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PubMed1991

Guidelines for the appropriate use of do-not-resuscitate orders. Council on Ethical and Judicial Affairs, American Medical Association.

Cardiopulmonary resuscitation (CPR) is routinely performed on hospitalized patients who suffer cardiac or respiratory arrest. Consent to administer CPR is presumed since the patient is incapable at the moment of arrest of communicating his or her treatment preference, and failure to act immediately is certain to result in the patient's death. Two exceptions to the presumption favoring CPR have been recognized, however. First, a patient may express in advance his or her preference that CPR be withheld. If the patient is incapable of expressing a preference, the decision to forgo resuscitation may be made by the patient's family or other surrogate decision maker. Second, CPR may be withheld if, in the judgment of the treating physician, an attempt to resuscitate the patient would be futile. In December 1987, the American Medical Association's Council on Ethical and Judicial Affairs issued a series of guidelines to assist hospital medical staffs in formulating appropriate resuscitation policies. The Council's position on the appropriate use of CPR and do-not-resuscitate orders is updated in this report.

American Medical Association↗

PubMed1993

Factors influencing physicians in recommending in-hospital cardiopulmonary resuscitation.

BACKGROUND: Cardiopulmonary resuscitation (CPR) is a dramatic, costly, and often futile intervention whose appropriate use is under scrutiny. Physicians often ask patients and families to make decisions about resuscitation for themselves or loved ones. Clinical variables and personal beliefs may influence physician recommendations about CPR. METHODS: Physicians (N = 451) at a tertiary care hospital were surveyed to determine the following: (1) the factors they consider when recommending in-hospital CPR, (2) the conditions under which they discuss CPR with patients, (3) their recent participation in CPR attempts, (4) their perceptions of its effectiveness, (5) their personal wishes regarding their own resuscitation, and (6) their personal and professional characteristics. RESULTS: The patient's self-reported wishes about resuscitation and physician judgment of medical utility were the most important influences on physician recommendations. Most physicians believe that patients with metastatic cancer or late Alzheimer's disease should not be resuscitated. Age alone was not viewed as an important clinical consideration. Guidance from hospital policies and ethics committees had the least influence on physicians. Physicians overestimated the likelihood of survival to hospital discharge after in-hospital CPR by as much as 300% for some clinical situations and predicted an overall success rate of 30%. CONCLUSION: These findings suggest that most physicians are thoughtful and discriminating in their recommendations to patients about CPR. Patient's wishes are of paramount importance, followed by physician judgment of medical utility. However, physicians do overestimate the efficacy of CPR and may thus misrepresent the potential utility of this therapy to patients and their families.

Adult↗

PubMed1998

[Ethics in preclinical emergency medicine--on the topic of medical futility and resuscitation efforts].

In prehospital emergency medicine, physicians are repeatedly faced with the question of when cardiopulmonary resuscitation (CPR) efforts should be withheld or terminated since they are clearly futile. Here, futile means the goal of saving life cannot be achieved. Determining futility involves qualitative und quantitative aspects. Does the possibility of simply restoring circulatory function justify the decision to initiate resuscitation or must the prospect of a prolonged meaningful life exist? The question of futility arises for the entire life-saving team during resuscitation efforts, for example, after traumatic cardiopulmonary arrest, prolonged down time, collapses in chronically-sick nursing home residents or during transport to hospital when prehospital CPR failed to restore spontaneous circulation. Possible solutions to this problem lie in restricting the objective of resuscitation to achieving a physiological effect in an organ system, i.e. regaining the cardiac pumping function, and in taking into account the chance of long-term survival and quality of life of the patient. Basically speaking, general ethical principles must be adhered to and these include consideration of a patient's right to self-determination. In the prehospital setting, however, the emergency physician is usually confronted with an unknown and unconscious patient and has no information about his preferences. In general, the patient's will to live and his desire for every effort to be made to save him can be assumed, even when there is only a slight chance of survival. Thus, unilateral decisions by emergency physicians to withhold CPR are only justified in special cases when it is obvious that CPR and preservation of life would not be in the patient's interest. When in doubt, resuscitation attempts must be made. The futility of these efforts may emerge later in hospital, or information becomes available regarding the patient's will which justifies an end to therapy.

Cardiopulmonary Resuscitation↗

PubMed2007

Continuous infusion of small-volume fluid resuscitation in the treatment of combined uncontrolled hemorrhagic shock and head injury.

OBJECTIVE: To determine the effect of continuous limited fluid resuscitation on the hemodynamic response and survival in rats in a model of uncontrolled hemorrhage shock due to massive splenic injury (MSI) and head injury (HI). DESIGN: An experimental study. PLACE AND DURATION OF STUDY: Dicle University Animal Research Laboratory, Turkey, between January and February 2005. SUBJECTS AND METHODS: Seventy Sprague-Dawley rats were used in this study. Group 1 rats (n=10) was sham-operated. In group 2 (n=10), only Massive Splenic Injury (MSI) was performed and untreated. In group 3 (n=10), only head injury (HI) was performed and untreated. In group 4 (n=10), HI and MSI were performed and were untreated. In group 5 (n=10), HI and MSI were performed and 15 minutes later treated with 7.5% NaCl. In group 6 (n=10), HI and MSI were performed, and rats were treated with Ringer's Lactate (RL) solution. In group 7 (n=10), HI and MSI were performed, rats were treated with 0.9 % NaCl. In groups 2,4,5,6 and 7 midline incision was reopened and splenectomy was performed at 45 minutes. RESULTS: In group 4 rats, Mean Arterial Pressure (MAP) was decreased from 104 +/- 6.1 mmHg to 75 +/- 19.5 mmHg at 15 minutes; heart rate decreased from 357 +/- 24.9 beats/min to 321 +/- 62.1 beats/min and hematocrit decreased from 46 +/- 1.3 % to 43 +/- 2.5 % (p<0.01). Similar early changes in MAP, heart rate and hematocrit were observed in groups 5, 6, and 7, at 15 minutes. At 45,60 and 120 minutes, in fluid resuscitated rats (group 5,6,7) MAP, heart rate and hematocrit values were measured higher than group 2 and 4 (p<0.01 for all). At 120 min. in group 6, hematocrit was higher than group 4, 5 and 7, in group 6, total blood loss after splenectomy was calculated at 20 +/- 2.4% of blood volume and was the best value compared to other fluid resuscitated group 5 and 7 (28% and 27% of blood volume) (p<0.01). Mortality was lower in all fluid resuscitated groups when compared to group 3 and 4 (p<0.05). The median survival time was again higher in fluid resuscitated groups. CONCLUSION: Continuous infusion of 7.5% NaCl, RL and 0.9 % NaCl following uncontrolled hemorrhagic shock with massive splenic injury and combined head injury resulted in better survival and RL did not increase abdominal bleeding before splenectomy was performed.

Animals↗

PubMed1998

Performance of advanced resuscitation skills by pediatric housestaff.

OBJECTIVE: To describe pediatric housestaff resuscitation experience and their ability to perform key resuscitation skills. DESIGN: Cohort study of 63 pediatric residents in a university-based training program. PARTICIPANTS AND METHODS: Investigators observed, scored, and timed resident performance on 4 key resuscitation skills. Cognitive ability was tested with 4 written scenarios. Housestaff provided self-reports of the number of months since their last American Heart Association Pediatric Advanced Life Support course, number of mock and actual codes attended, number of times skills were performed, and self-confidence with respect to resuscitation. RESULTS: A total of 45 pediatric residents (71%) participated. Median cognitive score was 5 (range, 1-5). Of all residents, 44 (97%) successfully bag mask-ventilated the mannequin; 24 (53%) and 36 (80%) used the correct bag and mask size, respectively. Thirty-nine residents (87%) placed a tube in the mannequin trachea, 12 (27%) checked that suction was working prior to intubation, and 30 (67%) chose the correct endotracheal tube size. Forty residents (89%) discharged the defibrillator, and 25 (56%) and 32 (71%) correctly chose asynchronous mode and infant paddles, respectively. Thirty-eight residents (84%) inserted an intraosseous line; 35 (78%) had correct placement. Median times for successful skill completion were 83 seconds for bag mask ventilation, 136 seconds for intubation, 149 seconds for defibrillation, and 68 seconds for intraosseous line placement. CONCLUSION: Pediatric housestaff previously trained in pediatric advanced life support were generally able to reach the end point of 4 key resuscitation skills but less frequently performed the specific subcomponents of each skill. This poor performance and the prolonged time to skill completion suggest the need for greater attention to detail during training.

Adult↗

PubMed1987

Evaluation of mask-bag ventilation in resuscitation of infants.

Performance of mask-bag ventilation was evaluated on an infant resuscitation mannequin to resolve uncertainty regarding the proficiency of pediatric resuscitation personnel in this technique and to determine whether the type of resuscitation bag used would affect performance. Performance using a self-inflatable resuscitation bag was generally adequate. Forty-six of 50 operators achieved an adequate minute ventilation, and 48 of 50 operators achieved a mean tidal volume exceeding that of the mask plus simulated physiologic dead space. Wide variation with a tendency to hyperventilate and to use excessive pressures indicate the need for improved standard training methods. Technical difficulties with an anesthesia bag impaired performance, suggesting that only self-inflatable bags should be used for mask-bag ventilation during pediatric resuscitation, unless the staff's proficiency with anesthesia bags is clearly demonstrated.

Equipment Design↗

PubMed1992

Retinal hemorrhages in newborn piglets following cardiopulmonary resuscitation.

OBJECTIVE: To determine whether conventional cardiopulmonary resuscitation causes retinal hemorrhages in piglets. DESIGN: Nonrandomized observations. SETTING: Animal physiology laboratory. PARTICIPANTS: Six 3.5- to 4.5-kg piglets. INTERVENTIONS: Fifty minutes of conventional, closed chest cardiopulmonary resuscitation. MEASUREMENTS/MAIN RESULTS: Intrathoracic venous pressure (right atrium) and intracranial venous pressure (sagittal sinus) were directly measured. At 5 minutes of cardiopulmonary resuscitation, the mean (+/- SEM) sagittal sinus pressure was 41 +/- 8 mm Hg and the mean right atrial pressure was 58 +/- 9 mm Hg. The pressures were sustained throughout the 50 minutes of cardiopulmonary resuscitation. At autopsy, there was no gross or microscopic evidence of retinal hemorrhages. CONCLUSION: These results support the conclusion that cardiopulmonary resuscitation does not cause retinal hemorrhages.

Animals↗

PubMed2000

Blunt trauma resuscitation: the old can respond.

HYPOTHESIS: Old and young trauma patients are capable of hyperdynamic response during standardized shock resuscitation. DESIGN: The responses of old and young trauma patients resuscitated using a standardized protocol are compared in an inception cohort study. A standardized resuscitation protocol was used to attain and maintain an oxygen delivery index of 600 mL/min x m2 or greater (DO2I > or = 600) for the first 24 hours in the intensive care unit. Interventions, responses, and outcomes for old (> or = 65 years) and young (<65 years) patients are described. Data were analyzed using analysis of variance, the chi2 test, and the t test; P<.05 was considered significant. SETTING: A 20-bed shock trauma intensive care unit in a regional level I trauma center. PATIENTS: Patients at high risk of postinjury multiple organ failure, ie, major organ or vascular injury and/or skeletal fractures, initial base deficit of 6 mEq/L or greater, need for 6 units or more of packed red blood cells in the first 12 hours, or age of 65 years or older with any 2 previous criteria. INTERVENTIONS: Pulmonary artery catheter, crystalloid fluid infusion, packed red blood cell transfusion, and moderate inotrope support, as needed in that sequence, to attain DO2I > or = 600. MAIN OUTCOME MEASURES: Intensive care unit length of stay and survival. RESULTS: During 19 months ending June 1999, 12 old patients (58% male; age, 76 +/- 2 years [mean +/- SEM] [P<.0011; Injury Severity Score, 20 +/- 2 [P=.02]) and 54 young patients (61% male; age, 37 +/- 2 years; Injury Severity Score, 32 +/- 2) were resuscitated. Initially, for old patients (cardiac index, 2.0 +/- 0.2 L/min x m2) and for young patients (cardiac index, 3.0 +/- 0.2 L/min x m2; P=.01), 24-hour volumes were as follows: 16 +/- 3 L of crystalloid and 12 +/- 3 units of packed red blood cells for the old patients and 21 +/- 2 L of crystalloid and 19 +/- 2 units of packed red blood cells for the young patients. For old patients, 9 (75%) attained DO2I > or = 600, and 11 (92%) survived 7 or more days and 5 (42%) 30 or more days. For young patients, 45 (83%) attained the DO2I goal, and 48 (89%) survived 30 or more days. Intensive care unit length of stay was 25 +/- 9 days for the old patients and 23 +/- 2 days for the young patients. CONCLUSIONS: Elderly patients have initially depressed cardiac index but generate hyperdynamic response. Although ultimate outcome is poorer than in the younger cohort, resuscitation is not futile.

Adult↗

PubMed2004

Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury: a randomized controlled trial.

CONTEXT: Prehospital hypertonic saline (HTS) resuscitation of patients with traumatic brain injury (TBI) may increase survival but whether HTS improves neurological outcomes is unknown. OBJECTIVE: To determine whether prehospital resuscitation with intravenous HTS improves long-term neurological outcome in patients with severe TBI compared with resuscitation with conventional fluids. DESIGN, SETTING, AND PATIENTS: Double-blind, randomized controlled trial of 229 patients with TBI who were comatose (Glasgow Coma Scale score, <9) and hypotensive (systolic blood pressure, <100 mm Hg). The patients were enrolled between December 14, 1998, and April 9, 2002, in Melbourne, Australia. INTERVENTIONS: Patients were randomly assigned to receive a rapid intravenous infusion of either 250 mL of 7.5% saline (n = 114) or 250 mL of Ringer's lactate solution (n = 115; controls) in addition to conventional intravenous fluid and resuscitation protocols administered by paramedics. Treatment allocation was concealed. MAIN OUTCOME MEASURE: Neurological function at 6 months, measured by the extended Glasgow Outcome Score (GOSE). RESULTS: Primary outcomes were obtained in 226 (99%) of 229 patients enrolled. Baseline characteristics of the groups were equivalent. At hospital admission, the mean serum sodium level was 149 mEq/L for HTS patients vs 141 mEq/L for controls (P<.001). The proportion of patients surviving to hospital discharge was similar in both groups (n = 63 [55%] for HTS group and n = 57 [50%] for controls; P =.32); at 6 months, survival rates were n = 62 (55%) in the HTS group and n = 53 (47%) in the control group (P =.23). At 6 months, the median (interquartile range) GOSE was 5 (3-6) in the HTS group vs 5 (5-6) in the control group (P =.45). There was no significant difference between the groups in favorable outcomes (moderate disability and good outcome survivors [GOSE of 5-8]) (risk ratio, 0.99; 95% confidence interval, 0.76-1.30; P =.96) or in any other measure of postinjury neurological function. CONCLUSION: In this study, patients with hypotension and severe TBI who received prehospital resuscitation with HTS had almost identical neurological function 6 months after injury as patients who received conventional fluid.

Adult↗

PubMed1988

Effects of tromethamine and sodium bicarbonate buffers during cardiac resuscitation.

The effects on cardiac resuscitability of iso-osmolal solutions of tris-hydroxymethyl-aminomethane (tromethamine), sodium bicarbonate (NaHCO3) and sodium chloride placebo were compared in 30 domestic pigs using a well-established model of electrically induced cardiac arrest and resuscitation. We hypothesized that a carbon dioxide (CO2) consuming buffer like tromethamine would reduce and sodium bicarbonate would increase the respiratory acidosis of mixed venous blood, which had recently been demonstrated in our laboratory, Tromethamine did decrease and sodium bicarbonate did increase both arterial and mixed venous CO2 during cardiopulmonary resuscitation (CPR). Both concentrations of end-tidal CO2 and coronary venous PCO2 were significantly lower after tromethamine than after bicarbonate. However, tromethamine produced an unexpected vasodilator effect with reduction of mean aortic and coronary perfusion pressures to levels that are known to reduce resuscitability and survival independently of its buffer action. Neither resuscitability nor survival was altered by bicarbonate therapy in comparison with sodium chloride placebo.

Acid-Base Equilibrium↗

PubMed1994

Effects of resuscitation on acute gastric mucosal injury: reperfusion injury versus rapid mucosal restitution.

Gastric mucosal injury after hemorrhagic shock may be a consequence of both ischemia and reperfusion, as toxic oxygen-derived compounds are generated when ischemic tissues are reperfused. The present study was designed to estimate the magnitude of the reperfusion component of gastric mucosal injury, in comparison with the known capacity of the gastric mucosal surface to rapidly restore or restitute its surface after removal of various insults. Twelve dogs were subjected to 2 hr of hemorrhagic shock, with intragastric acid infused to produce gastric mucosal injury. Half were sacrificed 15 min after return of shed blood, while half were fully resuscitated with additional crystalloids and sacrificed 2 hr later. Gross and microscopic injury to the gastric mucosal surface were not increased by resuscitation. Particularly in the antrum, the resuscitated animals had significantly less gastric mucosal injury than unresuscitated animals. The amount of gastric mucosal injury was strongly inversely related to the success of resuscitation after 2 hr, specifically correlating with left ventricular pressure, cardiac index, mean arterial pressure, and systemic pH. Our data suggest that gastric mucosal restitution rather than reperfusion injury may predominant within a few hours of hemorrhagic shock and show that the degree of shock-induced gastric mucosal injury is inversely related to hemodynamic performance after resuscitation.

Animals↗

PubMed1995

Regional blood flow redistribution in preterm piglets with hemorrhage and resuscitation.

Acute hemorrhage in premature infants occurs as the result of obstetrical complications, birth trauma, or operative procedures. This study evaluates the response of the preterm piglet to acute hemorrhage and resuscitation. Piglets delivered by Caesarean section 7-14 days preterm underwent acute arterial/venous hemorrhage (20 cc/kg). At 0, 15, and 60 min after hemorrhage, hemodynamic parameters and regional blood flows (reference organ technique) were measured. Animals were then resuscitated with shed blood (20 cc/kg), crystalloid (60 cc/kg), or colloid (dextran 40, 20 cc/kg) with study parameters obtained 30 min later (statistical analysis by ANOVA). Significant decreases in blood pressure (BP) and cardiac output (CO) occurred after hemorrhage. BP and CO were reestablished to near control levels following resuscitation with blood and crystalloid. Dextran failed to return BP to baseline; however, it resulted in CO 1.7 x control. Heart and CNS blood flow were not significantly influenced by hemorrhage; however, dextran increased flows to these organs significantly above control levels. In the kidney and small bowel, flows decreased significantly following hemorrhage; blood and crystalloid restored flows to near baseline, while dextran resulted in flows significantly greater. In summary, the preterm piglet responds to hemorrhage with maintenance of blood flow to the heart and brain and significantly decreased flows to the kidney and small intestine. Flows following resuscitation with blood and crystalloid are comparable to those in control. Dextran resuscitation resulted in flows significantly greater than baseline; this response might be detrimental with ongoing hemorrhage and/or prolonged ischemia.

Animals↗

PubMed1996

Hypertonic saline resuscitation restores hemorrhage-induced immunosuppression by decreasing prostaglandin E2 and interleukin-4 production.

It was previously shown that hypertonic saline (HTS) enhances in vivo and in vitro cellular immune function of normal mice and reverses in vitro prostaglandin E2 (PGE2)-induced immunosuppression of normal peripheral blood mononuclear cells. Hemorrhage induces immunosuppression despite adequate isotonic fluid resuscitation. The effects of HTS resuscitation on immunosuppression following hemorrhage were studied. A mouse model of hemorrhagic shock was used. Bleeding was performed through a catheter placed in the femoral artery. Phytohemagglutinin-induced splenocyte proliferation and interleukin (IL)-1, IL-2,IL-4, IL-6, IL-10, transforming growth factor beta, and PGE2 plasma levels were measured 2 and 24 hr following hemorrhage and resuscitation with lactated Ringer's and HTS. In vivo cellular immune function was measured using a contact hypersensitivity test. Suppression of splenocyte proliferation (40%) 24 hr following hemorrhage occurred after lactated Ringer's resuscitation. HTS prevented immunosuppression. In vivo cell-mediated immune function 24 hr after hemorrhage was improved by HTS. HTS-resuscitated animals showed significantly lower levels of IL-4 and PGE2, and slightly elevated levels of proinflammatory cytokines (IL-1, IL-2, and IL-6). HTS reverses hemorrhage-induced T-cell suppression by reducing the production and/or release of IL-4 and PGE2.

Animals↗

PubMed1996

Hepatic resuscitation after warm anoxia: one approach for increasing the donor pool for liver transplantation.

The deleterious effects of warm anoxia on the liver are seen to be irreversible if cooling and transplantation (LT) follow immediately after. The aim of our study is to demonstrate that livers subjected to anoxia may be suitable for LT if a period of resuscitation is interposed before the cooling process. Forty female Large White pigs were used. Preservation (Euro-Collins solution) and LT technique were the same in all 20 procedures. All donors underwent clamping of the porta hepatis at the end of harvesting dissection. In the so-called "resuscitated" groups (AR and BR), the clamp was released for a period of time before the liver was cooled. Then, all livers underwent 2 h of cold ischemia followed by LT. Ultrastructural study showed better maintenance of mitochondria and sinusoidal cell integrity in resuscitated livers after LT. Liver synthesis of total adenine nucleotides, graft function and recipient survival were found to be better in the "resuscitated" groups. In conclusion, anoxic livers may be retrieved for LT if a resuscitation period (i.e. aerobic perfusion) is allowed prior to cold preservation. Longer periods of warm anoxia are needed to further support these preliminary results.

Animals↗

PubMed1993

Brain resuscitation by extracorporeal circulation after prolonged cardiac arrest in cats.

OBJECTIVE: Brain reanimation after prolonged ischemia is limited by post-ischemic reperfusion deficits (no-reflow phenomenon). The present study was undertaken to establish whether after 30 min cardiac arrest extracorporeal circulation is able to restore brain reperfusion and to promote functional and metabolic recovery. DESIGN: Adult normothermic cats were submitted to 30 min cardiac arrest by KCl-induced cardioplegia. Resuscitation was carried out by extracorporeal circulation (ECC) until spontaneous heart function returned. The quality of brain recovery was assessed 3 h later by electrophysiological recording and by imaging of the regional distribution of brain energy metabolites. RESULTS: In 6 of 10 cats cardiac sinus rhythm returned after 32 +/- 15 min. In the other 4 cats cardiac function did not return or only intermittently returned during the 3 h observation period. Cerebral blood flow measured by laser Doppler flowmetry returned to 102% +/- 40% of control immediately after the beginning of resuscitation but then gradually declined to 43% +/- 32% after 3 h despite normotensive perfusion. In all cats pupils started to constrict within less than 5 min of recirculation but in 2 animals they secondarily dilated 1.5 and 2 h later, respectively. Spontaneous EEG activity reappeared in 4 of the 6 successfully resuscitated cats after 111 +/- 40 min but failed to recover in the others. Bioluminescent imaging of ATP after 3 h recirculation revealed near-complete depletion throughout the brain in all 4 cats without cardiac recovery. Of the 6 successfully resuscitated cats 5 exhibited patchy areas of low ATP, glucose and pH in 22%-92% of the cross sectional area of brain; in one cat recovery of energy metabolism and acid-base homoeostasis was homogeneous without any focal deficits. The cross sectional area of ATP recovery correlated directly with CBF and hematocrit and inversely with the plasma lactate level. CONCLUSIONS: This study demonstrates for the first time that ECC is able to restore electrophysiological and metabolic brain function after cardiac arrest of as long as 30 min, but recovery is heavily restricted by delayed post-ischemic disturbances of recirculation. Progress in cardiac resuscitation by ECC requires substantial improvement in the efficiency of cerebrovascular reperfusion.

Acid-Base Equilibrium↗

PubMed1991

Hyperthermia following cardiopulmonary resuscitation.

To clarify the clinical nature of post-resuscitation hyperthermia, we reviewed the charts of 18 patients who had cardiac arrest on arrival and regained cardiovascular stability for a study period of sufficient length. Patients with trauma, burns, poisoning and cerebrovascular accidents were excluded. We analyzed the hyperthermia (above 38 degrees C) occurring in the initial 48 h after resuscitation. After resuscitation, most patients showed a rapid rise in body temperature. Patients with later brain death showed significantly earlier appearance of hyperthermia (6.2 h after cardiac resuscitation; median) and a higher peak temperature (39.8 degrees C; median) compared with patients showing prolonged coma (12.7 h and 38.3 degrees C, respectively). Hyperthermia above 39 degrees C was associated with subsequent brain death. The incidence of factors influencing body temperature did not differ between the brain death and prolonged coma groups. Patients achieving full recovery did not show hyperthermia. In conclusion, hyperthermia is an early indicator of brain damage after resuscitation.

Adolescent↗

PubMed1996

The inability of physicians to predict the outcome of in-hospital resuscitation.

OBJECTIVE: To measure the accuracy, reliability, and discrimination of physicians' predictions of the outcome of in-hospital cardiopulmonary resuscitation (CPR), using a large series of detailed clinical vignettes of patients with known outcomes. DESIGN: Faculty and resident physicians at three university-affiliated generalist training programs were given one-page summaries of admission data for patients who later underwent in-hospital CPR. These summaries included all pre-arrest variables known to be related to the outcome of CPR. Physicians were asked to estimate the probability that patients would survive the resuscitation long enough to be stabilized, and the probability of survival to discharge. SETTING: Patient cases were derived from a consecutive series of patients undergoing CPR at two urban teaching hospitals in Detroit, Michigan. PARTICIPANTS: Faculty members and residents at a university-based department of internal medicine and two university-based departments of family medicine were surveyed. INTERVENTIONS: Accuracy of the physician predictions was assessed by comparing the mean predicted probability of survival with the percentage of patients who actually survived. The reliability of probability estimates of survival was evaluated by assessing the numerical proximity of the estimates to the actual outcome of the resuscitative effort. The ability to discriminate between survivors and nonsurvivors was measured by comparing the mean predicted probability of survival for those patients who survived CPR with that for those who did not, and by stratifying physician predictions and measuring the area under a receiver operating characteristic (ROC) curve. MEASUREMENTS AND MAIN RESULTS. Physicians (n = 51) made a total of 713 estimates, and showed poor accuracy, reliability, and discrimination in predicting the outcome of in-hospital CPR. The mean predicted probability of survival to discharge did not differ between patients who actually survived to discharge and those who did not (29.5% vs 26.4%, z = 0.35, p = .73). Similarly, the mean predicted probabilities of surviving resuscitation were the same for patients who actually survived long enough to be stabilized and those who did not (37.8% vs 39.9%, z = 0.55, p = .58). Accounting for type of physician and institution by analysis of variance did not change this finding. The area under the ROC curve for the prediction of arrest survival was 0.476, which is not significantly different from 0.5, and is consistent with an ability to discriminate between survivors and nonsurvivors that is no better than random choice. CONCLUSIONS: Physicians were no better at identifying patients who would survive resuscitation than would be expected by chance alone. Further work is needed to establish which variables are used by physicians in the decision-making process, and to design educational interventions that will make physicians more accurate prognosticators.

Adult↗

PubMed2002

[The use of arginine vasopressin during cardiopulmonary resuscitation. An analysis of experimental and clinical experience and a view of the future].

The risks and benefits of epinephrine given during cardiopulmonary resuscitation (CPR) are controversially discussed. Animal experiments revealed beta-receptor-mediated adverse effects of epinephrine such as increased myocardial oxygen consumption, ventricular arrhythmia, ventilation-perfusion defects, and cardiac failure in the postresuscitation phase. In clinical studies, high-dose vs. standard-dose epinephrine was unable to improve resuscitation success. During CPR in patients, endogenous arginine vasopressin (AVP) levels were increased and surviving vs. non-surviving patients had significantly higher AVP levels. This may indicate that the human body discharges AVP during life-threatening situations as an additional vasopressor to catecholamines in order to maintain cardiocirculatory homeostasis. In different experimental CPR models, AVP compared with epinephrine given during CPR significantly improved vital organ blood flow, coronary perfusion pressure, resuscitability, and long-term survival. During prolonged CPR with repeated drug administration, AVP but not epinephrine maintained coronary perfusion pressure on a level that ensured return of spontaneous circulation. Also, AVP can be administered successfully in the intravenous dose into the endobronchial tree, and also intraosseously. When given during CPR, AVP induces a transient splanchnic hypoperfusion, and an increase in systemic vascular resistance, both of which normalized spontaneously; furthermore, an oligo-anuric state was not observed. In two clinical studies, AVP vs. epinephrine improved 24-h survival during out-of-hospital CPR, and comparable CPR outcome during in-hospital CPR. The new CPR guidelines of both the American Heart Association and the European Resuscitation Council assign a given CPR intervention into classes of recommendation [class 1 (definitely recommended), class 2 A (intervention of choice), class 2B (alternative intervention), class X (neutral), or class 3 (not recommended)]. For CPR of adults with shock-refractory ventricular fibrillation, 40 units AVP or 1 mg epinephrine is recommended (class 2B); patients with asystole or pulseless electrical activity should be resuscitated with epinephrine. AVP is not recommended for adult cardiac arrest patients with asystole or pulseless electrical activity; or pediatric cardiac arrest patients due to a lack of clinical data. Until definitive data about AVP vs. epinephrine effects during CPR are available, the present state of knowledge should be interpreted that two vasopressors are available for use instead of one.

Animals↗