Hemorrhage from gastric mucosal tears complicating cardiopulmonary resuscitation

We observed at autopsy two patients in whom clinically significant gastrointestinal bleeding occurred from gastric mucosal tears following closed chest cardiac massage. Review of autopsy files showed that, when the Mallory-Weiss syndrome is excluded, linear mucosal tears along the lesser curvature of the stomach occur in about 2% of patients given cardiopulmonary resuscitation; similar lesions have not been observed in patients not subjected to resuscitation. The localization of the tears along the lesser curvature of the stomach is probably the consequence of the catenoidal configuration of that region. The importance of the mucosal tears lies in their propensity to hemorrhage if resuscitation is successful.     

Resuscitation in the hospital: circadian variation of cardiopulmonary arrest

Purpose

Over 25 reports have found outpatient frequency of sudden cardiac death peaks between 6 am and noon; few studies, with inconsistent results, have examined circadian variation of death in hospitalized patients. This study assesses circadian variation in cardiopulmonary arrest of in-hospital patients across patient, hospital, and event variables and its effect on survival to discharge.

Methods

A retrospective, single institution registry included all admissions to the Medical Center of Central Georgia in which resuscitation was attempted between January 1987 and December 2000. The registry included 4692 admissions; only the first attempt was reported. Analyses of 1-, 2-, 4-, and 8-hour intervals were performed; 1- and 4-hour intervals are presented.

Results

Significant circadian variation was found at 1 hour (P = .01), but not at 4-hour intervals. Significant circadian variation was found for initial rhythms that were perfusing (P = .03) and asystole (P = .01). A significantly higher percentage of unwitnessed events were found as asystole during the overnight hours (P = .002). Using simple logistic regression, time in 4-hour intervals and rhythm were each significantly related to patient survival until hospital discharge (P = .003 and P <.0001). In multivariate analysis, only rhythm remained significant.

Conclusions

Circadian variation of cardiopulmonary arrest in this hospital has several temporal versions and is related to survival. Late night variation in witnessed events and rhythm suggests a delay between onset of clinical death and discovery, which contributes to poorer outcomes.     

Resuscitation of the trauma patient: Restoration of hemodynamic functions using clinical algorithms

Two algorithms were developed for immediate fluid resuscitation and subsequent management of emergency trauma patients and critically ill postoperative patients. These algorithms were developed from decision rules based on objective physiologic values attained in patients surviving life-threatening shock and trauma. The improved mortality in prospective studies of these two algorithms supports the hypothesis that compensatory physiologic responses of survivors of life-threatening acute illness are major determinants of outcome. Therapy that supports these compensations and produces the survivor pattern was found to improve survival rates and reduce post-resuscitation complications. These prospective studies confirm the validity of an organized, coherent physiologic approach that has as its goal the achievement of optimal physiologic patterns in contrast to simple restoration of hemodynamic and chemical abnormalities to the normal range, as has been the endpoint of the traditional approach.     

Resuscitation of hospitalized patients

Effects of in-hospital resuscitations performed by a trained resuscitation team were studied over a 20-month period during which 1653 deaths were registered. Resuscitative attempts were made in 61 patients with a mean age of 71 years (range 0-86 years). The underlying disease was ischaemic heart disease in 38 cases and most arrests occurred in general wards. Twenty-one patients were initially resuscitated; 12, however, died after an average of 3.2 days while still in hospital. Nine patients were discharged and seven are still alive after two and a half years.     

Serum enzymes after cardiac surgery using cardiopulmonary bypass

Electrocardiographic and enzyme studies were made on an unselected series of 172 patients admitted to the intensive-care unit after cardiac surgery using cardiopulmonary bypass. Fifty-eight patients had aortic valve, 22 patients multiple valve, 40 patients mitral valve, 27 patients congenital, and 25 patients ischemic disease. There were five hospital deaths. The following observations were made preoperatively and on the first, second, and third postoperative days: 13-lead electrocardiograms, serum glutamic oxaloacetic transaminase, lactic dehydrogenase, creatine phosphokinase, and alkaline phosphatase. At least one further electrocardiogram was recorded later in the hospital stay. In 88 of the patients, isoenzymes of LDH were measured. Details of surgical technique and the postoperative course were recorded in each patient.SGOT and LDH values were elevated in all groups but were highest in patients with aortic- and multiple-valve disease. LDH isoenzyme patterns were typical of myocardial damage in only a small number of patients with high total enzymes. There was no relationship between high enzyme levels and age, hemolysis during bypass, or postoperative complications, but a correlation between enzyme levels and cardiopulmonary bypass time was shown in patients in the aortic and congenital groups and between enzyme levels and aortic cross-clamping time in patients in the aortic and mitral groups.Twenty-seven out of 34 patients with a peak postoperative SGOT level equal to or greater than 200 units per milliliter showed electrocardiographic evidence of myocardial damage but only nine out of 138 patients with SGOT levels less than 200 units per milliliter showed such evidence. All but one patient in the aortic and multiple groups showing myocardial damage had an SGOT level equal to or greater than 200 units per milliliter, but SGOT levels in patients in the mitral, congenital, and ischemic groups showing myocardial damage were usually around 100 units per milliliter. Myocardial damage was more common in the aortic, multiple, and ischemic groups. In patients in the aortic group prolonged ventricular fibrillation during operation was associated with high postoperative enzyme levels but this was largely explained by faulty coronary perfusion in some patients.It is concluded that postoperative elevation of serum enzymes is, in part, an inevitable consequence of cardiopulmonary bypass but exceptionally high levels usually indicate myocardial damage. Routine recording of electrocardiograms, serum SGOT, and serum LDH levels on the first two postoperative days is recommended for all patients.     

Haemodynamic effects of angiotensin converting enzyme inhibition after cardiopulmonary bypass in dogs

Recent studies have suggested a possible causative relationship between elevated plasma levels of Angiotensin II (AII) and the vasoconstriction associated with conventional cardiopulmonary bypass. The haemodynamic effects of SQ14225, a specific angiotensin converting enzyme inhibitor, have been studied in a group of five dogs submitted to a 60 min period of cardiopulmonary bypass (CPB). A 20 min infusion of SQ14225 in a dose of 2 microgram .kg-1 .h-1 was administered to each dog 2 h after the end of the period of CPB. Measurements of peripheral vascular resistance index (PVRI), cardiac index (CI) and plasma levels of Angiotensin II were obtained at the start and end of the infusion period. The results in the five blocked dogs were compared with a control series of ten unblocked dogs submitted to an identical cardiopulmonary bypass regine. In the blocked dogs, PVRI fell significantly during infusion of SQ14225 from 38.27 units to 21.70 units (P <0.01). There was a simultaneous significant increase in cardiac index from 3.00 to 3.98 litre.m2 .min-1 (P <0.01). Plasma Angiotensin 11 levels fell in the blocked dogs from 57 to 11.5 pg.cm-2 during the infusion period (normal levels <15 pg.cm-3). In the control unblocked dogs, there was no corresponding fall in PVRI, no rise in cardiac index, and no fall in elevated plasma AII levels. The difference between the groups were statistically highly significant (P <0.005). These results indicate that reduction in elevated plasma AII levels after CPB using converting enzyme inhibitor SQ14225 is associated with a significant fall in peripheral vascular resistance and a significant rise in cardiac index. In addition, the study confirms the causative relationship between elevated plasma levels of Angiotensin II and the increased vasoconstriction associated with non-pulsatile CPB.     

Thumper型CPR机对心脏复苏的疗效分析

目的探讨Thumper型CPR机对心脏停搏患者心肺复苏(CPR)的临床效果。方法将我院急诊科重症监护病房中发生心脏停搏的患者107例随机分为两组,对照组52例采用徒手胸外心脏按压,两人交替,CPR机组55例采用Thumper型CPR机进行胸外心脏按压,两组均按照《2005年国际CPR和心血管急救指南》进行急救,比较两组患者心脏复苏成功率,复苏成功时间,有创动脉血压,动脉血氧饱和度,动脉血氧分压,肋骨骨折发生率。结果 CPR机组心脏复苏成功率,有创动脉血压,血氧饱和度,动脉血氧分压明显优于对照组,差异具有统计学意义(P<0.05);CPR成功时间,肋骨骨折发生率明显低于对照组,两组差异具有统计学意义(P<0.05)。结论心脏停搏患者早期采用Thumper型CPR机进行心脏复苏,能显著提高CPR成功率,降低并发症的发生。     

Levosimendan for weaning from cardiopulmonary bypass after coronary artery bypass grafting

BACKGROUND: Although cathecholamines are well-established agents of myocardial support during weaning from cardiopulmonary bypass (CPB), there has been little experience with a new inotropic agent, levosimendan. Our aim was to present our experience with levosimendan usage in patients manifesting failure-to-wean from CPB after coronary artery bypass grafting (CABG) when conventional inotropic and intraaortic balloon counterpulsation (IABP) therapies proved to be insufficient. METHODS: Fifteen patients undergoing CABG received levosimendan as a loading dose of 12-24 microg/kg over 10 min, followed by a continuous infusion of 0.1-0.2 microg/(kg min) for 24h. Hemodynamic measurements were performed at baseline and at 1, 24 and 48 h postoperatively. RESULTS: Mean patient age was 63.2+/-2.2 years. CPB time was 149.7+/-19.5 min, while cross-clamp time was 67.8+/-10.5 min. All patients showed evidence of hemodynamic improvement with the start of levosimendan infusion and 14 patients (93.3%) were successfully weaned from CPB. Eight patients (53.3%) experienced significant increases in cardiac index and blood pressure leading to a lessening of the need for catecholamine support. Five patients (33.3%) were lost postoperatively in the ICU. CONCLUSION: Levosimendan appears to be useful in failure-to-wean from CPB after cardiotomy when conventional inotropic therapy proves inadequate.     

Factor VIIa-Antithrombin complexes during cardiac surgery using cardiopulmonary bypass

Antithrombin inhibits VIIa when bound to cellular tissue factor in the presence of heparin. VIIa concentrations increase within the surgical field during cardiopulmonary bypass surgery but decrease when measured in the patient. Using a new ELISA (Stago, Reading, UK), we measured VIIa-antithrombin complexes in patients undergoing cardiopulmonary bypass to determine whether antithrombin plays a physiological role in VIIa inhibition during cardiac surgery. Samples were taken from 13 adult patients undergoing cardiac surgery with cardiopulmonary bypass at the following time points: presurgery, postheparin, 20 min intervals during cardiopulmonary bypass and postprotamine. The presurgery concentrations of VIIa-antithrombin complexes were median of 52.7pm, and these rose postheparin bolus to a median of 110pM that was maintained throughout cardiopulmonary bypass and postprotamine administration. There is an approximate twofold increase in measurable VIIa-antithrombin complexes in patients undergoing cardiac surgery, which is apparent after heparin administration. Antithrombin appears to play an active role in VIIa inhibition during cardiac surgery.     

Outcome of in-hospital adult cardiopulmonary resuscitation assisted with portable auto-priming percutaneous cardiopulmonary support

Background

Outcome from in-hospital cardiopulmonary resuscitation (CPR) is still unsatisfactory. CPR assisted with percutaneous cardiopulmonary support (PCPS) is expected to improve the outcome of in-hospital CPR.

Methods

We retrospectively analyzed 83 consecutive cases of adult in-hospital CPR assisted by a portable pre-assembled auto-priming PCPS system (EBS, Terumo, Japan) from January 2004 to December 2007.

Results

PCPS was successfully performed in 97.6% of the patients and could be weaned in 57.8% of the patients. The survival-to-discharge rate was 41.0% with an acceptable neurological status in 85.3% of the patients. The 6-month survival was 38.6%. Survival-to-discharge decreased about 1% for each 1 min increase in the duration of CPR. The probability of survival was about 65%, 45%, and 19% when the duration of CPR was 10, 30, or 60 min, respectively. Multivariate analysis adjusted with clinical factors including organ dysfunction severity scores revealed that defibrillation and CPR duration less than 35 min were independent predictors for both survival-to-discharge (odds ratio = 8.0, 95% CI = 2.8-23.0, p < 0.001) and 6-month survival (hazard ratio = 3.3, 95% CI = 1.9-5.9, p < 0.001).

Conclusions

Our results showed that CPR assisted with PCPS results in an acceptable survival-to-discharge rate and mid-term prognosis.     

亚低温在心肺脑复苏中的应用

低温治疗用于临床已有很长历史。随着重症监护技术和表面降温技术的不断发展,使得各种大规模低温临床试验成为可能。研究发现,亚低温(28~35℃)对心、脑等重要器官具有明显的保护作用,且无明显不良反应。目前,多采用32~35℃亚低温治疗用于心肺脑复苏,取得了很好的效果。     

Correction of the bleeding time with lyophilized platelet infusions in dogs on cardiopulmonary bypass.

Lyophilized canine platelets were infused in a single large bolus dose into splenectomized dogs after 2 hours' perfusion on cardiopulmonary bypass to test their possible efficacy in restoring hemostasis after compromise of platelet function. The vessel bleeding time (VBT) was monitored by venipuncture of the exposed jugular vein. During cardiopulmonary bypass, platelet counts fell quickly and the VBTs became prolonged over baseline. Infusion of lyophilized platelets reconstituted in normal saline occurred just before or immediately after weaning from the cardiopulmonary bypass pump. The results showed consistent and persistent lowering of the VBTs by the infused lyophilized platelets. Controls showed continuously prolonged VBTs. The weighted average VBT in infused subjects was significantly lower than the average in controls: 3 minutes 10 seconds versus 6 minutes 59 seconds, respectively (t test, P= .01). These results in this setting indicate the possible effectiveness of similar human lyophilized platelet preparations in reducing postoperative bleeding in open heart surgery.     

心肺复苏后昏迷的评估研究

目的探讨准确、客观评估与判定心肺复苏后昏迷的方法。方法对35例心肺复苏后24h仍处于昏迷状态的患者进行前瞻性脑功能状态的动态评估,评估项目包括临床指标、神经电生理指标和脑血流指标。结果35例中深昏迷的24例患者,格拉斯哥昏迷评分均为3分,脑电图除4例外均≥Ⅳ级,脑干听觉诱发电位(BAEP)除3例外均为Ⅲ级,短潜伏期体感诱发电位(SLSEP)除1例外均为Ⅲ级,全部患者复苏后1个月内死亡。24例中11例(45.8%)判定为脑死亡,格拉斯哥预后分级(GOS)评为Ⅰ级;其余11例存活患者从昏迷到睁眼昏迷,5例脑电图为Ⅰ级、3例BAEP和SLSEP为Ⅰ级,GOS均为Ⅱ级,其中2例(18.2%)分别在第35、90天清醒,GOS评为Ⅲ级和Ⅳ级。结论临床与实验室指标相结合综合评定心肺复苏后昏迷更加客观、准确、可靠,并对临床医疗决策和提高脑复苏成功率具有重要的指导意义。     

Hemostatic complications of cardiopulmonary bypass

The-117(G→A) ^Aγ hereditary persistence of fetal hemoglobin (Greek HPFH) and β⁰39-thal mutations are rather frequent in Sardinia so that their interaction is to be expected. Characterization of eight compound heterozygotes for these defects indicated that HPFH was linked to haplotype VII and β⁰39-thal to haplotype II. Haplotype II β⁰39-thal chromosome carries the ^Aγ^T gene which is a useful marker of γ-gene expression. Since the Hb F level in these compound heterozygotes was significantly higher than in 46 ?117 HPFH carriers, the ^Aγ^t, and ^Gγ globin level was determined. ^Aγ^T was underexpressed while ^Gγ was significantly increased, which suggests that in ?117 ^Aγ HPFH/β⁰39-thal healthy subjects the increase in Hb F production is determined only by the ?117 mutated ^Aγ gene and the adjacent ^Gγ gene. © 1995 Wiley-Liss, Inc.