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PubMed2006

Effect of DHEA on the hemodynamic response to resuscitation in a porcine model of hemorrhagic shock.

BACKGROUND: Hemorrhagic shock is a major cause of death from trauma. Pharmacologic treatment has not been satisfactory. The objective of this study was to use a porcine model of hemorrhagic shock and resuscitation to access the hemodynamic effects of dehydroepiandrosterone (DHEA), an adrenal steroid hormone reported to improve cardiac function in patients. METHODS: Hemorrhagic shock was produced in 20- to 30-kg male Yorkshire pigs anesthetized with 2% isoflurane by withdrawing blood through a carotid cannula to a mean arterial pressure (MAP) of 40 to 45 mm Hg and maintaining that level for 60 minutes by further removals of blood. Resuscitation was with 21 mL/kg Ringer's lactate (LR), with (n = 6) or without (n = 6) DHEA (4 mg/kg) dissolved in propylene glycol. The animals were killed after 7 days. Continuous cardiac output (CCO) was recorded using a modified Swan-Ganz catheter system. MAP, heart rate (HR), central venous pressure (CVP), and pulmonary arterial pressure (PAP) were measured every 5 minutes until 60 minutes postresuscitation. From MAP, CCO, HR, and CVP, we calculated total peripheral resistance (TPR), stroke volume (SV), and left ventricular stroke work (SW). RESULTS: The MAP, CCO, SV, and SW decreased significantly during hemorrhagic shock, and then gradually increased to baseline levels during and 1 hour after resuscitation. The TPR was increased during hemorrhagic shock, and then gradually decreased to baseline levels during and after resuscitation. DHEA administration was associated with no significant improvement. CONCLUSION: DHEA when added to standard fluid resuscitation showed no added benefit as resumed by the hemodynamic response.

Adjuvants, Immunologic↗
PubMed2006

The effect of hypoxemic resuscitation of hemorrhagic shock on hemodynamic stabilization and inflammatory response: a pilot study in a rat experimental model.

BACKGROUND: Resuscitation of hemorrhagic shock is associated with tissue injury. The effect of hypoxemia during resuscitation was investigated. METHODS: Shock was induced by withdrawing blood to mean arterial pressure (MAP) 40 mm Hg and maintained for 60 minutes in 25 Wistar rats. Animals were randomly divided to receive either normoxemic (controls, FiO2 = 21%, n = 14) or hypoxemic (HypRes, FiO2 = 12%, n = 11) resuscitation by re-infusing their shed blood. Outcome was assessed through hemodynamic and inflammatory parameters. Another nine rats served to correlate different FiO2 to the corresponding PaO2. RESULTS: At 60 minutes of resuscitation HypRes had higher MAP than control animals (p = 0.008). The respective median (range) malondialdehyde and TNF-alpha levels was 1.7 (1-2.1) versus 3.1 (2.4-4.3) micromol/L, (p = 0.02) and 0 versus 5.8 (0-5.8) pg/mL, (p = 0.025). Glutathione, endotoxin, interferon-gamma, and nitric oxide values were similar between groups. FiO2 of 12% induced only a mild hypoxemia (PaO2 approximately 80 mm Hg). CONCLUSIONS: Even mild hypoxemia during resuscitation of shock leads to effective hemodynamic stabilization.

Animals↗
PubMed1982

Results of attempted cardiopulmonary resuscitation of patients dying suddenly outside the hospital in Reykjavik and the surrounding area, 1976-1979.

Cardiopulmonary resuscitation (CPR) was attempted in 222 cases of sudden death at the City Hospital, Reykjavik, during 1976-79. Of the 68 patients (31%) successfully resuscitated, 47 died in the hospital and 21 (9%) were discharged, 17 in good mental and physical condition. The mean combined response and transport time was 12.1 min and the ambulance mean time of response 7.3 min. The first ECG revealed considerable prognostic indications. Of the 90 patients who had ventricular fibrillation on admission, 42 (47%) were successfully resuscitated and 18 (20%) were subsequently discharged. Among 114 patients with asystole, resuscitation was successful in 23 (20%) and two (2%) were discharged. Immediate first aid in situ had a definite prognostic influence. These results compare favourably with those obtained elsewhere where the organization of first aid and emergency transport is similar. They do not, however, match the results achieved by fully specialized resuscitation teams trained to operate outside the hospital. Results of CPR of patients with cardiac arrest out of hospital in Reykjavik show increasing improvement over the years. This may be partly explained by a considerable public debate on this issue in 1978 and subsequent streamlining of activities.

Adolescent↗
PubMed2006

Coagulation patterns following haemoglobin-based oxygen carrier resuscitation in severe uncontrolled haemorrhagic shock in swine.

Massive blood loss due to penetrating trauma and internal organ damage can cause severe haemorrhagic shock (HS), leading to a severely compromised haemostatic balance. This study evaluated the effect of bovine polymerized haemoglobin (Hb) (Hb-based oxygen carrier, HBOC) resuscitation on haemostasis in a swine model of uncontrolled HS. Following liver injury/HS, swine received HBOC (n= 8), Hextend (HEX) (n= 8) or no resuscitation (NON) (n= 8). Fluids were infused to increase mean arterial pressure above 60 mmHg and to reduce heart rate to baseline. At 4 h, the animals were eligible for blood transfusions. Prothrombin time (PT), activated partial thromboplastin time, fibrinogen, thromboelastography (TEG) and platelet function analyser closure time (PFA-CT) were compared by using mixed statistical model. At 4 h, blood loss (% estimated blood volume) was comparable for HBOC (65.5 +/- 18.5%) and HEX (80.8 +/- 14.4%) and less for NON (58.7 +/- 10.1%; P < 0.05). Resuscitation-induced dilutional coagulopathy was observed with HBOC and HEX, as indicated by reduced haematocrit, platelets and fibrinogen (P < 0.05). At 4 h, PT was higher in HEX than in HBOC groups (P < 0.01). In the early hospital phase, a trend to increased TEG reaction time and PFA-CT indicates that dilutional effects persist in HBOC and HEX groups. PFA-CT returned to baseline later with HBOC than with HEX (48 vs. 24 h) following blood transfusion. At 4 h, all surviving HEX animals (n= 3) required transfusion, in contrast to no HBOC (n= 7) or NON (n= 1) animals. In this severe uncontrolled HS model, successful resuscitation with HBOC produced haemodilutional coagulopathy less than or similar to that produced by resuscitation with HEX.

Abdominal Injuries↗
PubMed1996

Assessment of mouth-to-mask ventilation in resuscitation of asphyxic newborn babies. A pilot study.

The aim of the study was to compare the effectiveness of mouth-to-mask ventilation (MM) in neonatal asphyxia with bag-and-mask ventilation (BM). A new mouth-to-mask infant resuscitation system was constructed. The study was performed in two university clinics with different resources. The KEM Hospital in Bombay was well equipped and neonatologists took part in all resuscitations; Muhimbili Medical Centre in Dar es Salaam was understaffed and had no physicians available at resuscitation. Therefore, different protocols had to be used. In Bombay, the study period was limited to 5 minutes. If needed, mask ventilation was then replaced by intubation. In Dar es Salaam, MM ventilation was continued for up to 10 minutes, the inspiratory pressure was adjusted to 30 cmH2O and the ventilation was slow (8-10 breaths/min). In Bombay, 30 babies were allocated to the BM and 24 to the MM groups. In Dar es Salaam 56 were in the BM and 64 in the MM groups. The results for term babies in Bombay and both term and pre-term babies in Dar es Salaam showed no significant differences between the two groups of treatment, as determined by Apgar score > or = 4 at 5 and 10 minutes, number of babies with their first gasp, heart rate > 130 beats/min or pulse oximeter values above 75%, all at 5 minutes. An Apgar score > or = 4 at 5 minutes was achieved in more than 75% of all infants, irrespective of treatment. The rates of early neonatal mortality and neonatal convulsions did not differ between the two methods of resuscitation. In Dar es Salaam, the low respiratory frequency used in both groups was associated with a slow increase in heart rate above 130 beats per min. This result indicates that further studies will be needed before such slow respiratory frequencies are used. We conclude that, if adequate training is provided and the respiratory frequency is kept within the normal range, MM ventilation is an alternative to assisted ventilation when no bag and mask is available. However, further studies are necessary, since this method has proved to be tiring and uncomfortable for the resuscitating health personnel.

Apgar Score↗
PubMed1982

Resuscitation skills among the population.

According to a postal survey, 49% of the population living in the Finnish Lapland county has been taught how to resuscitate, but only 19% of the whole population there thought they would be capable of resuscitating a patient. Even among those who had been properly instructed, only 33% thought they would be able to perform resuscitation. It thus seems that not enough teaching sessions have been arranged to teach resuscitation to the whole population. In addition, the teaching sessions arranged do not ensure an adequate resuscitation technique for those who have received instruction.

Adolescent↗
PubMed2004

Development and use of a portable paediatric resuscitation card.

OBJECTIVES: Inaccuracy and delay in decision making in paediatric resuscitation has been previously demonstrated and may result in preventable death. We assessed several domains of paediatric resuscitation knowledge amongst a sample of tertiary hospital paediatric doctors, developed a portable aide-memoire reference card containing reference normal values, including an algorithm for recognition and management of the seriously ill/arrested child, and assessed the ability of medical staff to use this card to obtain accurate information. METHODS: A convenience sample of 46 members of the Royal Children's Hospital medical staff completed a questionnaire. Knowledge deficits identified were used to create a 9 x 6 cm, name tag sized, laminated card providing physiological parameters and information required for paediatric resuscitation. The card was then distributed to all medical staff. A sample of 18 doctors completed an identical questionnaire 4 months after introduction of the card. Pre- and post-card results were analysed across a range of knowledge domains. RESULTS: Basic calculations were incorrect in over 40% of all pre-card responses. Seniority did not predict more correct answers. The post-card group obtained significantly more correct answers than the pre-card group. CONCLUSION: Medical staff wore, and were able to use the card to provide the correct values for paediatric resuscitation parameters. The use of a card significantly improved knowledge of the correct values for resuscitation data. This project has resulted in the card being issued to all medical and nursing staff and is now accessible via the Royal Children's Hospital internet at http://perseus.rch.unimelb.edu.au/genmed/resuscardontheweb.htm

Education, Medical, Continuing↗
PubMed1997

Pneumomediastinum in newborns induced by the Elder CPR/demand valve during resuscitation.

Two term and one post-term newborn infants with pneumomediastinum associated with the use of an Elder CPR (cardiopulmonary resuscitation)/demand valve during resuscitation are described. Because of apnea or irregular gasping respiration after vaginal delivery, they received repetitive positive-pressure ventilation with this resuscitator, which is designed to provide 100% oxygen with a limited pressure of up to 40 cmH2O. Following resuscitation, the infants had tachypnea and diminished breath sounds. Roentgenograms and computed tomography of the chest revealed pneumomediastinum in all three and cervical subcutaneous emphysema in one. They required 25-30% oxygen for 3-14 days until they recovered spontaneously. Thus, pressures as low as 40 cmH2O can cause barotrauma, and the Elder resuscitator, even when functioning properly, may injure the lungs of newborn infants.

Asphyxia Neonatorum↗
PubMed1993

Resuscitation following injury: an end or a means?

It is known that a successful outcome after injury requires haemostasis and replacement of intra- and extracellular fluid losses. In situations of controlled haemorrhage rapid replacement of these fluid losses is likely to be associated with the least morbidity. When considering uncontrolled haemorrhage, however, there is good evidence that effective resuscitative devices and strategies have proven to be associated with a worse outcome when used initially than when their use follows surgical control of bleeding. Despite newer developments in resuscitative technique, surgeons must continue to be involved in the early management of the severely injured so that they are in the best position to employ their skills and provide surgical haemostasis when and where it is required. The 'end' therefore in resuscitation of the injured is a normovolaemic, normotensive patient who is physiologically stable and able to have definitive management of his/her anatomic injuries. The 'means' are good prehospital care, accurate initial assessment and resuscitation that employs temporary and definitive haemostasis combined with adequate volumes of appropriately chosen and delivered resuscitation fluid.

Animals↗
PubMed2005

Cardiopulmonary resuscitation with vasopressin in a dog.

That endogenous vasopressin levels in successfully resuscitated human patients were significantly higher than in patients who died pointed to the possible benefit of administering vasopressin during cardiopulmonary resuscitation (CPR). Several CPR studies in pigs showed that vasopressin improved blood flow to vital organs, cerebral oxygen delivery, resuscitability and neurological outcome when compared with epinephrine. In a small clinical study, vasopressin significantly improved short-term survival when compared with epinephrine indicating its potential as an alternative pressor to epinephrine during CPR in human beings. As there was little clinical data available at that time, its recommended use was limited to adult human beings with shock-refractory ventricular fibrillation. In this report, we present the case of a dog in which the successful management of intraoperative asystolic cardiac arrest involved vasopressin. Unexpected cardiac arrest occurred during anaesthesia for the surgical removal of multiple mammary adenocarcinomata in a 11-year-old Yorkshire terrier. Despite an ASA physical status assignation of III, the dog was successfully resuscitated with external chest compressions, intermittent positive pressure ventilation and vasopressin (2 doses of 0.8 IU kg(-1)) and was discharged 3 days later without signs of neurological injury. We believe vasopressin contributed to restoring spontaneous circulation. It may prove increasingly useful in perioperative resuscitation in dogs.

Anesthesia↗
PubMedDate not supplied

Percutaneous central venous access for resuscitation in trauma.

OBJECTIVE: To determine the safety of percutaneous central venous access when used for trauma resuscitation and whether the initial hemodynamic status of the patient or the site of placement affects the ease or success of line placement. METHOD: Consecutive major-trauma patients were managed using a resuscitation protocol guiding intravenous line use. Percutaneous peripheral venous access was initially attempted in all patients. If this approach was unsuccessful or proved to be inadequate for volume resuscitation, venous access was attempted using central venous catheter-introducer sets. The site of the central venous access was determined by protocol. For thoracic injury, access was via the ipsilateral subclavian vein (SCV), the ipsilateral internal jugular vein (IJV), or the femoral vein. For suspected mediastinal injury, access was via the contralateral SCV or IJV, or the femoral vein. For abdominal or flank injury, access was via the SCV or IJV only. Multiple central venous access sites were used at the discretion of the trauma team. RESULTS: Central venous access was successful at 144 of 147 sites (99%) used in 122 patients during the study period. There was only one major complication (rate = 0.7%; 95% CI 0.0-3.8%). Mean catheter placement time was 1.9 minutes, and cannulation occurred with a mean of 1.8 needle passes. Most patients (81/122) were hypotensive (blood pressure < or = 90 torr) at the time of line placement, including 44 who were in cardiac arrest and four awake patients who had no obtainable blood pressure. Neither the access site nor the presence of hypotension was associated with the mean time to obtain central venous access, the mean number of attempts, or the complication rate. CONCLUSION: Percutaneous central venous access is relatively safe and reliable for gaining intravenous access when resuscitating trauma patients, when used in a center where physicians are experienced in the technique. Consideration should be given to expanding the use of central venous access in trauma resuscitation.

Adult↗
PubMed2001

Bench to bedside: resuscitation from prolonged ventricular fibrillation.

Ventricular fibrillation (VF) remains the most common cardiac arrest heart rhythm. Defibrillation is the primary treatment and is very effective if delivered early within a few minutes of onset of VF. However, successful treatment of VF becomes increasingly more difficult when the duration of VF exceeds 4 minutes. Classically, successful cardiac arrest resuscitation has been thought of as simply achieving restoration of spontaneous circulation (ROSC). However, this traditional approach fails to consider the high early post-cardiac arrest mortality and morbidity and ignores the reperfusion injuries, which are manifest in the heart and brain. More recently, resuscitation from cardiac arrest has been divided into two phases; phase I, achieving ROSC, and phase II, treatment of reperfusion injury. The focus in both phases of resuscitation remains the heart and brain, as prolonged VF remains primarily a two-organ disease. These two organs are most sensitive to oxygen and substrate deprivation and account for the vast majority of early post-resuscitation mortality and morbidity. This review focuses first on the initial resuscitation (achieving ROSC) and then on the reperfusion issues affecting the heart and brain.

Animals↗
PubMed2002

Small-volume resuscitation with HBOC-201: effects on cardiovascular parameters and brain tissue oxygen tension in an out-of-hospital model of hemorrhage in swine.

OBJECTIVE: Hemoglobin-based oxygen carriers, such as HBOC-201, offer several potential advantages over conventional resuscitation solutions or banked blood in the acute treatment of hemorrhagic shock. While previous studies with some hemoglobin solutions revealed vasoactive effects resulting in decreased oxygen delivery, these investigations were performed without directly measuring vital tissue oxygenation. The authors tested the hypothesis that a small-volume bolus of HBOC-201 would improve and sustain brain tissue oxygen tension (PbrO(2)) without adverse effects on cardiovascular end-points, when used in an acute out-of-hospital hemorrhage model. METHODS: Male Yorkshire swine (n = 7) were hemorrhaged to a mean arterial pressure (MAP) of 40 mm Hg while monitoring standard hemodynamic parameters. In addition, Clark-type polarographic probes were directly inserted into brain tissue to measure PbrO(2). Following institution of high-flow oxygen (FiO(2) = 1.0), resuscitation was performed with a bolus infusion of HBOC-201 (6 mL/kg). Swine were observed for two hours. RESULTS: Cardiac output (CO), MAP, pulmonary artery diastolic pressure (PAD), and PbrO(2) all decreased significantly with hemorrhage (p < 0.05). Immediately following resuscitation with HBOC-201 (mean volume = 239 mL), MAP and CO were restored to 83% and 84% of baseline levels, respectively. PbrO(2) increased significantly after treatment with HBOC-201, surpassing baseline levels by 66%. PAD rose above baseline levels during observation, but this increase was not significantly different from baseline levels (24.0 mm +/- 4.1 vs. 22.7 mm +/- 7.4). CONCLUSIONS: Small-volume resuscitation with HBOC-201 rapidly restored hemodynamic parameters and PbrO(2) following severe hemorrhage without detrimental vasoactive effects and without compromise to directly monitored brain tissue oxygenation. The results of this preliminary study demonstrate that HBOC-201 could potentially improve current resuscitation measures and that further investigations with HBOC-201 are warranted.

Animals↗
PubMed2005

Effects of tidal volume and positive end-expiratory pressure during resuscitation of very premature lambs.

BACKGROUND: Guidelines recommend neonatal resuscitation without controlling tidal volume or positive end-expiratory pressure (PEEP). However, these may improve gas exchange, lung volume and outcome. AIM: To investigate resuscitation of very premature lambs with a Laerdal bag without PEEP versus volume guarantee ventilation with PEEP. METHODS: Anaesthetized lambs (n=20) delivered at 125 d gestation were randomized to three groups receiving 15 min resuscitation: (1) Laerdal bag and no PEEP; (2) ventilation with a tidal volume of 5 ml/kg and 8 cm H(2)O PEEP; (3) ventilation with 10 ml/kg and 8 cm H(2)O PEEP. They were then all ventilated for 2 h with tidal volumes of 5 or 10 ml/kg, and 8 cm H(2)O PEEP. Ventilation parameters and blood gases were recorded. RESULTS: Different tidal volumes affected PaCO(2) within minutes, with 10 ml/kg causing severe hypocarbia. PEEP had little effect on PaCO(2). Oxygenation improved significantly with PEEP of 8 cm H(2)O, irrespective of tidal volume. CONCLUSION: Very premature lambs can be resuscitated effectively using volume-guarantee ventilation and PEEP. Tidal volumes affected PaCO(2) within minutes but had little effect on oxygenation. PEEP halved the oxygen requirement compared with no PEEP. Resuscitating premature babies with controlled tidal volumes and PEEP might improve their outcome.

Animals↗
PubMed2005

Use of supplementary equipment for resuscitation of newborn infants at tertiary perinatal centres in Australia and New Zealand.

AIM: Neonatal resuscitation is a common and important intervention. International consensus statements advise how newborns should be resuscitated and suggest equipment to be used. Use of equipment not specifically recommended in these guidelines has been advocated. We wished to determine how widely this supplementary equipment is used in a geographically defined region. METHODS: Each of the 25 tertiary perinatal centres with on-site deliveries in Australia and New Zealand was surveyed. The questionnaire asked about the use of the following items during delivery room resuscitation: pulse oximetry, exhaled carbon dioxide detection, polyethylene wrapping, oxygen blenders, laryngeal mask and oropharyngeal airways. RESULTS: Data were obtained from all centres. Pulse oximetry is used at 12 (48%) centres. Exhaled CO2 detection is used to confirm endotracheal tube placement at three (12%) of the centres. Polyethylene wrapping is used to prevent heat loss in very-low-birthweight infants at delivery at 11 (44%) centres. Oxygen blenders are used to modify the amount of oxygen delivered at nine (36%) centres. Laryngeal mask airways are infrequently used at two (8%) centres. Oropharyngeal airways are infrequently used at five (20%) centres. CONCLUSION: There is considerable variation in the equipment and techniques used to resuscitate newly born infants. Use of equipment not specifically recommended in international consensus statements is widespread. These are potentially effective tools to improve resuscitation. The evidence supporting their use is, however, limited. Urgent evaluation of their efficacy and safety is required before even more widespread use occurs.

Australia↗
PubMed2004

Family member presence during resuscitation in the emergency department: An Australian perspective.

OBJECTIVE: The practice of family member presence during resuscitation in the ED has attracted widespread attention over the last few decades. Despite the recommendations of international organizations, clinical staff remain reluctant to engage in this practice in many EDs. This paper separates the evidence from opinion to determine the current state of knowledge about this practice. METHODS: A search strategy was developed and used to locate research based publications, which were subsequently reviewed for the strength of evidence providing the basis for recommendations. RESULTS: The literature was examined to reveal what patients and their family members want; the outcomes of family presence during resuscitation for patients and their family members; staff views and practices regarding family presence during resuscitation. Findings suggest that providing the opportunity to be with their critically ill family member is both important to and beneficial for families, however, disparity in staff views has been identified as a major obstacle to family presence during resuscitation. Examination of published guidelines and staff practices described in the literature revealed consistent elements. CONCLUSION: Although critics point to the lack of rigour in this body of literature, the current state of knowledge suggests merit in pursuing future research to examine and measure effects of family member presence during resuscitation on patients, family members and healthcare providers.

Attitude of Health Personnel↗
PubMed1991

Endotracheal resuscitation of neonates using a rebreathing bag.

Thirty asphyxiated neonates were resuscitated endotracheally with an anaesthetic rebreathing bag. The system was not limited either by pressure or by volume and chest movement was used as the criterion for adequate inflation. Inflation pressure and flow were recorded during resuscitation, and flow was integrated to obtain volume. Median mean pressure over the first 10 inflations was 40 cm H2O and this dropped during later resuscitation to 29 cm H2O. The volume delivered did not change significantly, so volume divided by pressure increased from a median of 0.18 to 0.35 ml/kg/cm H2O. Fourteen infants formed part of their functional residual capacity with artificial ventilation and five with spontaneous breaths. Eleven infants showed no evidence of functional residual capacity formation. In the 22 preterm infants there was a strong association between absence of functional residual capacity formation and later hyaline membrane disease that required ventilation. We suggest that pressures of more than than 30 cm H2O may be helpful during initial resuscitation and that there should be further study of devices using positive end expiratory pressure for resuscitation of preterm infants.

Anesthesia, Closed-Circuit↗
PubMed1993

A survey of basic resuscitation knowledge among resident paediatricians.

A telephone questionnaire was undertaken to evaluate the knowledge of resident paediatricians on the subject of the basic resuscitation of the acutely sick child. The questionnaire was targeted at 88 resident paediatricians in hospitals accepting paediatric emergencies in four health regions. Outcome was measured as a correct response to questions based on several emergency scenarios and on the confidence expressed of basic resuscitation knowledge. The subject of emergency management of the child with a compromised upper airway was poorly answered with 40/73 (55%) resident paediatricians suggesting an incorrect endotracheal tube size for an 8 year old child. Fluid management was also deemed unsatisfactory with only 36/73 (49%) providing adequate transfusion secondary to haemorrhagic shock. In addition only 19/73 (26%) mentioned the intraosseous route as a means of obtaining vascular access in a child in extremis. Confidence of the knowledge of basic resuscitation of children was low among resident paediatricians with only 30/73 (41%) expressing confidence and 69/73 (94%) expressing a desire for more formal training in paediatric resuscitation. Resident paediatricians are usually the key personnel in the management of very sick children. This survey demonstrates a low level of basic resuscitation knowledge among resident paediatricians of all grades that must be remedied at a local and national level.

Cardiopulmonary Resuscitation↗