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PubMed1994

Effect of moderate hypothermia on lipid peroxidation in canine brain tissue after cardiac arrest and resuscitation.

BACKGROUND AND PURPOSE: We sought to examine the effect of moderate hypothermia (30 degrees C to 32 degrees C) initiated after resuscitation on the scavenging systems of free radicals and lipid peroxidation in canine brain tissue after cardiac arrest and resuscitation. METHODS: Twenty-one dogs were divided into four groups: group A, nonischemic controls (shams) (n = 4); group B, 15-minute cardiac arrest without reperfusion (n = 4); group C, 15-minute cardiac arrest and standard resuscitation (n = 6); and group D, 15-minute cardiac arrest and hypothermic resuscitation (n = 7). During the period of 10 to 120 minutes after resuscitation, brain temperature and core temperature in group D remained at 30 degrees C to 32 degrees C and were 4 degrees C to 5 degrees C lower than in group C. For each dog, a sample of right parietal cerebral cortex was obtained from group A, group B, or from group C and group D at 2 hours after resuscitation. The sample was assayed for tissue malondialdehyde (MDA), the content of reduced glutathione (GSH), and the activities of superoxide dismutase (SOD) and glutathione peroxidase (GSH-PX). RESULTS: In group B, a 15-minute cardiac arrest induced an increase in MDA, a significant reduction of GSH, and no change in SOD and GSH-PX activities compared with group A. In group C, there were further increases in MDA and reductions in GSH content and GSH-PX activity compared with group A; SOD activity remained substantially unchanged. The content of MDA was higher in group D than in group A but less elevated in group D than in group C. The GSH content and SOD and GSH-PX activities were significantly higher in group D than in group C. CONCLUSIONS: Moderate hypothermia initiated after resuscitation can significantly inhibit the accumulation of lipid peroxidation products and the consumption of free radical scavengers in the brain tissue.

Animals↗
PubMed1986

Manual resuscitators and portable ventilators.

This paper reviews the state of the art in Australia of manually operated, self-inflating bag resuscitators, including the Laerdal, Air Viva and Ambu; manually operated bags dependent upon an oxygen supply, including Mapleson B, C, E and F, the CIG Medishield Oxy-Saver and modified Oxy-Viva Resuscitator 3, and the Komesaroff Oxy-Resuscitator RD85; oxygen-powered resuscitators, including the Oxy-Viva Resuscitator 3 with Demand and RM2 Valves, and the Oxylife FM85; and portable ventilators, including the Drager Oxylog, and Ohmeda Logic 07. Specific comment is made to the effect that the design of the resuscitator is often less important than the knowledge and ability of the operator in using the equipment to achieve adequate lung ventilation. The simplest, cheapest, most useful resuscitators are the manually operated self-inflating bag assemblies. With special training, use of more complex equipment can be justified in some circumstances. The more complex the equipment, the greater the risk of inappropriate use, and the greater the risk of equipment malfunction unless a regular maintenance program is followed.

Humans↗
PubMed1990

The Melbourne Chart--a logical guide to neonatal resuscitation.

Resuscitation of the asphyxiated infant is one of the great emergencies in medical practice. Properly done, it can save many lives and greatly reduce the morbidity resulting from hypoxic-ischaemic encephalopathy, but if it is ineptly performed, the effects of hypoxic-ischaemic encephalopathy may be accentuated, with resultant increased morbidity and even mortality. Other than paediatricians, few practitioners have regular experience in neonatal resuscitation: indeed many, including obstetricians, anaesthetists, general practitioners and midwives may only rarely face the problem of severe asphyxia. It is therefore essential for the occasional practitioner to have ready reference to a logical guide to resuscitation. We have designed such a guide which is widely distributed in delivery suites and operating theatres in Victoria. Its basic form has been in use for over a decade and it has recently been revised. Use of the chart assists the resuscitator to judge the level of resuscitation required. It is our experience that much unnecessary intervention occurs at resuscitation, and we believe the methods outlined in this schematic chart represent a more conservative but logical approach to neonatal resuscitation. The chart is based on the pathophysiological changes that occur in perinatal asphyxia, directing the user to the appropriate manoeuvres required to correct those changes, depending on the degree of asphyxia which is determined by clinical signs and by use of the Apgar score.

Apgar Score↗
PubMed2005

Microvascular resuscitation as a therapeutic goal in severe sepsis.

Sepsis causes microvascular dysfunction. Increased heterogeneity of capillary blood flow results in local tissue hypoxia, which can cause local tissue inflammation, impaired oxygen extraction, and, ultimately, organ dysfunction. Microvascular dysfunction is clinically relevant because it is a marker for mortality: it improves rapidly in survivors of sepsis but fails to improve in nonsurvivors. This, along with the fact that resuscitation of mean arterial pressure and cardiac output alone fails to improve microvascular function, means that microvascular resuscitation is therefore a therapeutic goal. In animal studies of sepsis, volume resuscitation improves microvascular permeability and tissue oxygenation, and leads to improved organ function, including a reduction in myocardial dysfunction. Microvascular resuscitation strategies include hemodynamic resuscitation using the linked combination of volume resuscitation, judicious vasopressor use, and inotropes and vasodilators. Alternative vasoactive agents, such as vasopressin, may improve microcirculatory function to a greater degree than conventional vasopressors. Successful modulation of inflammation has a positive impact on endothelial function. Finally, targeted treatment of the endothelium, using activated protein C, also improves microvascular function and ultimately increases survival. Thus, attention must be paid to the microcirculation in patients with sepsis, and therapeutic strategies should be employed to resuscitate the microcirculation in order to avoid organ dysfunction and to reduce mortality.

Animals↗
PubMed2006

Factors associated with survival and neurological outcome after cardiopulmonary resuscitation of neurosurgical intensive care unit patients.

OBJECTIVE: We investigated predictors of survival and the neurological outcomes of neurosurgical patients who experienced cardiac arrest and received cardiopulmonary resuscitation after being admitted to the neurosurgical intensive care unit. METHODS: A retrospective study was conducted of adult patients in the neurosurgical intensive care unit who had experienced cardiac arrest and received cardiopulmonary resuscitation. Factors relevant to the cardiac arrest (before and after arrest) were used to study association with survival (immediate or short-term) and neurological outcome (unconscious or conscious) via statistical methods. RESULTS: Immediate survival was seen in 105 patients (49%), 19 survived until hospital discharge, and 11 were still alive at the conclusion of this study. Of the immediate survivors, 41 patients were conscious and 64 were unconscious. Multivariate analysis showed increased mortality in patients with infection, asystole, or resuscitation time exceeding 30 minutes (P < 0.05). Additional factors associated with high in-hospital mortality included lack of spontaneous respiration, no caloric-vestibular reflex, and unconsciousness after resuscitation (P < 0.05). In addition, neurological recovery was poor in patients with infection, asystole, no caloric-vestibular reflex, conscious recovery, or resuscitation lasting more than 30 minutes (P < 0.05). CONCLUSION: Even after initially successful resuscitation, survival and neurological recovery is quite dismal in patients with cerebral lesions. Prognostic factors for neurosurgical patients should be assessed on an individual basis to determine medical futility in the early post-resuscitation period.

Adult↗
PubMed1992

Extracorporeal circulation as an alternative to open-chest cardiac compression for cardiac resuscitation.

Open-chest direct cardiac compression represents a more potent but highly invasive option for cardiac resuscitation when conventional techniques of closed-chest cardiac resuscitation fail after prolonged cardiac arrest. We postulated that venoarterial extracorporeal circulation might be a more effective intervention with less trauma. In the setting of human cardiac resuscitation, however, controlled studies would be limited by strategic constraints. Accordingly, the effectiveness of open-chest cardiac compression was compared with that of extracorporeal circulation after a 15-min interval of untreated ventricular fibrillation in a porcine model of cardiac arrest. Sixteen domestic pigs were randomized to resuscitation by either peripheral venoarterial extracorporeal circulation or open-chest direct cardiac compression. During resuscitation, epinephrine was continuously infused into the right atrium, and defibrillation was attempted by transthoracic countershock at 2-min intervals. Systemic blood flows averaged 198 ml.kg-1.min-1 with extracorporeal circulation. This contrasted with direct cardiac compression, in which flows averaged only 40 ml.kg-1.min-1. Coronary perfusion pressure, the major determinant of resuscitability on the basis of earlier studies, was correspondingly lower (94 vs 29 mm Hg). Extracorporeal circulation, in conjunction with transthoracic DC countershock and epinephrine, successfully reestablished spontaneous circulation in each of eight animals after 15 min of untreated ventricular fibrillation. This contrasted with the outcome after open-chest cardiac compression, in which spontaneous circulation was reestablished in only four of eight animals (p = .038). We conclude that extracorporeal circulation is a more effective alternative to direct cardiac compression for cardiac resuscitation after protracted cardiac arrest.

Acidosis↗
PubMed1999

Persistent gastric intramucosal ischemia in patients with sepsis following resuscitation from shock.

STUDY OBJECTIVES: (1) To determine the effects of resuscitation of patients with severe sepsis to conventional hemodynamic end points and normal blood lactate levels on postresuscitation sequential assessments of gastric intramucosal pH (pHi). (2) To determine whether trends in pHi are reflected in trends in systemic hemodynamic, oxygen utilization, and acid-base assessments. DESIGN: Prospective cohort study. SETTING: Medical ICU in an inner-city, university-based medical center. PATIENTS: Twelve recently admitted patients with severe sepsis and signs of circulatory shock who were successfully resuscitated to normal hemodynamic end points and lactate levels and who were also monitored with pulmonary artery catheters and gastric tonometers. INTERVENTIONS: Because of the observational nature of this study, no specific interventions were employed. The physician staff administered i.v. fluids and pharmacologic agents, during and after the resuscitative period, to treat infection and to achieve and maintain hemodynamic stability. Mechanical ventilation and supplemental oxygen were provided as needed. The hemodynamic and physiologic monitoring employed was determined by the managing physicians and established medical ICU routines. MEASUREMENTS AND RESULTS: A total of 12 patients were studied. Systemic hemodynamic, oxygen utilization, and acid-base assessments and pHi were recorded following resuscitation, and every 12 h thereafter. pHi decreased from 7.33 +/- 0.08 (mean +/- SD) following resuscitation to 7.26 +/- 0.04 at 24 h, 7.20 +/- 0.07 at 36 h (p < 0.05), and 7.24 +/- 0.08 at 48 h. Corresponding statistically significant and clinically relevant changes in systemic hemodynamic, oxygen utilization, and acid-base variables were not observed. The hospital mortality of this patient group was high (10 of 12; 83%). CONCLUSIONS: Gastric intramucosal acidosis develops and persists for at least 48 h in patients resuscitated from septic shock to conventional resuscitative end points, including the normalization of lactate levels. These regional changes were not reflected in corresponding changes in systemic acid-base and oxygen utilization variables. Direct determinations of pHi and therapy directed toward the resolution of splanchnic ischemia may be required to improve the outcome in these patients.

Acid-Base Equilibrium↗
PubMed2005

Treatment preferences for resuscitation and critical care among homeless persons.

CONTEXT: Homeless people are at increased risk of critical illness and are less likely to have surrogate decision makers when critically ill. Consequently, clinicians must make decisions independently or with input from others such as ethics committees or guardians. No prior studies have examined treatment preferences of homeless to guide such decision makers. DESIGN: Interviewer-administered, cross-sectional survey of homeless persons. SETTING: Homeless shelters in Seattle, WA. PARTICIPANTS: Two hundred twenty-nine homeless individuals with two comparison groups: 236 physicians practicing in settings where they are likely to provide care for homeless persons and 111 patients with oxygen-dependent COPD. MEASUREMENTS: Participants were asked whether they would want intubation with mechanical ventilation or cardiopulmonary resuscitation in their current health, if they were in a permanent coma, if they had severe dementia, or if they were confined to bed and dependent on others for all care. RESULTS: Homeless men were more likely to want resuscitation than homeless women (p < 0.002) in coma and dementia scenarios. Homeless men and women were both more likely to want resuscitation in these scenarios than physicians (p < 0.001). Nonwhite homeless were more likely to want resuscitation than white homeless people (p < 0.033), and both were more likely to want resuscitation than physicians (p < 0.001). Homeless are also more likely to want resuscitation than patients with COPD. The majority (80%) of homeless who reported not having family or not wanting family to make medical decisions prefer a physician make decisions rather than a court-appointed guardian. CONCLUSIONS: Homeless persons are more likely to prefer resuscitation than physicians and patients with severe COPD. Since physicians may be in the position of making medical decisions for homeless patients and since physicians are influenced by their own preferences when making decisions for others, physicians should be aware that, on average, homeless persons prefer more aggressive care than physicians. Hospitals serving homeless individuals should consider developing policies to address this issue.

Adult↗
PubMed2005

The resuscitation outcome: revisit the story of the stony heart.

Postresuscitation syndrome is a state of myocardial dysfunction after the restoration of circulation by successful resuscitation. Despite several advances in the field of resuscitation, the management of out-of-hospital cardiac arrest is still suboptimal. The high fatality rate shortly after successful resuscitation is mainly related to postresuscitation myocardial dysfunction. Postresuscitation myocardial stunning is reversible, while stony heart is irreversible due to prolonged unsuccessful resuscitation. This article reviews most of the published articles concerning the causes, mechanism, pathophysiology, and the updated trials for management of postresuscitation myocardial dysfunction. Further studies are warranted to highlight postresuscitation disease and its hemodynamic sequences and then to intervene according to the different phases of cardiac arrest. By modifying the conventional modalities of resuscitation together with new promising agents, the rescuers will be able to salvage the jeopardized postresuscitation myocardium and prevent its progression to the dismal stony heart. Community awareness and staff education are crucial to shorten resuscitation time and improve short-term and long-term outcomes. There is an urgent need to revise the guidelines for cardiopulmonary resuscitation in community setting, but how? It is a matter of where and when it is of enough value to be efficacious and cost-effective.

Calcium↗
PubMed1989

Withholding cardiopulmonary resuscitation: one hospital's policy.

We investigated prospectively the current "do not resuscitate" policy at the Royal Adelaide Hospital, to assess the success of the policy in limiting cardiopulmonary resuscitation and to review how orders to withhold resuscitation were documented. We studied the medical records of 272 patients who died in hospital wards over a three-month period in 1987, and found that in 61% of patients a "do not resuscitate" order had been written, including in 75% of those patients who died with a malignant disease. "No resuscitation" was the most common wording, which occurred in 23% of the orders, whereas only 16% of orders used the terminology "for ordinary measures"--the wording that is recommended in the hospital policy. We conclude from this study of hospital deaths that "do not resuscitate" orders are used frequently and serve to limit the use of cardiopulmonary resuscitation in patients who die in hospital, but are documented without regard to official policy.

Adolescent↗
PubMed1979

Bystander-initiated cardiopulmonary resuscitation in the management of ventricular fibrillation.

We assessed the influence of bystander-initiated cardiopulmonary resuscitation upon outcome in 316 consecutive patients treated for out-of-hospital ventricular fibrillation. Of 109 patients who received bystander-initiated cardiopulmonary resuscitation, 47 (43%) were ultimately discharged home. Of 207 patients for whom resuscitation was delayed until arrival of fire department personnel, 43 (21%) survived (P less than 0.001). Improved survival was largely due to a reduction in subsequent hospital mortality rather than to a higher rate of initially effective resuscitation. In a separate analysis of 118 patients treated at a single institution after resuscitation, the reduced hospital mortality reflected a decrease in deaths due to shock and to anoxic encephalopathy. In addition, neurologic dysfunction was significantly less common if bystanders had initiated cardiopulmonary resuscitation. Bystander participation in cardiopulmonary resuscitation represents an important adjunct to a rapid-response emergency care system.

Consciousness↗
PubMed2000

[Link between indication for cesarean section and need for resuscitation of the neonate].

OBJECTIVE: To study the relationship between the indication for caesarean section (CS) and the need for resuscitation of the infant. DESIGN: Prospective cohort study. METHODS: During one year the following information was collected for each CS in a secondary teaching hospital (Isala klinieken/Weezenlanden Hospital), Zwolle, the Netherlands: indication for the CS, Apgar scores after 1 and 5 min and measures taken by the attending paediatrician at birth. These measures were divided into two groups: resuscitation (bag and mask ventilation or endotracheal intubation and ventilation) or no resuscitation (stimulation, supplemental oxygen, or no action at all). RESULTS: During the study year 202 CS were carried out. In the 50 CS carried out because of a narrow pelvis or a previous CS and in the 61 CS carried out for non-progressive labour there was little need for resuscitation of the newborn (4 and 3.3%, respectively), similar to resuscitation requirements after vaginal birth. The need for resuscitation of the newborn was significantly greater in the other indication groups, namely in 6/37 (16%) of cases of foetal malposition, in 3/10 (30%) of placental dysfunction, and in 11/44 (25%) of foetal distress. One infant had to be intubated directly after birth. The 1-minute Apgar score was lower in infants born after CS under general anaesthesia than under spinal anaesthesia (p = 0.002), regardless of the indication for the CS. CONCLUSION: Based on the indication for a CS, a paediatrician or physician experienced in neonatal resuscitation is required for a high-risk CS (foetal malposition, placental dysfunction, foetal distress, and general anaesthesia).

Anesthesia, General↗
PubMed2000

Basic resuscitation--knowledge and skills of full-time medical practitioners at public hospitals in northern province.

OBJECTIVES: To establish the level of knowledge and skill in basic resuscitation among medical practitioners and to determine the differences in characteristics between those with and those without knowledge and skills. DESIGN: Cross-sectional study. SETTING: Public hospitals in Northern Province. SUBJECTS: All the doctors in full-time employment, except interns and those in full-time administration. OUTCOME MEASURES: Practice on manikins using structured interview/evaluation sheet. RESULTS: Of 152 participants, 7 (4.6%) scored 80% and above and 37 (24.3%) scored 50% and above. The medical practitioners who performed better were younger and more likely to have received undergraduate and postgraduate resuscitation training, and resuscitation training within the last 2 years. The country of qualification, sex, postgraduate qualification, frequency of continuing medical education and past experience of resuscitating cardiac arrest patients were not associated with a performance on the evaluation. CONCLUSION: Medical practitioner skills and knowledge of basic resuscitation were poor and resuscitation experience without training was not found to be beneficial. It is therefore recommended that formal training in resuscitation be mandatory at undergraduate and postgraduate level, with refresher courses held every 2 years.

Cross-Sectional Studies↗
PubMed1997

Active resuscitation in Malaysian district hospitals--is it adequate?

Adequacy of active resuscitation in collapsed inpatients aged 12 and above (excluding those with terminal illness) were studied in 6 Malaysian district hospitals for 3 months starting 1/1/93. Results showed 59.5% (25 out of 42 inpatients) were inadequately resuscitated measured by: failure of nurses to initiate resuscitation (24%), duration of resuscitation less than 30 minutes (42%) and incompletely equipped emergency trolleys (44%). Questionnaires revealed lack of knowledge and training in cardiopulmonary resuscitation in medical staff. Regular cardiopulmonary resuscitation courses, regular spot checks on emergency trolleys and management protocols on active resuscitation are recommended. Each hospital should design its own criteria for adequacy.

Adolescent↗
PubMed1999

[Effect of hypertonic saline/dextran 70 on delayed resuscitation of dogs with burn shock].

OBJECTIVE: To investigate the effect of hypertonic saline/dextran 70 on delayed resuscitation of burn shock. METHODS: Eighteen mongrel dogs with 35% TBSA, third-degree burn were used in this study. Lactated Ringer's (LR) or 7.5% NaCl+ 6% dextran 70 (HSD) was given for resuscitation 6 h postburn. The volumes and rates of fluid infusion were controlled basically on the urinary output of 1.0 ml.kg-1.h-1 and cardiac output (CO) of 70%-80% of preburn values. The volume load, +dp/dtmax, -dp/dtmax, CI,DO2 and VO2 were obtained to evaluate the effect of HSD resuscitation. RESULTS: The resuscitated volume of HSD was 30.56% less during first 24 h postburn and 59.50% less at 4 h after resuscitation than LR's. The +dp/dtmax, CI,DO2 and VO2 were increased significantly with HSD infusion at 2 h, 1 h and 0.5 h after resuscitation compared with LR's. CONCLUSION: HSD could expand plasma volume significantly with small quantity. The cardiac contractility was enhanced and the oxygen delivery, oxygen consumption were increased in delayed resuscitation of burn shock.

Animals↗
PubMed2002

[Effect of propofol on protecting Rhesus macaques from reperfusion lung injury during hemorrhagic shock and resuscitation].

OBJECTIVE: To investigate the protective efficacy of propofol against lung injury during hemorrhagic shock and resuscitation among Rhesus macaques. METHODS: Two healthy rhesus monkeys (Rhesus macaques) were killed and their lungs were taken out as samples of normal lung. Two healthy rhesus monkeys were made animal models of hemorrhagic shock and then were killed with their lungs taken out as samples of hemorrhagic shock lung. Another 12 healthy rhesus monkeys were randomly divided into two groups of six animals: propofol group (administered with propofol to a plasma concentration of 8 mg/L by target control infusion with computer before hemorrhagic shock) and control group. The monkeys were bled through the right femoral vein till the mean arterial pressure remained at the shock level of 40 mm Hg +/- 5 mm Hg. Two hours later, the total amount of bled blood and normal saline of the volume 2 times the volume of blood loss were reinfused into the animals quickly. Another 2 hours later hemodynamic parameters were measured, and blood samples were taken for measurement of malondialdehyde (MDA), superoxidedismutase (SOD) and lactate before bleeding, two hours after shock appeared, and 2 hours after resuscitation. The monkeys were killed 2 hours after resuscitation; their lungs were taken for pathologic examination and determination of water-to-dry weight ratio. RESULTS: The lungs of the 2 normal rhesus monkeys were normal with the W/D of 5.545 +/- 0.191. There is not remarkable change in the lung constitution of the 2 shock rhesus monkeys with a W/D ratio of 5.655 +/- 0.474. The mean pulmonary arterial pressure (MPA) and pulmonary vascular resistance index (PVRI) of the control group 2 hours after hemorrhagic shock and 2 hours after resuscitation were 17.00 +/- 4.42 and 22.83 +/- 5.11 respectively, both significantly higher than those of the propofol group (10.83 +/- 2.71 and 18.66 +/- 3.38, both P < 0.05). The pulmonary vascular resistance index (PVRI) of the control group 2 hours after hemorrhagic shock and 2 hours after resuscitation were 458.67 +/- 91.92 and 260.17 +/- 57.85 respectively, both significantly higher than those of the propofol group (258.67 +/- 63.02 and 159.17 +/- 47.98 respectively, both P < 0.05). The W/D ratio of the control group 2 hours after resuscitation was significantly higher than that of the propofol group (P < 0.05). The pulmonary edema of the control group was more serious than that of the propofol group by light microscopy and electron microscopy. CONCLUSION: Propofol remarkably relieves the lung injury occurring during hemorrhagic shock and resuscitation stage by ameliorating pulmonary circulation.

Animals↗
PubMed2003

Perceived self-efficacy in performing and willingness to learn cardiopulmonary resuscitation in an elderly population in a suburban community.

BACKGROUND: Older persons are the group most likely to respond to cardiac arrests in private residences. OBJECTIVE: To characterize the knowledge about, attitudes toward, and perceived self-efficacy of older persons in learning and providing cardiopulmonary resuscitation. METHODS: A total of 2743 surveys were mailed to adults 55 years and older who resided in a single Michigan suburb. Data were collected on demographics, medical history, training in and willingness to provide cardiopulmonary resuscitation, and concerns about providing this intervention. RESULTS: The 631 persons (24.6%) who responded were elderly (mean age, 73.5 years) and had a mean of 1.7 occupants per household. More than one third lived alone. Of all respondents, 275 (43.6%) had received training in cardiopulmonary resuscitation, 370 (58.6%) indicated a willingness to learn cardiopulmonary resuscitation, and 412 (65.3%) thought that they had the ability to perform this intervention. Respondents 80 years or younger were significantly more likely than respondents more than 80 years old to be willing to learn cardiopulmonary resuscitation (65.7% vs 19.0%, P < .001) and perceived themselves as able to perform it (73.0% vs 34.0%, P < .001). The absence of mouth-to-mouth ventilation as part of training had minimal impact on the willingness of either age group to receive training (61.2% vs 58.6%, P = .19). Perceived ability to learn and perform cardiopulmonary resuscitation did not vary with the medical history of the respondent or the respondent's spouse. CONCLUSION: Adults 56 to 80 years old perceive themselves as able to perform cardiopulmonary resuscitation and are interested in receiving training.

Aged↗
PubMed2003

Targets for resuscitation from shock.

Resuscitation from circulatory and respiratory failure represent mainstays of emergency and critical care management. Importantly, no amount of resuscitative effort will be successful in promoting patient survival if the primary reason for the shock state is not identified and treated, independent of resuscitation. Having said that, aggressive resuscitation to normal functional levels of blood flow and organ perfusion pressure during the first 6 hours following the development of shock improves outcome both in patients with trauma or sepsis. However, clinical studies have demonstrated that restoration of total blood flow to supranormal levels in subjects with established shock that has been present for over 6 hours does not improve survival. Still, some defined clinical targets are essential in these patients as well to prevent further organ injury due to ischemia and its associated inflammatory response. Thus, the rapid restoration of normal hemodynamics by conventional means, including fluid resuscitation and surgical repair, results in a better log term outcome than inadequate or delayed resuscitative efforts. Clear initial targets for resuscitation are a mean arterial pressure > 60 mm Hg, and a cardiac output and O(2) transport to the body adequate enough to prevent tissue hypoperfusion. The level of cardiac output needed to achieve this goal is probably different among subjects and within subjects over time. Indirect signposts of adequate perfusion, such as venous O2 saturation, mentation, urine output and local measures of tissue blood flow are useful in monitoring this response.

Fluid Therapy↗