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PubMed1991

The effect of hypertonic saline resuscitation on bacterial translocation after hemorrhagic shock in rats.

Translocation of enteric bacteria occurs in rats after hemorrhagic shock. A proposed mechanism involves intestinal mucosal injury by hypoperfusion. Recent work suggests that moderate hypovolemia causes gut arteriolar constriction, which is ameliorated by hypertonic saline resuscitation. Bacterial translocation should, therefore, be reduced when hypertonic saline (HS) is used as the resuscitative fluid. Seventy-eight Sprague-Dawley rats were anesthetized and subjected to 30 minutes of hemorrhagic shock (systolic blood pressure 30 to 50 mm Hg) through a modified Wigger's model. Resuscitation was performed with either shed blood (B), 3% HS + 1/2B (1:1), or with 7.5% HS + 1/2B (1:1). Spleen, liver, and mesenteric lymph nodes were sent for quantitative culture 24 hours later. Translocation occurred if enteric organisms were cultured from at least one organ. Statistical analysis used the Fisher exact test. Compared to autotransfusion, hemodilutional resuscitation from hemorrhagic shock with hypertonic saline resulted in a significant reduction in bacterial translocation (p values were 0.03 and 0.04 for 3% and 7.5% hypertonic saline, respectively). The reduction in translocation after hypertonic saline resuscitation may be the consequence of microcirculatory alterations preventing gut hypoperfusion.

Animals↗
PubMed1991

Regurgitation of fat and marrow emboli into coronary veins during resuscitation.

Three groups of patients were examined at autopsy for the presence of fat and marrow emboli in the lungs, heart, and other organs. Group 1 was composed of patients with massive pulmonary thromboembolism and attempted cardiopulmonary resuscitation; group 2, patients with pulmonary thromboembolism and without attempted cardiopulmonary resuscitation; and group 3, patients without pulmonary thromboembolism and with attempted cardiopulmonary resuscitation. The results confirm that pulmonary fat and marrow emboli are frequent in those patients who are resuscitated. A novel observation is the finding of multiple coexistent cardiac venous emboli in those resuscitated patients who have pulmonary artery obstruction with pulmonary thromboemboli. These findings suggest that these emboli regurgitate from the right side of the heart to the coronary sinus and cardiac veins in cases of pulmonary artery hypertension.

Adolescent↗
PubMed1991

A survey of resuscitation training in Canadian undergraduate medical programs.

OBJECTIVES: To establish a national profile of undergraduate training in resuscitation at Canadian medical schools, to compare the resuscitation training programs of the schools and to determine the cost of teaching seven resuscitation courses. DESIGN: Mail survey in 1989 and follow-up telephone interviews in 1991 to update and verify the information. SUBJECTS: The undergraduate deans of the 16 Canadian medical schools. INTERVENTION: The mail survey asked five questions: (a) Is completion of a standard first aid or cardiopulmonary resuscitation (CPR) course a requirement for admission to medical school? (b) Are these courses and those in basic and advanced cardiac, trauma and neurologic life support for children and adults provided to undergraduate students? (c) During which undergraduate year are these courses offered? (d) Is their successful completion required for graduation? and (e) Who funds the training courses? RESULTS: The medical schools placed emphasis on the seven courses differently. More than half the schools required the completion of courses before admission or taught some courses but did not require the completion of the courses for graduation. On average, fewer than three of the seven courses were taught, and the completion of fewer than two was required for graduation. About half of the courses were funded by the universities. The annual projected maximum cost of teaching the seven courses was $1790 per medical student. CONCLUSION: The seven resuscitation courses have not been fully implemented at the undergraduate level in Canadian medical schools.

Adult↗
PubMed1990

The do-not-resuscitate order: outpatient experience and decision-making preferences.

Do-not-resuscitate (DNR) orders have become a widespread part of modern medical practice. This study examined patient experience and decision-making preferences regarding cardiopulmonary resuscitation. A random sample of 800 outpatients (one half aged over 70 years) was surveyed by questionnaire, with a 51% response rate. While only 11% of patients had ever discussed resuscitation with a physician, 67% had thought about the issue, and 44% had discussed it with someone other than a physician. Patients overwhelmingly preferred to preserve a good quality of life, even if it meant not living longer (93.9%). When asked who they would have help them with DNR decisions, physicians were most often selected, while spouses were the most valued advisors. In a series of scenarios such factors as dementia, drug or alcohol use, age, and pain had a significant effect on a patient's decision about resuscitation. Discussions about DNR issues in the outpatient setting should be encouraged, as patient interest is strong, and greater physician awareness of patients' values and preferences can prevent unwanted resuscitation in the acute setting.

Age Factors↗
PubMed1990

Cardiopulmonary resuscitation policies and practices. A statewide nursing home study.

We determined the prevalence of written cardiopulmonary resuscitation policies in North Carolina nursing homes and evaluated their content according to predetermined criteria. Questionnaires were mailed to 236 state-registered facilities. Two hundred nine nursing homes (88.5%) responded to the questionnaire; 83% reported having a written policy, and half (86 nursing homes) provided copies. Nine of ten nursing homes reported that cardiopulmonary resuscitation was performed at their institution, and a similar number (92%) permitted physician orders restricting cardiopulmonary resuscitation. Written policies were systematically compared with 10 model criteria. Policy content varied substantially. More than half of the policies contained provisions for authorization, informed consent, documentation, competency, review, and applicability of do not resuscitate orders. Less than half contained criteria for autonomy, treatment alternatives, dignity and quality of care, and patient identification. Nursing homes that had written policies were newer, larger, and for-profit; had a greater proportion of skilled nursing care beds; and were more likely to have both Medicare and Medicaid certification. The variations in these policies place nursing home residents at risk for having important personal rights limited or ignored. Inclusion of these 10 policy criteria in a comprehensive cardiopulmonary resuscitation policy would represent an important step toward enhancing the quality of decision making by nursing home residents.

Aged↗
PubMed1990

Resuscitation at birth.

Birth asphyxia is frequent and often severe, occurring in about 10% and 1% respectively of all births; in a third it is unexpected. Delivery rooms must be organised and equipped and trained staff readily available so as to provide appropriate and timely resuscitation of the newborn. Simple procedures designed to prevent hypothermia, maintain a patent airway, improve oxygenation and ventilation are sufficient for the majority of babies. Circulatory support and biochemical resuscitation will be needed in a few. In the absence of other abnormalities, the long term prognosis for newborns who respond promptly to resuscitation is good. Every baby, no matter how severely asphyxiated must therefore be promptly and vigorously resuscitated. Only those with a Apgar score of less than 4 at 10 minutes, prolonged hypotonia or seizures have a poor prognosis. With the needs in cardio-pulmonary resuscitation understood and met, research is now being directed at neuroresuscitation.

Apgar Score↗
PubMed1987

[Arrhythmia profile and sudden cardiac death in early and late resuscitated patients following myocardial infarct].

The arrhythmia profile has been studied in 40 patients (pts) with acute myocardial infarction (MI) resuscitated early (less than 24 hours post MI, group I) and late (4-12 weeks post MI, group II) using 24 h Holter monitoring (HM) at the time of LV- and coronary angiography (HM A) with an average follow-up of 27 months (7-61) (HM B). Forty pts with an acute MI without resuscitation served as controls (group III). Mortality for sudden cardiac death (scd) (death within 24 hours after beginning of symptoms) was significantly higher in group II (6/14 or 42.9%; 13% per year) than in group I (4/26 or 15.4%; 5.9% per year) (p less than 0.05) or in group III (3/40 or 7.5%; 1.8% per year) (p less than 0.001). In HM A there were no significant differences with regard to PVCs and complex arrhythmias using qualitative and quantitative analysis in groups I-III as well as between survivors and scd-pts. In HM B survivors in group II had significantly more PVCs (mean = 1347), couplets (mean = 29) and salvos (mean = 11) than in group I (PVC, mean = 355; couplets, mean = 3; salvos, mean = 0.1; p less than 0.05) or in group III (PVC, mean = 455; couplets, mean = 4; salvos, mean = 0.8; p less than 0.05). They also showed significantly more PVCs (mean = 1480), couplets (mean = 35) and salvos (mean = 15) than in HM A (PVC, mean = 1347; couplets, mean = 3; salvos, mean = 0; p less than 0.05). There were no significant differences between HM A and HM B in groups I and III. It can be concluded that the risk of sudden cardiac death was increased in pts resuscitated 4-12 weeks post MI in comparison to pts with early resuscitation or without resuscitation post MI. In these high risk pts repeated studies using Holter monitoring were helpful in estimating the further risk of sudden cardiac death.

Adult↗
PubMed1989

Evaluation of inhospital cardiopulmonary resuscitation.

Of 77 patients who received cardiopulmonary resuscitation (CPR) for an inhospital cardiac arrest from Jan. 1987 to Mar. 1988. 48(68%) survived the initial resuscitation, but only 11(16%) survived to leave hospital. A follow-up survey to Oct. 1988, of these 11 patients showed that one died within 11 months of discharge, but that others were all alive and living independently. The major cause of cardiopulmonary arrest was airway obstruction. Survival rates were lower if resuscitation efforts lasted more than 30 minutes or if the event occurred between midnight and 8:00 AM. Thirty of the 48 patients who were successfully resuscitated initially were transferred to the intensive care unit for prolonged cardiac life support. Of the patients who had underlying disease or severe neurologic impairment due to hypoxic encephalopathy, 19(63%) were dead within a few days or even hours after CPR. Therefore, we recommend (1) programs for routine CPR assessment (2) extension of CPR training for key personnel, especially ward staff working night shifts (3) assessment by CPR providers as to whether or not to continue or to give DNR (do-not-resuscitate) orders.

Adult↗
PubMed1989

[Cardio-pulmo-cerebral resuscitation in myocardial infarct in the emergency medical service].

Of 1234 patients with confirmed myocardial infarction who were treated at the emergency medical service station in Ostrava in 95 (8%) circulatory arrest developed and cardiopulmocerebral resuscitation was applied. In 60 (63%) it was not possible to restore spontaneous circulation and they were subjected to necropsy after resuscitation efforts. A total of 35 (37%) of the resuscitated patients were taken to hospital. Resuscitation was permanently successful in 19 (20%) of patients with myocardial infarction. The authors discuss the most frequent shortcomings of urgent resuscitation as well as other possible ways how to improve the final results.

Heart Arrest↗
PubMed1989

Crystalloid versus colloid fluid resuscitation: a meta-analysis of mortality.

Controversy persists over the best choice of fluid to use for resuscitation. A number of published articles promote the use of either colloid or crystalloid fluids. Most of the arguments for use of one fluid or the other are based on cardiopulmonary data collected during and after fluid resuscitation. Although many studies report the mortality rate of patients treated with both fluids, none have critically analyzed this most important aspect of therapy. Meta-analysis is a relatively new statistical method whereby data from a number of clinical trials can be pooled to produce more reliable data. In this study meta-analysis was used to pool mortality data from reports of eight previously published, randomized, clinical trials, in which the efficacy of crystalloid and colloid fluid resuscitation was compared. The overall treatment effect when the data from all the clinical trials were pooled showed a 5.7% relative difference in mortality rate in favor of crystalloid therapy. When the data from only those studies using trauma patients were pooled, the overall treatment effect showed a 12.3% difference in mortality rate in favor of crystalloid therapy. However, when data from studies that used nontrauma patients were pooled, there was a 7.8% difference in mortality rate in favor of colloid treatment. In patients with trauma who are septic and in whom the capillary leak syndrome leads to adult respiratory distress syndrome, it may be assumed that colloid resuscitation would be no better than crystalloid resuscitation. In this study the meta-analysis of published data showed that this form of treatment is deleterious. In patients who are nonseptic or having elective surgery, however, the basement membrane is intact, and meta-analysis of data in this setting showed that treatment with colloids would be efficacious.

Colloids↗
PubMed1987

Resuscitation of the elderly.

Concerns about quality of life and the cost of medical care raise questions about the effectiveness of cardiopulmonary resuscitation (CPR) efforts. This study explores the role of age in resuscitation outcome by focusing on the CPR experience of all patients age 75 years and older in a community hospital during a one-year period. Data are based on a retrospective study of the medical records of 86 such patients. While 41 percent survived the initial resuscitation effort, only 23 percent regained conscious functioning, 12 percent left the hospital, and only 7 percent survived to be discharged from the hospital and were alive one year later. None of the 26 patients over the age of 85 survived resuscitation. Among the 75 to 84-year-old patients, the diagnosis of acute onset arrhythmia and dementia were associated with a better survival prognosis. Crude estimates of cost based on charges for crash carts, intensive care, and bed rates totalled over $100,000; over one-half the amount was allocated to the 21 patients who were unconscious before finally dying the hospital. The study suggests the importance of continuing discussion about quality of life and cost implications of resuscitation of elderly patients.

Aged↗
PubMed1988

[Pharmacokinetics and dynamics of endogenously released and therapeutically administered adrenaline in resuscitation. A comparative animal experimental study].

In this study, catecholamine plasma levels and hemodynamic response were measured to compare the effects of endogenously released (group A; n = 8), intravenously injected (group B; 10 micrograms/kg; n = 8), and endobronchially instilled (e.b.) epinephrine (group C; 100 micrograms/kg; n = 8) on resuscitation. Although the endogenous release of epinephrine produced peak plasma concentrations of 214 +/- 86 ng/ml (mean +/- SEM) during cardiac massage, only 5 animals were successfully resuscitated in group A. Mean arterial pressure and cardiac output were significantly lower in the first hour of restored spontaneous circulation compared to groups B and C. Endobronchial and intravenous epinephrine administration proved equally effective with regard to resuscitability and hemodynamic response during cardiac massage. All animals in groups B and C were successfully resuscitated and peak plasma concentrations of epinephrine were achieved with comparable onset times (317 +/- 53 ng/ml after 2.5 min in group B, 634 +/- 202 ng/ml after 3 min in group C). The tenfold epinephrine dose administered endobronchially was able to generate only a twofold increase in peak plasma epinephrine concentrations. The mean bioavailability with this route of administration, however, was 40% (5-71%). The ongoing absorption and therefore significantly longer half life of e.b. epinephrine compared to i.v. administration improved the hemodynamic situation of group C animals during the early postresuscitation period. More extensive use of e.b. epinephrine administration can be recommended, especially in out-of-hospital resuscitation, when intubation is achieved before an intravenous line can be established.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1988

In-hospital cardiopulmonary resuscitation.

A retrospective review of 399 cardiopulmonary resuscitation (CPR) efforts in 329 veterans was performed to evaluate the observation that few geriatric patients were discharged alive after they underwent CPR. Cardiopulmonary resuscitation efforts with witnessed arrests were more frequently successful than efforts with unwitnessed arrests (47.7% vs 29.9%) and resulted in live discharge more often than efforts with unwitnessed arrests. Cardiopulmonary resuscitation efforts that resulted in a live discharge were more brief and involved a lower mean number of medication doses. Of the 77 CPR efforts in patients 70 years of age or older who had arrests, 24 (31%) were successful, and in 22 (92%), patients were alive after 24 hours. None lived to discharge. There were 322 CPR efforts in the younger cohort; 137 (43%) were successful, in 124 (91%) of these 137 efforts, patients were alive after 24 hours, and in 22 (16%), patients were discharged alive. Older patients were significantly less likely to live to discharge both at the time of arrest and 24 hours after successful resuscitation. When a multivariate analysis was used, the presence of sepsis, cancer, increased age, increased number of medication doses administered, and absence of witness were all "predictive" of poor outcome. Cardiopulmonary resuscitation should be administered only to those who have the greatest potential benefit from this emotionally and physically traumatic procedure.

Adult↗
PubMed1986

Dextrose containing intravenous fluid impairs outcome and increases death after eight minutes of cardiac arrest and resuscitation in dogs.

Use of dextrose in intravenous resuscitation fluids is common practice; however, this study indicates that 5% dextrose solutions, even if administered in physiologic quantities, greatly worsens the outcome of survivable cardiac arrest. Twelve adult male mongrel dogs were premedicated with morphine, anesthetized with halothane, instrumented, intubated, and ventilated. Each dog was first given 500 ml of either lactated Ringer's (LR) (n = 6) or 5% dextrose in LR (D5LR) (n = 6). Halothane was stopped and fibrillation was induced (60 Hz). Blood glucose just before cardiac arrest was 129 mg/dl in the LR dogs and was increased to 335 mg/dl in the D5LR dogs. After eight minutes of arrest, resuscitation, including internal cardiac massage and standard advanced cardiac life support drug protocols (modified for dogs), was begun. When stable cardiac rhythm was obtained, the chest was closed, and LR or D5LR continued until a total of 1L was given. A neurologic score (0 = normal to 100 = dead) was assigned at 1, 2, 6, and 24 hours. The LR group did not differ statistically from the D5LR group in operative time, number of defibrillatory shocks, time to spontaneous ventilation, time to extubation, or drugs required. Resuscitation was successful in all six LR and five of six D5LR group; however, by 2 hours after resuscitation and thereafter, D5LR group had a significantly greater neurologic deficit (p less than 0.05) than did the LR group. By 9 hours, four of six D5LR dogs displayed convulsive activity and died. At 24 hours the D5LR group had a greater (p less than 0.008) neurologic deficit (82 +/- 11) than did the LR group (21 +/- 7), which walked and ate. We conclude that the addition of 5% dextrose to standard intravenous fluids greatly increases the morbidity and mortality associated with cardiac resuscitation.

Animals↗
PubMed1986

Identification of a high-risk group for sudden infant death syndrome among infants who were resuscitated for sleep apnea.

Of the 1,153 infants who completed monitoring by Aug 1, 1984, through our program at Massachusetts General Hospital, 76 infants had an initial apnea spell during sleep which was characterized by a change in tone and color, was unresponsive to repeated vigorous stimulation, and was terminated only after mouth to mouth resuscitation. The infants were hospitalized for observation and evaluation, and no cause could be identified. All were discharged on a home apnea or cardiorespiratory monitor, and subsequent episodes of apnea and/or bradycardia were reviewed. We grouped infants based on the intervention used to terminate subsequent episodes: Group 1, resuscitation; group 2, vigorous stimulation; and group 3, neither resuscitation or vigorous stimulation. There was no significant difference in clinical features or in the results of the initial evaluation in groups 1 and 2, compared with group 3. However, the mortality rate was significantly higher in group 1 (4/13) and group 2 (3/12) than in group 3 (3/51) (P less than .007). Siblings of victims of sudden infant death syndrome (n = 8) were at a significantly higher risk of an adverse outcome (two deaths and four resuscitations) than nonsiblings (P less than .02). A seizure disorder that developed during monitoring was associated with a high mortality (4/11 v 6/65, P less than .02). We conclude that these relatively rare infants who have sleep-onset apnea that responded only to resuscitation and have a subsequent similar episode or are siblings of victims of sudden infant death syndrome or develop a seizure disorder during monitoring have a very high risk of dying (31%, 25%, and 36% respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Bradycardia↗
PubMedDate not supplied

[Significance of cardiopulmonary resuscitation in thoracic surgery].

45 patients admitted in the thoracic non-cardiac surgery service of the U.L.B. between 1966 and 1983 (17 yrs) were short- or longterm survivors of cardiopulmonary resuscitation. In november 1979 the traditional system was supplanted by a mobile unit with reduction of the interval between cardiopulmonary arrest and resuscitation to 1 minute. The obtained results are as follows: A mobile thoracic wall or intra-thoracic visceral lesions or displacement of thoracic content secondary to a recent thoracic intervention or serious injury do not constitute a contra-indication. Closed chest massage was mainly applied. Displacement of the heart secondary to chronic tuberculosis or pneumonectomy or serious thoracic injury are not formal contra-indications. Open cardiac massage was applied during surgical interventions or with hypovolemic shock secondary to massive intra-thoracic hemorrhage or cardiac tamponade. Pulmonary resuscitation with extra-corporeal circulation was only applied when mechanical ventilation did not suffice. All patients succumbed due to an associated lung involvement with destruction of the pulmonary parenchyma. The use of a mobile unit increased the number of successful resuscitations but did not change at all the duration of survival of the patients nor the number of neurological deficits. The survival time was only affected by 2 factors; the primary disease for which the patient was hospitalized and the presumed cause of arrest. All the other factors had no influence on the duration of survival; a. type of intervention; b. place of C.P. arrest and c. method of resuscitation.

Adolescent↗
PubMed1983

Fluid resuscitation in circulatory shock: a comparison of the cardiorespiratory effects of albumin, hetastarch, and saline solutions in patients with hypovolemic and septic shock.

Twenty-six consecutive patients in hypovolemic shock were randomized to fluid challenge with 5% albumin (A), 6% hetastarch (H), or 0.9% saline (S) solutions. Fluid challenge consisted of 250 ml of test fluid every 15 min until the pulmonary artery wedge pressure (WP) reached 15 mm Hg. Thereafter, WP was maintained at 15 mm Hg for an additional 24 h with infusions of the same test fluid. Vital signs, hemodynamic and respiratory variables, as well as arterial lactate and colloid osmotic pressure (COP) were monitored according to protocol. Chest x-rays were performed by standardized technique before fluid challenge and at 12 and 24 h of maintenance fluid therapy and were evaluated for evidence of pulmonary edema. Cardiac function and hemodynamic stability were restored by fluid challenge with A, H, and S. Two to 4 times the volume of S as A or H was required to achieve similar hemodynamic endpoints. COP was increased by fluid challenge with A or H but was markedly reduced by fluid challenge with S and throughout the 24-h maintenance period. Fluid challenge resulted in reductions in COP-WP gradient of 62% in the A, 43% in the H, and 125% in the S groups. Resuscitation with S resulted in a significantly higher incidence of pulmonary edema (87.5%) than did resuscitation with A (22%) or H (22%). Urine output was not different among the groups at any time during the study. We conclude that 6% H performs as well as 5% A as a resuscitative fluid and that resuscitation with either of these colloids is associated with a lower incidence of pulmonary edema than is resuscitation with 0.9% S.

Aged↗
PubMed1983

Measurement of extravascular lung water in sheep during colloid and crystalloid resuscitation from smoke inhalation.

The pathophysiology of pulmonary inhalation injury, a major cause of morbidity and mortality from fires, is poorly understood. To examine the effects of colloid and crystalloid resuscitation on extravascular lung water (EVLW) during a standard smoke inhalation injury, we subjected 12 sheep to 8 minutes of cool pine smoke inhalation. The animals were then resuscitated to a pulmonary capillary wedge pressure (PCWP) of 10 +/- 1.5 mm Hg with either lactated Ringer's solution or plasma protein derivative. EVLW, cardiac output, vascular resistance, colloid oncotic pressure (COP), arterial and pulmonary artery pressures, PCWP, and blood gases were monitored during 4 hours of resuscitation. In colloid-treated animals, EVLW increased from 8.3 +/- 1.2 to 11.1 +/- 0.9 ml/kg with injury; it increased only to 12.5 +/- 1.3 ml/kg during resuscitation. In crystalloid-treated animals, EVLW increased from 8.0 +/- 1.0 to 10.3 +/- 0.8 ml/kg with injury and further increased to 17.4 +/- 1.6 ml/kg during resuscitation, a level significantly higher than that in the colloid group (P less than 0.05). The increases in EVLW were associated with progressive hypoxia, which was worse in the crystalloid group. In the crystalloid group, COP decreased from 27.3 +/- 0.9 to 14.2 +/- 0.4 mm Hg and intravascular driving force (COP-PCWP) dropped from 17.6 to 3.26 +/- 1.5 mm Hg; COP and COP-PCWP were maintained in the colloid group. These data demonstrate that supporting serum COP minimizes the increase in EVLW with smoke inhalation injury and suggests that smoke inhalation does not lead to a dramatic increase in alveolar capillary membrane permeability to protein.

Animals↗