Development of pneumoperitoneum after CPR

INTRODUCTIONChest compressions are performed routinely and have several well-known complications, however one of the rare complications is pneumoperitoneum caused by air entry through a perforation of the viscus. The exact cause of the perforation is not always clear. Furthermore, this rarely reported condition does not have clear management guidelines.PRESENTATION OF CASEWe present an uncommon complication of pneumoperitoneum following successful resuscitation possibly caused by the presence of an orogastric tube at the time of compressions in a 79 year old Hispanic male. Following chest compressions, a distended and tympanic abdomen was noted and air seen under the diaphragm in X-ray imaging.DISCUSSIONA review of previous case reports along with etiology and evaluation of risk factors is presented.CONCLUSIONAlthough the exact cause of pneumoperitoneum cannot be confirmed, emergency personnel should be aware of the risk factors associated with viscus perforation during chest compressions.     

Protective Effects of Estradiol on Myocardial Contractile Function Following Hemorrhagic Shock and Resuscitation in Rats

Background:

Hemorrhagic shock (HS) results in myocardial contractile dysfunction. Studies showed that 17β-estradiol protects the myocardium against contractile dysfunction. The study investigated the cardioprotective effects of treatment with 17β-estradiol before resuscitation following 1 h of HS and resuscitation.

Methods:

Male Sprague-Dawley rats were assigned to 2 sets of experimental protocols: Ex vivo and in vivo treatment and resuscitation. Each set had three experimental groups (n = 6 per group): Normotensive (N), HS and resuscitation (HS-R) and HS rats treated with 17β-estradiol (E) and resuscitated (HS-E-R). Rats were hemorrhaged over 60-min to reach a mean arterial blood pressure of 40 mmHg. In the ex vivo group, hearts were resuscitated by perfusion in the Langendorff system. In the 17β-estradiol treated group, 17β-estradiol 280 µg/kg was added for the first 5 min. Cardiac function was measured. Left ventricular generated pressure (LVGP) and +dP/dt were calculated. In the in vivo group, rats were treated with 17β-estradiol 280 µg/kg s.c. after 60-min HS. Resuscitation was performed in vivo by the reinfusion of the shed blood for 30-min to restore normotension.

Results:

Treatment with 17β-estradiol before resuscitation in ex vivo treated and resuscitated isolated hearts and in the in vivo treated and resuscitated rats following HS improved myocardial contractile function. In the in vivo treated group, LVGP and +dP/dt max were significantly higher in 17β-estradiol treated rats compared to the untreated group (LVGP 136.40 ± 6.61 compared to 47.58 ± 17.55, and +dP/dt 661.85 ± 49.88 compared to 88.18 ± 0.85). Treatment with 17β-estradiol improved LVGP following HS.

Conclusions:

The results indicate that treatment with 17β-estradiol before resuscitation following HS protects the myocardium against dysfunction.     

The Effect of New Duty Hours on Resident Academic Performance and Adult Resuscitation Outcomes

Background

From July 2011, the Accreditation Council for Graduate Medical Education implemented new resident duty hours throughout the US. This study aimed to determine whether changes to call schedules due to these new duty hours achieved the intended goals of excellent patient care and improved resident learning.

Methods

We conducted a retrospective cohort study at an academic hospital. For patient outcomes, we used the hospital registry for code blues and rapid responses to compare the proportion of deaths and transfers to an intensive care unit (July 2010 to June 2011; July 2011 to June 2012). For resident learning, we compared delta percentage scores for annual in-service training examinations (2009 to 2010; 2010 to 2011; 2011 to 2012).

Results

We recorded 187 code blues and 469 rapid responses during the 2-year period: 48 (7.3%) deaths, 374 (57.0%) transfers to the intensive care unit, and 234 (35.7%) stabilizations on the floor. Of all transfers to the intensive care unit, those due to a code blue decreased after implementation of the new duty hours (36% [63/174] vs 25% [49/200], P = .02; adjusted odds ratio = 0.59; 95% confidence interval, 0.37-0.92). The median (interquartile range) delta percentage scores for annual in-service training examinations decreased significantly from the first time-period (2009 to 2010: 7 [4-11]) to the third time-period (2011 to 2012: 5 [2-8], P = .02).

Conclusion

We observed a reduced proportion of transfers to the intensive care unit with a code blue after implementation of new resident duty hours. Resident academic performance experienced a small but significant decrease in in-service training examination delta percentage score. We need large, multicenter studies to corroborate these findings.     

Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation

Background

High ratios of fresh frozen plasma:packed red blood cells in damage control resuscitation (DCR) are associated with increased survival. The impact of volume and type of resuscitative fluid used during high ratio transfusion has not been analyzed. We hypothesize a difference in outcomes based on the type and quantity of resuscitative fluid used in patients that received high ratio DCR.

Methods

A matched case control study of patients who received transfusions of ≥ four units of PRBC during damage control surgery over 4 1/2 y, was conducted at a Level I Trauma Center. All patients received a high ratio DCR, >1:2 of fresh frozen plasma:packed red blood cells. Demographics and outcomes of the type and quantity of resuscitative fluids used in combination with high ratio DCR were compared and analyzed. A Kaplan-Meier survival analysis was computed among four groups: colloid (median quantity = 1.0 L), <3 L crystalloid, 3–6 L crystalloid, and >6 L crystalloid.

Results

There were 56 patients included in the analysis (28 in the crystalloid group and 28 in the colloid group). Demographics were statistically similar. Intraoperative median units of PRBC: crystalloid versus colloid groups was 13 (IQR 8-21) versus 16 (IQR 12–19), P = 0.135; median units of FFP: 12 (IQR 7–18) versus 12 (IQR 10–18), P = 0.440. OR for 10-d mortality in the crystalloid group was 8.41 [95% CI 1.65–42.76 (P = 0.01)]. Kaplan-Meier survival analysis demonstrated lowest mortality in the colloid group and higher mortality with increasing amounts of crystalloid (P = 0.029).

Conclusions

During high ratio DCR, resuscitation with higher volumes of crystalloids was associated with an overall decreased survival, whereas low volumes of colloid use were associated with increased survival. In order to improve outcomes without diluting the survival benefit of hemostatic resuscitation, guidelines should focus on effective low volume resuscitation when high ratio DCR is used. A multi-institutional analysis is needed in order to validate these results.     

Single‐Center Experience With Extracorporeal Life Support in 103 Nonpostcardiotomy Patients

Extracorporeal membrane oxygenation (ECMO) has been successfully used to support patients with cardiac arrest failing to respond to conventional cardiopulmonary resuscitation (CPR). Preimplant factors being indicative for success are unknown up to now. The study describes single center experience with special focus on differences between survivors and nonsurvivors. Between 2002 and 2009, 103 patients were supported within the scope of CPR by means of ECMO. Besides primary diagnosis, duration, and outcome, pH, lactate, mean arterial pressure, aspartate aminotransferase, bilirubin, catecholamine dosage, and oxygenation ratio before ECMO, after 2 h, 1 day, and at explantation were analyzed. One hundred three patients (51.2 ± 16 years, 35 women, 68 men) were analyzed. Primary cardiac failure led to CPR in 54%. Duration of support was 4.8 ± 0.6 days. Twenty‐nine (28.1%) patients survived to hospital discharge. On ECMO support, pH, lactate, and mean arterial pressure improved significantly. Catecholamine dosage was significantly reduced after ECMO implantation. Demographic data and primary diagnosis revealed no significant influence on outcome. pH, lactate, creatinine, and bilirubin differed significantly between survivors and nonsurvivors in the course of ECMO support. ECMO support during CPR reliably improves the circulatory and respiratory situation. Considering observed survival critical patient selection is mandatory. Although there are several significant differences between surviving patients and patients with fatal outcome, patient selection turns out to be difficult as clinically relevant factors show only limited predictive value. Future research should focus on better defining a population that may be best of all suited for the use of ECMO support in CPR.     

失血性休克大鼠复苏前后胃Cajal 间质细胞及Cx43的变化

目的：探讨失血性休克复苏前后大鼠胃Cajal间质细胞及间隙连接蛋白Connexin 43（Cx43）的变化。方法：SD大鼠随机均分为对照组与实验组。对照组大鼠行假手术;实验组大鼠通过放血制作失血性休克模型,维持休克状态1 h后行液体复苏。分别于休克1 h和复苏治疗后3,6,12,24 h取大鼠胃组织于电镜下观察Cajal细胞超微结构;免疫荧光染色及Western blot检测Cx43的表达。结果：电镜显示实验组休克1 h时Cajal细胞水肿、核皱缩、基膜破坏;复苏治疗后3,6 h无明显变化,12 h时结构开始逐渐恢复,至24 h Cajal细胞恢至接近对照组状态。免疫荧光染色发现实验组Cx43荧光强度于休克1 h明显减弱,但从复苏治疗后逐渐升高,至24 h基本接近对照组。Western blot法显示Cx43蛋白表达量变化与免疫荧光染色结果相一致。结论：失血性休克能导致Cajal细胞损伤与Cx43表达减少,两者改变所造成细胞间信息传递缺陷可能是失血性休克时胃肠道动力障碍的重要原因之一。     

Outcomes after cardiac arrest in an adult burn center

Objective

Adult burn patients who experience in-hospital cardiac arrest (CA) and undergo cardiopulmonary resuscitation (CPR) represent a unique patient population. We believe that they tend to be younger and have the added burden of the burn injury compared to other populations. Our objective was to determine the incidence, causes and outcomes following cardiac arrest (CA) and cardio-pulmonary resuscitation (CPR) within this population.

Methods

We conducted a retrospective review at the US Army Institute of Surgical Research (ISR) burn intensive care unit (BICU). Charts from 1st January 2000 through 31st August 2009 were reviewed for study. Data were collected all on adult burn patients who experienced in-hospital CA and CPR either in the BICU or associated burn operating room. Patients undergoing CPR elsewhere in our burn unit were excluded because we could not validate the time of CA since they are not routinely monitored with real-time rhythm strips. The study population included civilian burn patients from the local catchment area and burn casualties from the conflicts in Iraq and Afghanistan, but patients with do-not-resuscitate (DNR) orders were excluded.

Results

We found 57 burn patients who had in-hospital CA and CPR yielding an incidence of one or more in-hospital CA of 34 per 1000 admissions (0.34%). Fourteen of these patients (25%) survived to discharge while 43 (75%) died. The most common initial cardiac rhythm was pulseless electrical activity (50.9%). The most common etiology of CA among burn patients was respiratory failure (49.1%). The most significant variable affecting survival to discharge was duration of CPR (P < 0.01) with no patient surviving more than 7 min of CPR.

Conclusions

CPR in burn patients is sometimes effective, and those patients who survive are likely to have good neurological outcomes. However, prolonged CPR times are unlikely to result in return of spontaneous circulation and may be considered futile. Further, those who experience multiple CA are unlikely to survive to discharge.     

参附注射液用于成人脓毒性休克患者早期复苏的Meta分析

摘 要 目的：采用Meta分析方法评价参附注射液用于成人脓毒性休克患者早期复苏的疗效。方法：计算机检索The Cochrane Library（2017年3期）、PubMed、Embase、CNKI、VIP、万方数据库（WanFang Data）中关于参附注射液治疗成人脓毒性休克的随机对照试验（RCTs）,检索时间为建库至2017年3月。由两位评价者按照纳入与排除标准独立筛选文献、提取资料并评价偏倚风险后,采用RevMan 5.3软件进行统计分析。结果：共纳入8个RCTs,包括587例患者。Meta分析结果显示：①治疗组（常规疗法+参附注射液）与对照组（常规疗法）相比,28 d病死率的差异无统计学意义[OR=0.73,95%CI（0.44,1.21）,P=0.22];②两组提高治疗后6 h的平均动脉压（MAP）的差异无统计学意义[MD=7.12,95%CI（-3.08,17.31）,P=0.17];③与对照组相比,治疗组可显著改善治疗后6h的血乳酸值（Lac） [MD=-1.92,95%CI（-3.34,-0.51）,P=0.008]。5个结局指标因文献间存在临床异质性或仅1项研究提及,仅作描述性分析,结果显示：①与对照组相比,治疗组可显著增加治疗后6 h的尿量（P＜0.05）;②与对照组相比,治疗组可显著提高治疗后6 h的中心静脉压（CVP）（P＜0.05）;③3项研究比较了治疗后6 h的上腔静脉血氧饱和度（ScvO2）或混合静脉血氧饱和度（SvO2）,综合结果尚不能得出肯定结论（P＞0.05）;④2项研究治疗组6 h的乳酸清除率（LAC）均高于对照组,差异均有统计学意义（P＜0.05）;⑤1项研究提及不良反应发生情况,结果显示两组均无不良发应发生。结论：参附注射液联合常规疗法治疗脓毒性休克患者对提高治疗后6h的CVP、尿量,降低Lac,提高LAC均优于单用常规疗法;对提高治疗后6 h的ScvO2或SvO2,尚不能得出肯定结论;对降低28 d病死率,提高治疗后6 h的MAP与单用常规疗法比较未显示出优势。受纳入研究数量和治疗所限,上述结论需开展更多高质量研究予以验证。