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PubMed2006

Normoxic resuscitation after cardiac arrest protects against hippocampal oxidative stress, metabolic dysfunction, and neuronal death.

Resuscitation and prolonged ventilation using 100% oxygen after cardiac arrest is standard clinical practice despite evidence from animal models indicating that neurologic outcome is improved using normoxic compared with hyperoxic resuscitation. This study tested the hypothesis that normoxic ventilation during the first hour after cardiac arrest in dogs protects against prelethal oxidative stress to proteins, loss of the critical metabolic enzyme pyruvate dehydrogenase complex (PDHC), and minimizes subsequent neuronal death in the hippocampus. Anesthetized beagles underwent 10 mins ventricular fibrillation cardiac arrest, followed by defibrillation and ventilation with either 21% or 100% O2. At 1 h after resuscitation, the ventilator was adjusted to maintain normal blood gas levels in both groups. Brains were perfusion-fixed at 2 h reperfusion and used for immunohistochemical measurements of hippocampal nitrotyrosine, a product of protein oxidation, and the E1alpha subunit of PDHC. In hyperoxic dogs, PDHC immunostaining diminished by approximately 90% compared with sham-operated dogs, while staining in normoxic animals was not significantly different from nonischemic dogs. Protein nitration in the hippocampal neurons of hyperoxic animals was 2-3 times greater than either sham-operated or normoxic resuscitated animals at 2 h reperfusion. Stereologic quantification of neuronal death at 24 h reperfusion showed a 40% reduction using normoxic compared with hyperoxic resuscitation. These results indicate that postischemic hyperoxic ventilation promotes oxidative stress that exacerbates prelethal loss of pyruvate dehydrogenase and delayed hippocampal neuronal cell death. Moreover, these findings indicate the need for clinical trials comparing the effects of different ventilatory oxygen levels on neurologic outcome after cardiac arrest.

Animals↗
PubMed1999

Would physicians override a do-not-resuscitate order when a cardiac arrest is iatrogenic?

OBJECTIVE: To assess whether physicians would be more likely to override a do-not-resuscitate (DNR) order when a hypothetical cardiac arrest is iatrogenic. DESIGN: Mailed survey of 358 practicing physicians. SETTING: A university-affiliated community teaching hospital. PARTICIPANTS: Of 358 physicians surveyed, 285 (80%) responded. MEASUREMENTS AND MAIN RESULTS: Each survey included three case descriptions in which a patient negotiates a DNR order, and then suffers a cardiac arrest. The arrests were caused by the patient's underlying disease, by an unexpected complication of treatment, and by the physician's error. Physicians were asked to rate the likelihood that they would attempt cardiopulmonary resuscitation for each case description. Physicians indicated that they would be unlikely to override a DNR order when the arrest was caused by the patient's underlying disease (mean score 2.55 on a scale from 1 "certainly would not" to 7 "certainly would"). Physicians reported they would be much more likely to resuscitate when the arrest was due to a complication of treatment (5.24 vs 2. 55; difference 95% confidence interval [CI] 2.44, 2.91; p <.001), and that they would be even more likely to resuscitate when the arrest was due to physician error (6.32 vs 5.24; difference 95% CI 0. 88, 1.20; p <.001). Eight percent, 29%, and 69% of physicians, respectively, said that they "certainly would" resuscitate in these three vignettes (p <.001). CONCLUSIONS: Physicians may believe that DNR orders do not apply to iatrogenic cardiac arrests and that patients do not consider the possibility of an iatrogenic arrest when they negotiate a DNR order. Physicians may also believe that there is a greater obligation to treat when an illness is iatrogenic, and particularly when an illness results from the physician's error. This response to iatrogenic cardiac arrests, and its possible generalization to other iatrogenic complications, deserves further consideration and discussion.

Advance Directive Adherence↗
PubMed2000

Out-of-hospital resuscitation in Tartu: effect of reorganization of Estonian EMS system.

The objective of this study was to evaluate the effect of reorganization of Estonian emergency medical services (EMS) system. The outcomes of out-of-hospital resuscitation in the Tartu urban area were investigated during the 6-year study period. The main aim of reorganization was to provide rapid access to early defibrillation with simultaneous advanced cardiac life support (ACLS) procedures on the scene. The changes were implemented since summer 1994 in Tartu at first. Quick availability of a mobile intensive care unit for high-risk calls; implementation of standards for resuscitation, and routine systematic, realistic, compulsory ACLS training for all ambulance staff were established. There were 368 out-of-hospital resuscitations. Comparison of periods before and after basic reorganization of EMS system showed that the number of resuscitation attempts had evident tendency to increase. The rates of return of spontaneous circulation and survival in patients with cardiac arrest of presumed cardiac origin increased from 32.5% to 58.6% (P < .05) and from 7.5% to 25.7% (P < .05) respectively. Thus, implementation in the EMS system of mobile intensive care, ACLS units, and standard resuscitation training program diminished mortality from sudden cardiac arrest.

Aged↗
PubMed2001

Cardiopulmonary resuscitation and contrast media reactions in a radiology department.

AIM: To assess current knowledge and training in the management of contrast media reactions and cardiopulmonary resuscitation within a radiology department. MATERIALS AND METHODS: The standard of knowledge about the management of contrast media reactions and cardiopulmonary resuscitation among radiologists, radiographers and nurses were audited using a two-section questionnaire. Our results were compared against nationally accepted standards. Repeat audits were undertaken over a 28-month period. Three full audit cycles were completed. RESULTS: The initial audit confirmed that although a voluntary training programme was in place, knowledge of cardiopulmonary resuscitation techniques were below acceptable levels (set at 70%) for all staff members. The mean score for radiologists was 50%. Immediate changes instituted included retraining courses, the distribution of standard guidelines and the composition and distribution of two separate information handouts. Initial improvements were complemented by new wallcharts, which were distributed throughout the department, a series of lectures on management of contrast reactions and regular reviews with feedback to staff. In the third and final audit all staff groups had surpassed the required standard. CONCLUSION: Knowledge of contrast media reactions and resuscitation needs constant updating. Revision of skills requires a prescriptive programme; visual display of advice is a constant reminder. It is our contention all radiology departmental staff should consider it a personal duty to maintain their resuscitation skills at appropriate standards.

Cardiopulmonary Resuscitation↗
PubMed2001

Resuscitation of newborn infants with room air or oxygen.

Oxygen is a toxic agent and a critical approach regarding its use during resuscitation at birth is developing. Animal data indicate that room air is efficient for newborn resuscitation. Three clinical studies have established that normal ventilation is delayed after oxygen resuscitation. Oxidative stress is augmented for several weeks in infants exposed to oxygen at birth -- the long-term implications of these observations remain unclear. There are limited data regarding the use of room air during complicated resuscitations, i.e. in meconium aspiration, the severely asphyxiated infant and in the preterm infant. Thus, it is necessary to continue ongoing rigorous examination of the long-accepted practice of oxygen administration during neonatal resuscitation.

Air↗
PubMed2001

Ethical considerations in neonatal resuscitation: clinical and research issues.

The recent publication of guidelines for ethical decision making for resuscitation of infants has highlighted the problems inherent in using the currently available data to define those situations in which resuscitation should be or might be withheld or withdrawn. Prior selection criteria for resuscitation, criteria for inclusion into the study group, incomplete resuscitation, gestational age determination, intrauterine growth restriction, subjective assessment of 'poor' outcome, and other factors make setting specific parameters for acting or not acting difficult, if not dangerous, and possibly impossible. Research in neonatal resuscitation poses some potential ethical obstacles, but national and international regulations and guidelines are available to assist investigators in study design.

Asphyxia Neonatorum↗
PubMed2001

[Successful cardiopulmonary resuscitation with a high-dosage bolus injection of rt-PA after fulminant pulmonary embolism].

The fulminant pulmonary embolism is one of the most feared complications of hospitalized patients. A high percentage of those patients need resuscitation within a short period of time. In such cases, the thrombolysis is a quickly attained therapeutical alternative to pulmonary embolectomy. A 77-year-old man with a surgically managed femoral fracture who suffered a massive pulmonary embolism, had to be resuscitated on the 11th postoperative day. Because of the fast confirmation of the diagnosis with the ECG and transthoracical echocardiography, it was possible to initiate thrombolysis with a bolus of 100 mg rt-PA immediately after the beginning of cardiac arrest and resuscitation. After 20 min of cardiopulmonary resuscitation (CPR), the patient could be stabilized under high dosage of catecholamines. The patient survived after prolonged intensive care treatment without severe bleeding complications, neither did he present any neurological deficit. We conclude that in the case of massive pulmonary embolism with small chance of resuscitation, the high-dose bolus injection of rt-PA could enrich the therapeutical possibilities.

Aged↗
PubMed1994

[Randomized use of an active compression-decompression technique within the scope of preclinical resuscitation].

INTRODUCTION: Despite its worldwide propagation, external chest compression is of limited efficacy. Recently a new method of cardiac resuscitation, active compression-decompression (ACD), was presented. In animals and a small series of patients resuscitated within the hospital ACD proved to augment blood flow during cardiac resuscitation as a result of greater intrathoracic pressure gradients. AIM OF THE STUDY: We investigated whether ACD does provide superior survival in patients suffering from out-of-hospital cardiac arrest. METHODS: Doctors and paramedics of the mobile intensive care unit at Mannheim University Hospital were trained in the new method. 56 patients were randomly assigned to either standard chest compression according to recommendations of the American Heart Association, AHA (Group I, 30 patients) or to ACD (Group II, 26 patients). ACD was performed by use of a hand-held suction device (CardioPump, Ambu Int.). Compression (30-50 kp) and decompression (10-15 kp) were alternately applied to the patients' chest with a frequency of 80/min. Duration of compression was 50% of the cycle. In both groups advanced life support was performed according to AHA standards. RESULTS: In Group I, 40% of the patients could be resuscitated; and 13.3% were discharged from hospital. In Group II, 38.5% of the patients regained spontaneous circulation, and 11.5% of the patients were discharged. (Group I vs. Group II: n.s.). One patient in each group survived with a severe neurological deficit. ACD caused greater physical efforts than standard chest compression. Furthermore ACD was difficult to perform in patients with ventricular fibrillation once electrode gel had been used. ACD was not feasible in five patients because of large breast (four women) and kyphoscoliosis (one patient). The rate of serious complications was lower in Group II. CONCLUSIONS: Methods to verify the efficacy of ACD in dummy training should be developed. Paramedics performing ACD should relieve each other every 5 minutes. In patients resuscitated by ACD self-adhesive defibrillation paddles instead of electrode gel should be used. Modifications in the design of the CardioPump are desirable to enhance the efficacy of ACD. With regard to future multicentre trials all paramedics should be skilled in the new technique to reach more patients in a shorter period of time.

Adult↗
PubMed1983

Survival after cardiopulmonary resuscitation in the hospital.

Little is known about prognostic factors that determine outcomes after in-hospital cardiopulmonary resuscitation. We studied prospectively 294 consecutive patients who were resuscitated in a university teaching hospital. Forty-one patients (14 per cent) were discharged from the hospital; three quarters of them were still alive six months later. A multivariate analysis revealed that pneumonia, hypotension, renal failure, cancer, and a homebound life style before hospitalization were significantly associated with in-hospital mortality (P less than 0.05). None of the 58 patients with pneumonia and none of the 179 in whom resuscitation took longer than 30 minutes survived to be discharged. On the other hand, fully 42 per cent of the patients who survived for 24 hours after resuscitation left the hospital. At the time of discharge from the hospital and again six months later, 93 per cent of the survivors were mentally intact. Although depression was generally present at the time of discharge, it tended to resolve subsequently. However, all patients reported some decrease in functional capacity, often attributed to fear. This persisted at six months after discharge. Age alone did not appear to influence the prognosis for survival after cardiopulmonary resuscitation or the adjustment to chronic illness after discharge from the hospital.

Adolescent↗
PubMed2002

Follow-up into young adulthood after cardiopulmonary resuscitation in term and near-term newborn infants. I. Educational achievements and social adjustment.

AIM: Long-term sequelae after perinatal asphyxia have generally been assessed at preschool or school age. The aim of the study was to confirm the hypothesis that there could be impairment of cognitive and memory functions that does not become apparent until education and adult life impose special demands. METHODS: Seventy-one term or near-term newborns in need of cardiopulmonary resuscitation because of presumed perinatal asphyxia were investigated with evoked EEG potentials during the first week of life and were investigated at a follow-up clinic until 18 mo of age. At that time 12 subjects showed signs of neuro-developmental impairment. The remaining 59 were considered healthy. They were contacted at young adult age and given a questionnaire containing questions about type of education, need for extra support at school, present activity/employment, living conditions, spare-time activities and self-estimation of health. RESULTS: Thirty-five control subjects were approached at the same time. From the group that was resuscitated at birth, 53 questionnaires were returned and 30 from the control group. Although the resuscitated subjects had signs of both encephalopathy and pathologic evoked responses during their neonatal period, the questionnaire revealed that they had coped with school equally as well as their peers, that the rate of entering university studies was the same and that living conditions were similar between the groups. CONCLUSION: These individuals who were resuscitated at birth and who demonstrated various degrees of neonatal encephalopathy suffered either brain injury that could be diagnosed at 18 mo of age or managed as well as their non-resuscitated peers in terms of educational achievement and social adjustment at young adult age.

Asphyxia Neonatorum↗
PubMed1988

Medical aspects of lay resuscitations in Rotterdam.

In the Rotterdam system of prehospital care for patients with circulatory failure, the cardiopulmonary resuscitation (CPR) training programme for lay persons contributes to the first link in the chain of care, i.e. the period of time spent awaiting the arrival of professional staff. In this paper we describe some of the medical aspects of this programme. The material used was obtained in a study of 5312 trainees who had followed a CPR course. Case histories were reconstructed of 91 victims who had been resuscitated by 109 respondents. At least 20% of resuscitated persons had collapsed as a result of non-cardiac causes. In this category the longer term survival rates were relatively the most favourable. In several instances the indication for resuscitation had been incorrect, while the technical proficiency in the delivery of CPR was often inadequate. We conclude that one course is insufficient for the development of the required 'skill'. We also conclude that the courses should dwell more elaborately on the non-cardiac causes of collapse, particularly in training programmes addressing the public at large. Attention is drawn to the need of designing and implementing special courses for family members and relatives of persons known to be cardiac patients. The need for continuing evaluation, involving active contributions from lay resuscitators, is underlined.

Adolescent↗
PubMed1997

Neonatal resuscitation and newborn outcomes in rural Kenya.

Neonatal resuscitation methods vary in developing countries. This study describes the delivery experience at one rural Kenyan mission hospital, retrospectively analysing delivery data and newborn outcomes for a 12-month period, and prospectively characterizing neonatal resuscitation practices. Thirty-six of 878 newborns (4 per cent) suffered unfavourable outcomes, significantly associated with caesarean, breech, and vacuum deliveries (nine infants, P < 0.01) and birthweight of 2000 g or less (10 infants, P < 0.001). Observed neonatal resuscitation practices were inconsistent and notable for umbilical vein injections given in lieu of bag and mask ventilation. A basic neonatal resuscitation protocol was developed. It is concluded that at one Kenyan hospital, unfavourable newborn outcomes were significantly associated with delivery other than normal vaginal and with birthweights of 2000 g or less. Neonatal resuscitation methods could be modified for use in this setting, and might be most useful for term infants delivered by caesarean, breech, or vacuum deliveries.

Delivery, Obstetric↗
PubMed2000

The National Movement of Neonatal Resuscitation in India.

Birth asphyxia is an important cause of preventable neonatal morbidity and mortality in developing countries. Of the 26 million births each year in India, 4-6 per cent of neonates fail to establish spontaneous breathing at birth. These babies can be helped, if healthcare professionals present at the time of birth are skilled in the art of neonatal resuscitation. Since the introduction of the Neonatal Resuscitation Programme (NRP) by the American Academy of Pediatrics and American Heart Association, organized training programmes for instructors and providers have been launched in India, under the aegis of the National Neonatology Forum (NNF) since 1990. The initial goal was to train the trainers and provide them with the necessary equipment. The NNF created a national faculty of 150 pediatricians and nurses for NRP by conducting certification courses in various regions of the country. The certified faculty members in turn trained 12,000 healthcare professionals in various parts of India over the following 2 years. Simultaneously, in several teaching institutions, NRP was introduced into the curricula of medical and nursing students. This programme provides a uniform, systematic and action-oriented approach to the resuscitation of the newborn. Prospective evaluation of the resuscitation programme in teaching hospitals has revealed the use of rational resuscitation practices and a significant decline in asphyxia-related deaths.

Asphyxia Neonatorum↗
PubMed2004

Intensive care for very low birthweight infants in South Africa: a survey of physician attitudes, parent counseling and resuscitation practices.

Improving outcomes have promoted utilization of intensive care for premature infants in developing countries with available fiscal and technological resources. Physician counseling and decision-making have not been characterized where economic restrictions, governmental guidelines, and physician cultural attitudes may influence decisions about the appropriateness of neonatal intensive care. A cross-sectional survey of all neonatologists and pediatricians providing neonatal care in public and private hospitals in South Africa (n=394) was carried out. Physicians returned 93 surveys (24 per cent response rate). Frequency of counseling increased with increasing gestational age (GA) but was not universally provided at any GA. Morbidity and mortality were consistently discussed and fiscal considerations frequently discussed when antenatal counseling occurred. Resuscitation thresholds were 25-26 weeks and 665-685 g, and were higher in public than in private hospitals. Decisions to limit resuscitation were based more on expected outcome than on patients' wishes or economics. At 24-25 weeks, 91 per cent of physicians would not resuscitate despite parents' wishes; 93 per cent of physicians would resuscitate 28-29-week-old infants over parents' refusal. Parents expecting premature infants are not invariably counseled. In making life-support decisions, physicians consider infants' best interests and, less frequently, financial and emotional burdens. Thresholds for resuscitation and intensive care are higher in public hospitals, and higher than in developed countries. Physicians relegate parents to a passive role in life-support decisions.

Adult↗
PubMed2005

Room air vs. 100 per cent oxygen for neonatal resuscitation: a controlled clinical trial.

The aim of the study was to determine whether neonates resuscitated with room air compared with 100 per cent oxygen in the delivery room were less likely to have hypoxic ischemic encephalopathy and/or death before discharge. A controlled clinical trial was carried out at a tertiary care institute. All newborns weighing 1000 g or more with apnea or gasping respiration and/or heart rate less than 100 beats/min requiring positive pressure ventilation after initial steps of resuscitation were included. All eligible neonates were randomized to receive room air or 100 per cent oxygen for the first 90 s after birth if they required positive pressure ventilation. The composite primary outcome variable was hypoxic ischemic encephalopathy (HIE) and/or death before discharge. A total of 204 neonates fulfilling the inclusion criteria were enrolled. Of these, 107 neonates received room air and 97 neonates received 100 per cent oxygen for resuscitation. The composite primary outcome occurred in 41.1 per cent of the neonates assigned to receive room air and 43.3 per cent of those in the 100 per cent oxygen group (odds ratio in the group assigned to room air, 0.92; 95 per cent confidence interval, 0.52-1.60). Resuscitation of a newborn baby with room air instead of the current practice of 100 per cent oxygen does not confer a benefit in terms of reduced HIE and/or mortality. Significantly, there is no increase in adverse outcome with the use of room air, which can be recommended for resuscitation if oxygen is not available.

Apnea↗
PubMed2006

A pilot study to determine if nurses trained in basic neonatal resuscitation would impact the outcome of neonates delivered in Kampala, Uganda.

AIMS AND OBJECTIVES: To determine if a team dedicated to basic neonatal resuscitation in the delivery ward of a teaching hospital would impact the outcome of neonates delivered in Kampala, Uganda. METHODS: A five-member team of nurses, trained in basic neonatal resuscitation attended 1046 deliveries over a thirty-one day pilot period. They were available in the delivery ward twenty-four hours each day. Outcomes studied included the number of stillbirths recorded on the delivery ward, the number of neonates admitted to the special care baby unit (SCBU), the number of babies admitted to SCBU who died and the mortality in the different weight categories. APGAR scores before and after intervention was also compared. Admission diagnoses between the two groups were also compared. Outcome data collected during this pilot period was compared with historic controls from the previous 31 days in the same unit. PATIENTS AND SETTING: A delivery ward, 22,000 deliveries per year. RESULTS: The stillbirth rate and admission rate to the SCBU were unchanged. Basic neonatal resuscitation in this setting decreased the incidence of asphyxia (defined as failure to initiate and sustain breathing or an APGAR score of <7 at 5 min), improved APGARS and a decrease in the mortality of babies weighing more than 2 kg. CONCLUSION: The resuscitation team reduced the incidence of and mortality from asphyxia and improved the outcome of babies greater than 2 kg. This pilot study provides evidence of the beneficial effect of basic neonatal resuscitation in this setting.

Apgar Score↗
PubMed1997

Fat embolism with the use of intraosseous infusion during cardiopulmonary resuscitation.

The objective of this prospective study was to assess the incidence and magnitude of fat emboli after cardiopulmonary resuscitation and intraosseous infusions. An animal laboratory at a university center was used to study 33 mixed-breed piglets. The piglets underwent hypoxic cardiac arrest followed by chest compressions and mechanical ventilation for a minimum of 30 minutes. The animals were divided in groups: group 1 (n = 5), which had no intraosseous cannulas, group 2 (n = 6), which had intraosseous cannulas with infusion, groups 3 (n = 6), 4 (n = 6), and 5 (n = 8), which had intraosseous cannulas with infusion of epinephrine, normal saline, and sodium bicarbonate respectively, and group 6 (n = 2), which was a sham group with no intraosseous cannulas and no cardiopulmonary resuscitation. At cessation of cardiopulmonary resuscitation, representative lung samples were collected from upper and lower lobes of each lung and observed for fat globules and bone marrow elements. Fat globules were seen in the peribronchial blood vessels and intravascular areas throughout all lung fields of groups 1 through 5. There was no difference in appearance or distribution of fat globules among the 5 treatment groups. Analysis of variance showed no statistical significance (P < 0.05) within or among groups 1 through 5. The use of the intraosseous cannula for infusion of emergency drugs and fluids did not increase the magnitude of fat embolization over cardiopulmonary resuscitation alone in this animal model. The benefits of using this procedure in critically ill children as a means of rapid vascular access for resuscitation is well established. However, the risk of fat embolism in this population needs further study.

Analysis of Variance↗
PubMed1991

Regional cerebral blood flow following resuscitation from hemorrhagic shock with hypertonic saline. Influence of a subdural mass.

After severe hemorrhage, hypertonic saline restores systemic hemodynamics and decreases intracranial pressure (ICP), but its effects on regional cerebral blood flow (rCBF) when used for resuscitation of experimental animals with combined shock and intracranial hypertension have not been reported. We compared rCBF changes (by radiolabeled microsphere technique) after resuscitation from hemorrhage with either 0.8 or 7.2% saline in animals with and without a right hemispheric subdural mass. We studied 24 mongrel dogs anesthetized with 0.5% halothane and 60% nitrous oxide. In group 1 (n = 12), hemorrhage reduced mean arterial pressure (MAP) to 45 mmHg for 30 min. In group 2 (n = 12), ICP was increased and maintained constant at 15 mmHg, whereas hemorrhage reduced MAP to 55 mmHg for 30 min (cerebral perfusion pressure [CPP] approximately 40 mmHg in each group). After the 30-min shock period, 6 animals in each group received one of two randomly assigned resuscitation fluids over a 5-min interval: 1) 7.2% hypertonic saline (HS; sodium 1,232 mEq.l-1, volume 6.0 ml.kg-1); or 2) 0.8% isotonic saline (SAL; sodium 137 mEq.l-1, volume 54 ml.kg-1). Once fluid resuscitation began, ICP was permitted to vary independently in both groups. Data were collected at baseline (before subdural balloon inflation in group 2), midway through the shock interval (T15), immediately after fluid infusion (T35), and 60 and 90 min later (T95, T155). In groups 1 and 2, ICP was significantly less in animals resuscitated with HS compared to those receiving SAL (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗