has not previously been studied. STUDY DESIGN AND METHODS: In an in vitro model, highly iron-saturated cord blood plasma from 10 preterm and 10 term babies was mixed with FFP, pasteurized plasma protein solution, and 0.9-percent saline. Plasma from 10 healthy adult volunteers was used as a control. Before and after the mixing with any resuscitation fluid, NPBI levels and ceruloplasmin iron-oxidizing and transferrin iron-binding antioxidant capacities were measured. RESULTS: After the in vitro mixing with FFP, the incidence and concentration of NPBI were markedly decreased and the iron-binding antioxidant capacity was increased in the plasma of the preterm and term babies. Being mixed with pasteurized plasma protein solution and 0.9-percent saline did not influence the iron-binding antioxidant capacity of newborn babies' plasma. In the control plasma, results were not changed after the mixing with any resuscitation fluid. In every group, the iron-oxidizing antioxidant capacity was not changed after the mixing with any fluid. CONCLUSION: Iron-induced oxidative tissue damage may be influenced by resuscitation fluids. In the ongoing debate over the choice of crystalloid or colloid resuscitation fluids, the influence of each fluid on the patient's antioxidant capacity warrants more attention.

Adult↗
PubMed2003

[Comparison of different laryngeal mask airways in a resuscitation model].

OBJECTIVE: The standard laryngeal mask airway LMA-Classic is recommended in the ILCOR guidelines as alternative to facemask and tracheal tube during cardiopulmonary resuscitation. LMA-Unique, LMA-Fastrach and LMA-ProSeal are additional variants that are compared with the standard LMA in a resuscitation model. METHODS: Tidal volumes, chest compressions and signs of gastric inflation are measured in a standardized resuscitation model (Ambu Cardiac Care Trainer with notebook and thumper). Ten 3-minute resuscitation cycles were performed with facemask and all LMAs (Classic, Unique, Fastrach, ProSeal, all size 4) with a ventilation : compression ratio of 2:15. To allow comparison with tracheal tube and to judge safety margins, another ten resuscitation cycles were performed with tracheal tube and all laryngeal masks with continuous chest compressions after two initial ventilations. The bag-valve device used for ventilation was replaced by an automatic transport ventilator in a third series with continuous chest compressions. Cuff pressures were set at 80 cm H2O. RESULTS: During interrupted chest compressions, adequate ventilation was possible with all devices. Tidal volumes for facemask, LMA-Fastrach and LMA-ProSeal were significantly (p < 0.001) higher than with LMA- Classic and LMA-Unique. During continuous chest compressions, significant differences (p < 0.001) occurred when comparing tracheal tube, Fastrach and ProSeal with the other two laryngeal mask airways, which did not reach recommended tidal volumes. During ventilation with the automatic transport ventilator, values for all devices except LMA-ProSeal dropped significantly, adequate ventilation was possible with tracheal tube, Fastrach and ProSeal. Signs of gastric inflation were found during ventilation with facemask and - to a lesser extent - with LMA-Classic. CONCLUSION: In the resuscitation model chosen, all laryngeal mask airways are possible alternatives for ventilation during cardiopulmonary resuscitation. The new LMA-ProSeal and also the LMA-Fastrach allow higher tidal volumes even during elevated intrathoracic pressures caused by continuous chest compressions, performing superior to the standard laryngeal mask airway. For inclusion of these devices in the ILCOR guidelines, further research in patients is warranted.

Cardiopulmonary Resuscitation↗
PubMed1991

[Successful treatment of a fulminant pulmonary embolism using a high-dose bolus injection of urokinase during cardiopulmonary resuscitation].

Experience has shown that the bolus injection of streptokinase during resuscitation in case of fulminant pulmonary embolism considerably improves the prognosis. In the case presented here a 64-year old female patient with a fulminant pulmonary embolism was injected with 2 x 1,000,000 I.U. urokinase after 20 minutes of unsuccessful cardiopulmonary resuscitation. Ten minutes after the second injection the circulation could be stabilised by drugs only. The patient survived without any lasting damage. The mechanism of fibrinolysis during resuscitation is discussed. It is also possible to check the diagnosis during resuscitation using echocardiography or angiography. However, treatment must usually start immediately only on clinical diagnosis. Resuscitation in the case of a pulmonary embolism can even be successful after much longer than one hour. Contra-indications must be ignored in such cases. Side effects, which are usually haemorrhages, can as a rule be treated. In our opinion urokinase should be given by preference in the bolus injection during resuscitation. The exception to this is the primary operation during resuscitation. Pulmonary embolectomy is also possible after unsuccessful fibrinolysis.

Female↗
PubMed1997

Laerdal infant resuscitators are unreliable as free-flow oxygen delivery devices.

Laerdal Infant Resuscitators (Laerdal Medical Co., NY) are commonly used as free-flow oxygen delivery devices during neonatal resuscitation in situations where oxygen but not mechanical ventilation is desired. This study evaluates the performance of these resuscitators as free-flow oxygen devices. Efficiency was measured by comparing oxygen flow entering the resuscitator to oxygen flow delivered by the resuscitator. Clinical impact was assessed by measuring simulated patient fiO2. Three randomly selected resuscitator bags were tested for oxygen delivery efficiency by comparing oxygen inflow to outflow over an inflow range of 1 to 15 liters per minute (lpm). Measured outflow was 18-24% of inflow, demonstrating that as much as 82% of the oxygen flow escapes via the safety air inlet, safety blow-off valves, and other leaks. With the patient valve assembly removed, efficiency improved to 53-59%. Simulated fiO2 ranged from 0.23 to 0.68 at 5 lpm oxygen flow. We conclude that use of the Laerdal Infant Resuscitator for the delivery of free-flow oxygen, even with the valve assembly removed, generates highly variable patient fiO2. The use of self-inflating bags for delivery of oxygen without manual ventilation should be reconsidered.

Equipment Design↗
PubMed2003

Oxidative stress in asphyxiated term infants resuscitated with 100% oxygen.

OBJECTIVE: To test the hypothesis that resuscitation of asphyxiated infants with pure oxygen causes hyperoxemia and oxidative stress.Study design Asphyxiated term newborn infants (n = 106) were randomly resuscitated with room air (RAR = 51) or 100% oxygen (OxR = 55). The Apgar score, time of the first cry, and establishment of a sustained pattern of respiration were recorded. Assays performed included: blood gases; reduced glutathione (GSH) and oxidized glutathione (GSSG) in whole blood; glutathione-related enzyme activities; and superoxide dismutase activity (SOD) in erythrocytes. RESULTS: The RAR group needed less time of ventilation for resuscitation (5.3 +/- 1.5 vs 6.8 +/- 1.2 min; P <.05). Pure oxygen caused hyperoxemia (PO(2), 126.3 +/- 21.8 mm Hg) that did not occur with the use of room air (PO(2), 72.2 +/- 6.8 mm Hg). GSH was decreased and GSSG, the glutathione cycle enzymes, and SOD activities were increased in both asphyxiated groups. However, the 100% oxygen-resuscitated group showed significantly greater alterations that correlated positively with hyperoxemia. CONCLUSIONS: Asphyxia causes oxidative stress in the perinatal period, and resuscitation with 100% oxygen causes hyperoxemia and increased oxidative stress. Because there are no advantages to resuscitation with 100% oxygen, room air may be preferred under certain circumstances for the resuscitation of asphyxiated neonates.

Apgar Score↗
PubMedDate not supplied

Resuscitation in the out-of-hospital setting: medical futility criteria for on-scene pronouncement of death.

The complete and irreversible cessation of life is often difficult to determine with complete confidence in the dynamic environment of out-of-hospital emergency care. As a result, resuscitation efforts often are initiated and maintained by emergency medical services (EMS) providers in many hopeless situations. Medical guidelines are reviewed here to aid EMS organizations with respect to decisions about: 1) initiating or waiving resuscitation efforts; 2) the appropriate duration of resuscitation efforts; and 3) recommended procedures for on-scene or prehospital pronouncement of death (termination of resuscitation). In cases of nontraumatic cardiac arrest, few unassailable criteria, other than certain physical signs of irreversible tissue deterioration, exist for determining medical futility at the initial encounter with the patient. Thus, the general medical recommendation is to attempt to resuscitate all patients, adult or child, in the absence of rigor mortis or dependent lividity. Conversely, wellfounded guidelines now are available for decisions regarding termination of resuscitation in such patients once they have received a trial of advanced cardiac life support. In practice, however, the final decision to proceed with on-scene pronouncement of death for these patients may be determined more by family and provider comfort levels and the specific on-scene environment. For patients with posttraumatic circulatory arrest, the type of injury (blunt or penetrating), the presence of vital signs, and the electrocardiographic findings are used to determine the futility of initiating or continuing resuscitation efforts. In general, patients who are asystolic on-scene are candidates for on-scene pronouncement, regardless of mechanism. With a few exceptions, blunt trauma patients with a clearly associated mechanism of lethal injury are generally candidates for immediate cessation of efforts once they lose their pulses and respirations. Regardless of the medical futility criteria, specialized training of EMS providers and targeted related testing of operational issues need to precede field implementation of on-scene pronouncement policies. Such policies also must be modified and adapted for local issues and resources. In addition, although the current determinations of medical futility, as delineated here, are important to establish for societal needs, the individual patient's right to live must be kept in mind always as new medical advances are developed.

Adolescent↗
PubMed1998

Chronic resuscitation after trauma-hemorrhage and acute fluid replacement improves hepatocellular function and cardiac output.

OBJECTIVE: To determine whether prolonged (chronic) resuscitation has any beneficial effects on cardiac output and hepatocellular function after trauma-hemorrhage and acute fluid replacement. BACKGROUND DATA: Acute fluid resuscitation after trauma-hemorrhage restores but does not maintain the depressed hepatocellular function and cardiac output. METHODS: Male Sprague-Dawley rats underwent a 5-cm laparotomy (i.e., trauma was induced) and were bled to and maintained at a mean arterial pressure of 40 mmHg until 40% of maximal bleed-out volume was returned in the form of Ringer's lactate (RL). The animals were acutely resuscitated with RL using 4 times the volume of maximum bleed-out over 60 minutes, followed by chronic resuscitation of 0, 5, or 10 mL/kg/hr RL for 20 hours. Hepatocellular function was determined by an in vivo indocyanine green clearance technique. Hepatic microvascular blood flow was assessed by laser Doppler flowmetry. Plasma levels of interleukin-6 (IL-6) were determined by bioassay. RESULTS: Chronic resuscitation with 5 mL/kg/hr RL, but not with 0 or 10 mL/kg/hr RL, restored cardiac output, hepatocellular function, and hepatic microvascular blood flow at 20 hours after hemorrhage. The regimen above also reduced plasma IL-6 levels. CONCLUSION: Because chronic resuscitation with 5 mL/kg/hr RL after trauma-hemorrhage and acute fluid replacement restored hepatocellular function and hepatic microvascular blood flow and decreased plasma levels of IL-6, we propose that chronic fluid resuscitation in addition to acute fluid replacement should be routinely used in experimental studies of trauma-hemorrhage.

Animals↗
PubMed2002

Hypertonic saline resuscitation of hemorrhagic shock diminishes neutrophil rolling and adherence to endothelium and reduces in vivo vascular leakage.

OBJECTIVE: To evaluate the in vivo effects of hypertonic saline (HTS) resuscitation on the interactions of endothelial cells (ECs) and polymorphonuclear neutrophils (PMNs) and vascular permeability after hemorrhagic shock. SUMMARY BACKGROUND DATA: The PMN has been implicated in the pathogenesis of EC damage and organ injury following hemorrhagic shock. Compared to Ringer's lactate (RL), HTS resuscitation diminishes PMN and EC adhesion molecule expression and organ sequestration of PMNs. METHODS: In a murine model of hemorrhagic shock (50 mmHg for 45 minutes followed by resuscitation) using intravital microscopy on cremaster muscle, the authors studied PMN-EC interactions and vascular leakage (epifluorescence after 50 mg/kg fluorescent albumin) in three resuscitation groups: HTS (shed blood + 4 cc/kg 7.5% HTS, n = 12), RL (shed blood + RL [2x shed blood volume], n = 12), and sham (no hemorrhage or resuscitation, n = 9). EC ICAM-1 expression was evaluated by immunohistochemistry. Data, presented as mean +/- SEM, were evaluated by analysis of variance with Bonferroni correction. RESULTS: There were no differences between groups in flow mechanics. Compared to RL, HTS animals (t = 90 minutes) displayed diminished PMN rolling and PMN adhesion to EC at time intervals beyond t = 0. There were no differences between the sham and HTS groups. Vascular leakage was 45% lower in HTS than in RL-resuscitated animals. Cremaster EC ICAM-1 expression was similar in the two groups. CONCLUSIONS: Using HTS instead of RL to resuscitate hemorrhagic shock diminishes vascular permeability in vivo by altering PMN-EC interactions. HTS could serve as a novel means of immunomodulation in hemorrhagic shock victims, potentially reducing PMN-mediated tissue injury.

Animals↗
PubMed1982

Colloid osmotic pressure and fluid resuscitation with hetastarch, albumin, and saline solutions.

The effects of fluid resuscitation with 6% hetastarch, 5% albumin, or 0.9% saline solutions on plasma colloid osmotic pressure (COP) were examined in 26 patients with hypovolemic circulatory shock. One liter of hetastarch produced a 36% increase in COP compared to an 11% increase after 1 L of albumin (p less than 0.001). One liter of saline resulted in a 12% decrease in COP (p less than 0.05). The mean COP increased from 16.3 +/- 1.6 (SE) mm Hg to a maximum of 23.7 +/- 1.4 mm Hg during the first 24 h of hetastarch resuscitation (p less than 0.01), and from 17.0 +/- 1.1 to 22.3 +/- 1.5 mm Hg with albumin (p less than 0.001). Saline resuscitation decreased the COP from 17.1 +/- 1.1 mm Hg to a minimum of 12.7 +/- 1.1 mm Hg (p less than 0.02). These changes persisted from 2-5 days after resuscitation. Saline resuscitation required significantly larger amounts of fluid. The authors conclude that fluid resuscitation of circulatory shock with colloid solutions increases COP and requires less volume of resuscitative fluid.

Aged↗
PubMed1996

Nociceptive somatic nerve stimulation and skeletal muscle injury modify systemic hemodynamics and oxygen transport and utilization after resuscitation from hemorrhage.

OBJECTIVE: To examine if either nociceptive somatic nerve stimulation or skeletal muscle injury modified systemic hemodynamics and oxygen transport and utilization after resuscitation from hemorrhage in anesthetized pigs. DESIGN: Prospective, randomized, controlled laboratory study. SETTING: Animal laboratory. SUBJECTS: Twenty isoflurane-anesthetized and mechanically ventilated large white pigs. INTERVENTIONS: Three groups of animals were instrumented with femoral arterial and thermodilution pulmonary artery catheters. One group of animals had bilateral brachial nerve electric stimulation before hemorrhage (brachial nerve stimulation + hemorrhage, n = 7). The second group of animals had bilateral hindlimbs skeletal muscle injury induced by firing a captive-bolt handgun with standard charges before hemorrhage (skeletal muscle injury + hemorrhage, n = 6). The third group had neither insult before hemorrhage (control, n = 7). Controlled bleeding was initiated to reduce the cardiac index and systemic oxygen delivery (Do2) by 50% in all animals. Animals were then left for 30 mins before resuscitation. All animals were resuscitated with 4.5% human serum albumin at 45 mL/kg and observed for 2 hrs. MEASUREMENTS AND MAIN RESULTS: Plasma volume, systemic hemodynamics, and oxygen transport variables were measured and calculated after resuscitation. Similar increases of plasma volume and supranormal cardiac index were observed in all groups immediately after resuscitation. The branchial nerve stimulation and hemorrhage group maintained higher heart rate, cardiac index, Do2, and oxygen consumption (Vo2) than the hemorrhage group. In contrast, the skeletal muscle injury and hemorrhage group had lower systemic mean arterial pressure and vascular resistance, and a tendency for decrease in Vo2, than the hemorrhage group, although heart rate, cardiac index, and Do2 were similar in both groups. Hemorrhage increased the arterial plasma lactate concentration, which was later normalized in all groups 60 mins after resuscitation. CONCLUSIONS: Neither nociceptive brachial nerve stimulation nor skeletal muscle injury attenuated the increase in plasma volume, cardiac index, or the repayment of systemic oxygen debt after resuscitation from hemorrhage. Brachial nerve stimulation was associated with augmented cardiac index, systemic Do2, and increased Vo2 requirements related to increased sympathetic nervous system activation. Skeletal muscle injury produced early systemic arterial hypotension and vasodilation, and a decrease in Vo2 that was suggestive of pathologic supply dependency on systemic Do2.

Animals↗
PubMed1996

Intraosseous resuscitation of hemorrhagic shock in a pediatric animal model using a low sodium hypertonic fluid.

OBJECTIVE: To study the efficacy of a low sodium hypertonic resuscitation fluid for resuscitation of severe hemorrhage in a pediatric animal, using the intraosseous route. DESIGN: Prospective, randomized, controlled animal study. SETTING: University physiology laboratory. SUBJECTS: Seventeen immature (6- to 9-wk-old) piglets, weighing 10.6 +/- 0.4 kg, were studied under anesthesia. INTERVENTIONS: A new 2400 mosm/L hypertonic fluid, "Isosal" was formulated with reduced (3.45%) sodium content compared with a 2400-mosm/L (7.5%) hypertonic saline solution. This formulation was accomplished by substituting glucose and mixed amino acids for sodium. Piglets were subjected to 1 hr of hemorrhage, reducing the cardiac output to 50% of baseline value. Resuscitation was carried out through the intraosseous route with an initial 6 mL/kg bolus of either hypertonic saline, Isosal, or lactated Ringer's solution. After the initial bolus, additional test fluid was given to maintain the cardiac output at baseline value for a 2-hr period. MEASUREMENTS AND MAIN RESULTS: Total resuscitation volumes, hemodynamic variables, and electrolytes were measured. Intraosseous vascular access was easily established in all animals, and fluid resuscitation was carried out effectively through this route. Resuscitation volumes were significantly lower for both of the hypertonic fluids (12.7 +/- 1.2 mL/kg for hypertonic saline, and 12.5 +/- 1.7 mL/kg for Isosal solution) compared with lactated Ringer's solution (75.3 +/- 11.6 mL/kg) (p = .01). Both hypertonic saline and Isosal solution resulted in an immediate supranormal response in cardiac output that lasted 20 mins. In contrast, when lactated Ringer's solution was used, multiple boluses were required over a 20-min period to normalize cardiac output. Serum sodium was significantly higher in the hypertonic saline group compared with the Isosal or lactated Ringer's groups (p = .001). CONCLUSIONS: Isosal solution was as effective as hypertonic saline in "small volume" resuscitation of severe hemorrhagic shock in a pediatric animal model through the intraosseous route, and produced significantly less hypernatremia when compared with hypertonic saline.

Amino Acids↗
PubMed1999

Resuscitation in the hospital: differential relationships between age and survival across rhythms.

OBJECTIVE: Assess the frequency and outcome of inhospital resuscitation and determine the relationship between patient age and survival and whether it is affected by initial rhythm. DESIGN: Retrospective, single-institution, registry study of inhospital resuscitation. SETTING: A 550-bed, tertiary-care, teaching hospital in Macon, GA. PATIENTS: All admissions for which a resuscitation was attempted in the Medical Center of Central Georgia during the period of January 1, 1987 through December 31, 1993. The registry sample included 2,394 admissions, for which 2,813 resuscitation attempts were made; only the first resuscitation attempt during an admission was analyzed. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Rates of survival to discharge steadily increased from 24.4% in 1987 to 38.6% in 1993; the overall survival rate was 26.8%. Age, used as a continuous variable, was strongly related to survival (odds ratio = 0.984; p < .0001). Categorically, overall survival rates for pediatric, adult, and geriatric patients were 56.4%, 29.0%, and 24.0%, respectively. Survival rates also varied significantly (odds ratio = 0.469; p < .0001) among initial rhythms, i.e., supraventricular tachycardia (60.7%), ventricular tachycardia (57.6%), perfusing rhythms (49.84%), ventricular fibrillation (32.0%), pulseless electrical activity (14.6%), and asystole (9.1%). The relationship between age and survival did not change across the years included in the study, but did vary as a function of initial rhythm (p < .0001). Age was positively related to survival when initial rhythm was supraventricular tachycardia (p = .04), negatively related to survival when the initial rhythm was perfusing (p < .0001) or pulseless electrical activity (p = .0002), and not related to survival when the initial rhythm was ventricular tachycardia (p = .98), ventricular fibrillation (p = .14), or asystole (p = .21). CONCLUSIONS: The relationship between patient age and a successful resuscitation attempt is not as simple as reported earlier. Whether age is related to increased or decreased survival, or is unrelated to survival, depends on the rhythm extant when resuscitation attempts begin. Survival rates were higher than most reported elsewhere and improved significantly over time. Multicentered studies are needed to determine whether these results are unique to the institution studied.

Adolescent↗
PubMed2002

Improved resuscitation minimizes respiratory dysfunction and blunts interleukin-6 and nuclear factor-kappa B activation after traumatic hemorrhage.

OBJECTIVE: We hypothesized that modifying resuscitation would alter hemorrhagic shock-induced respiratory dysfunction and correlate with nuclear factor-kappa B and cytokine expression. DESIGN: Randomized, controlled, prospective study. SETTING: University hospital trauma research laboratory. SUBJECTS: Female, Swiss Webster mice, 8-12 wks old. INTERVENTIONS: Hemorrhagic shock was induced by removing 0.025 mL of blood/g of body weight via a carotid catheter. Animals were resuscitated 30 mins later. Mice were randomized into four groups: group I was cannulated but not bled (sham); group II received normal saline to three times their shed blood volume; group III received their shed blood; and group IV received shed blood + normal saline at two times shed blood volume. MEASUREMENTS AND MAIN RESULTS: We measured the following: serum lactates at the end of shock and after resuscitation, pulmonary function before any instrumentation and after 24 hrs, cytokine concentrations by enzyme-linked immunosorbent assay, and nuclear factor-kappa B activity by electrophoretic mobility shift assay. Groups that were hemorrhaged had significant hypotension and a significant increase in serum lactates over 30 mins. Resuscitation returned the blood pressure to baseline in all groups, and lactates improved in all groups except group II. Group II also demonstrated a significant decrease in pulmonary function characterized by increased airway resistance and decreases in minute volume, lung compliance, and alveolar function. Bronchoalveolar fluid and serum interleukin-6 and whole lung nuclear factor-kappa B activity also were elevated significantly in group II. CONCLUSIONS: Group II demonstrated the least improvement in serum lactate after resuscitation, the most significant acute lung injury, and the greatest interleukin-6 and nuclear factor-kappa B response. Group IV mice had the least acute lung injury, with no detectable interleukin-6 response. Improved resuscitation with crystalloid and shed blood minimized acute lung injury. The reduction in pulmonary dysfunction after improved resuscitation may be attributable to a blunting of the nuclear factor-kappa B and interleukin-6 responses to hemorrhage.

Airway Resistance↗
PubMedDate not supplied

The relationship between oxygen delivery and oxygen consumption during fluid resuscitation of burn-related shock.

Although burn-related shock resuscitation based on invasive hemodynamic monitoring has been reported at an increased rate, little is known about appropriate hemodynamic end points. Shock resuscitation based on oxygen transport criteria has been widely used for patients with trauma and patients who undergo surgery, and supranormal values of oxygen delivery (DO2) have been reported in association with an improved survival rate. This improved survival rate has been attributed to a shifting of the critical threshold of DO2 to higher values in these patients. In patients with thermal injuries, the effects of the manipulation of hemodynamics to optimize oxygen transport have not been proven. It is still unclear whether these patients exhibit delivery-dependent oxygen consumption (VO2) during the shock phase. The goal of this study was to evaluate the existence of oxygen supply dependency and to determine critical levels of DO2 in patients with burns. In a prospective study that included 16 patients with serious thermal injuries, we studied the effects of volume loading on DO2 and VO2. A transpulmonary double dilution technique was used for hemodynamic monitoring, and resuscitation end points included a normalization of preload and cardiac output parameters within 24 hours of the thermal injury. Fluid loading with crystalloids and colloids, according to our resuscitation protocol, was used to augment cardiac output and DO2. Of the 16 patients with a mean of 46% total body surface area burned (range, 22%-80%), 8 patients survived and 8 patients died. With the use of progressive fluid loading, cardiac index was restored within 24 hours of admission in all of the patients. Successful resuscitation was associated with increased levels of DO2 and VO2 and with declining serum lactate levels. VO2 appeared to be dependent on DO2 during the resuscitation period (r = 0.596), and the correlation was significantly stronger in the patients who survived (r = 0.744) than in the patients who died (r = 0.368; P < .05). A critical threshold of oxygen supply could not be identified. We concluded that increasing DO2 by fluid resuscitation increases VO2 during hypovolemic shock after a severe burn injury.

Adult↗
PubMed1981

Resuscitation with pyridoxalated stroma free hemoglobin: tolerance to sepsis.

The contribution of the reticuloendothelial system (RES) in pyridoxalated stroma-free hemoglobin (SFH-P) clearance may be insignificant. The magnitude of this is not at present clear. Any compromise of RES function would militate against its potential benefit as an oxygen-carrying resuscitation fluid. The relationship between lethal hemorrhagic shock resuscitation with SFH-P and subsequent host depression was examined in a rat model. Host tolerance to a standard intra-abdominal polymicrobial septic challenge was assessed 5 days after hemorrhagic shock. Shock resuscitation with pyridoxalated stroma-free hemoglobin was equal to or better than all other resuscitation groups evaluated. Tolerance to a standard septic challenge 5 days after resuscitation was no different between resuscitation groups. There appears to be no compromise to host defense in general in tolerating intra-abdominal sepsis 5 days following shock resuscitation with pyridoxalated stroma-free hemoglobin.

Animals↗