Cardiac arrest, stony heart, and cardiopulmonary resuscitation: An updated revisit

The post-resuscitation period is recognized as the main predictor of cardiopul-monary resuscitation(CPR)outcomes.The first description of post-resuscitation syndrome and stony heart was published over 50 years ago.Major manifestations may include but are not limited to,persistent precipitating pathology,systemic ischemia/reperfusion response,post-cardiac arrest brain injury,and finally,post-cardiac arrest myocardial dysfunction(PAMD)after successful resuscitation.Why do some patients initially survive successful resuscitation,and others do not?Also,why does the myocardium response vary after resuscitation?These ques-tions have kept scientists busy for several decades since the first successful resuscitation was described.By modifying the conventional modalities of resu-scitation together with new promising agents,rescuers will be able to salvage the jeopardized post-resuscitation myocardium and prevent its progression to a dismal,stony heart.Community awareness and staff education are crucial for shortening the resuscitation time and improving short-and long-term outcomes.Awareness of these components before and early after the restoration of circulation will enhance the resuscitation outcomes.This review extensively addresses the underlying pathophysiology,management,and outcomes of post-resuscitation syndrome.The pattern,management,and outcome of PAMD and post-cardiac arrest shock are different based on many factors,including in-hospital cardiac arrest vs out-of-hospital cardiac arrest(OHCA),witnessed vs unwitnessed cardiac arrest,the underlying cause of arrest,the duration,and protocol used for CPR.Although restoring spontaneous circulation is a vital sign,it should not be the end of the game or lone primary outcome;it calls for better understanding and aggressive multi-disciplinary interventions and care.The development of stony heart post-CPR and OHCA remain the main challenges in emergency and critical care medicine.

Successful rescue of disseminated Nocardia infection with multiple abscesses in a patient with membranous nephropathy after cardiopulmonary resuscitation:A three-year follow-up

Nocardiosis manifests as an opportunistic infection,primarily affecting individuals who are immunocompromised and susceptible to the infection.We present a case study of one patient with nephrotic syndrome and membranous nephropathy,who underwent treatment with prednisone and cyclosporine in 2016.In early 2017,the patient was diagnosed with a"fungal infection"and discontinued the use of cyclosporine.After one month of anti-infection therapy,a cranial magnetic resonance imaging scan showed multiple abscesses in the right temporal region.The diagnosis of nocardiosis was confirmed based on the presence of metastatic abscess masses,multiple lung and brain lesions,and a positive culture of Nocardia in the drainage.We changed the anti-infection therapy to a combination of trimethoprim-sulfamethoxazole(TMP-SMX),minocycline,and voriconazole.However,the patient experienced a sudden cardiac arrest and subsequently recovered after cardiopulmonary resuscitation.During the five-month follow-up period following the discharge,the patient displayed an enhanced nutritional status and stable renal function.The focal infection ultimately resolved during the subsequent three years.Neuro-infection caused by Nocardia should be considered in immunocompromised patients,and TMP-SMX is the preferred initial therapy;however,because of the high mortality rate,a long-term combination therapy with imipenem,cefotaxime,amikacin,and TMP-SMX is suggested.

Analysis of the Application Value of Virtual Reality Combined with Flipped Classroom Teaching Mode in Cardiopulmonary Resuscitation Teaching

Objective:To analyze the value of using virtual reality combined with the flipped classroom teaching model in teaching cardiopulmonary resuscitation(CPR).Methods:Two classes of our nursing program were randomly selected for the study from September 2022 to September 2023,Class A(52 students,conventional teaching method)and Class B(52 students,virtual reality combined with flipped classroom teaching mode).The assessment scores and independent learning ability scores of the students in the two classes were compared.Results:CPR theory and operation scores,passing rate,and independent learning ability scores of Class B were higher than those of Class A(P<0.05).Conclusion:the use of virtual reality combined with the flipped classroom teaching mode in CPR teaching is conducive to the improvement of students’assessment scores and independent learning ability.

Do cardiopulmonary resuscitation real-time audiovisual feedback devices improve patient outcomes? A systematic review and metaanalysis

BACKGROUND Cardiac arrest is a leading cause of mortality in America and has increased in the incidence of cases over the last several years.Cardiopulmonary resuscitation(CPR)increases survival outcomes in cases of cardiac arrest;however,healthcare workers often do not perform CPR within recommended guidelines.Real-time audiovisual feedback(RTAVF)devices improve the quality of CPR performed.This systematic review and meta-analysis aims to compare the effect of RTAVF-assisted CPR with conventional CPR and to evaluate whether the use of these devices improved outcomes in both in-hospital cardiac arrest(IHCA)and out-of-hospital cardiac arrest(OHCA)patients.AIM To identify the effect of RTAVF-assisted CPR on patient outcomes and CPR quality with in-and OHCA.METHODS We searched PubMed,SCOPUS,the Cochrane Library,and EMBASE from inception to July 27,2020,for studies comparing patient outcomes and/or CPR quality metrics between RTAVF-assisted CPR and conventional CPR in cases of IHCA or OHCA.The primary outcomes of interest were return of spontaneous circulation(ROSC)and survival to hospital discharge(SHD),with secondary outcomes of chest compression rate and chest compression depth.The methodo-logical quality of the included studies was assessed using the Newcastle-Ottawa scale and Cochrane Collaboration’s“risk of bias”tool.Data was analyzed using R statistical software 4.2.0.results were statistically significant if P<0.05.RESULTS Thirteen studies(n=17600)were included.Patients were on average 69±17.5 years old,with 7022(39.8%)female patients.Overall pooled ROSC in patients in this study was 37%(95%confidence interval=23%-54%).RTAVF-assisted CPR significantly improved ROSC,both overall[risk ratio(RR)1.17(1.001-1.362);P=0.048]and in cases of IHCA[RR 1.36(1.06-1.80);P=0.002].There was no significant improvement in ROSC for OHCA(RR 1.04;0.91-1.19;P=0.47).No significant effect was seen in SHD[RR 1.04(0.91-1.19);P=0.47]or chest compression rate[standardized mean difference(SMD)-2.1;(-4.6-0.5);P=0.09].A significant improvement was seen in chest compression depth[SMD 1.6;(0.02-3.1);P=0.047].CONCLUSION RTAVF-assisted CPR increases ROSC in cases of IHCA and chest compression depth but has no significant effect on ROSC in cases of OHCA,SHD,or chest compression rate.

The neuro-prognostic value of the ion shift index in cardiac arrest patients following extracorporeal cardiopulmonary resuscitation

BACKGROUND:The ion shift index(ISI) as a prognostic indicator that can show the severity of hypoxic-ischemic injury.We aimed to evaluate the performance of the ISI in predicting unfavorable neurological outcomes at hospital discharge in cardiac arrest(CA) patients following extracorporeal cardiopulmonary resuscitation(ECPR) and to compare its performance to other prognostic predictors.METHODS:This was a retrospective observational study including adult CA patients treated with ECPR between January 2018 and December 2022 in a tertiary hospital.Data regarding clinical characteristics and laboratory parameters were collected from medical records.The ISI was determined based on the first available serum electrolyte levels after ECPR.The primary outcome was unfavorable neurological status at hospital discharge,defined as Cerebral Performance Categories 3–5.Comparisons of the characteristics between the two groups were made using the χ2 test for categorical variables and the t-test or non-parametric Mann-Whitney U-test for continuous variables,as appropriate.Correlation analysis was performed using Spearman’s rank correlation coeficient.A two-tailed P-value <0.05 was considered statistically significant.RESULTS:Among the 122 patients involved,46(37.7%) had out-of-hospital CA,and 88 had unfavorable neurological outcomes.The ISI was significantly higher in the unfavorable outcome group than in the favorable outcome group(3.74 [3.15–4.57] vs.2.69 [2.51–3.07],P<0.001).A higher ISI level was independently related to unfavorable outcome(odds ratio=6.529,95% confidence interval 2.239–19.044,P=0.001).An ISI level >3.12 predicted unfavorable outcomes with a sensitivity and specificity of 74.6% and 85.2%,respectively(P<0.001).The prognostic performance of ISI(area under the curve [AUC]=0.887) was similar to that of other predictors,such as gray-to-white matter ratio(AUC=0.850,P=0.433) and neuronspecific enolase(AUC=0.925,P=0.394).CONCLUSION:ISI may be used as a prognostic biomarker to predict neurological outcomes in CA patients following ECPR.

Cardiac arrest and cardiopulmonary resuscitation in“hostile”environments:Using automated compression devices to minimize the rescuers’danger

Mechanical automated compression devices are being used in cardiopulmonary resuscitation instead of manual,“hands-on”,rescuer-delivered chest compressions.The-theoretical-advantages include high-quality non-stop compressions,thus freeing the rescuer performing the compressions and additionally the ability of the rescuer to stand reasonably away from a potentially“hazardous”victim,or from hazardous and/or difficult resuscitation conditions.Such circumstances involve cardiopulmonary resuscitation(CPR)in the Cardiac Catheterization Laboratory,especially directly under the fluoroscopy panel,where radiation is well known to cause detrimental effects to the rescuer,and CPR during/after land or air transportation of cardiac arrest victims.Lastly,CPR in a coronavirus disease 2019 patient/ward,where the danger of contamination and further serious illness of the health provider is very existent.The scope of this review is to review and present literature and current guidelines regarding the use of mechanical compressions in these“hostile”and dangerous settings,while comparing them to manual compressions.

Vagus nerve stimulation protects against cerebral injury after cardiopulmonary resuscitation by inhibiting inflammation through the TLR4/NF-κB and α7nAChR/JAK2 signaling pathways

BACKGROUND: Our previous research proved that vagus nerve stimulation(VNS) improved the neurological outcome after cardiopulmonary resuscitation(CPR) by activating α7 nicotinic acetylcholine receptor(α7nAChR) in a rat model, but the underlying mechanism of VNS in neuroprotection after CPR remains unclear.METHODS: In vivo, we established a mouse model of cardiac arrest(CA)/CPR to observe the survival rate, and the changes in inflammatory factors and brain tissue after VNS treatment. In vitro, we examined the effects of α7nAChR agonist on ischemia/reperfusion(I/R)-induced inflammation in BV2 cells under oxygen-glucose deprivation/reoxygenation(OGD/R) conditions. We observed the changes in cell survival rate, the levels of inflammatory factors, and the expressions of α7nAChR/Janus kinase 2(JAK2) and toll-like receptor 4(TLR4)/nuclear factor-κB(NF-κB).RESULTS: In vivo, VNS preconditioning enhanced functional recovery, improved the survival rate, and reduced hippocampal CA1 cell damage, and the levels of inflammatory mediators after CA/CPR. The application of α7nAChR agonists provided similar effects against cerebral injury after the return of spontaneous circulation(ROSC), while α7nAChR antagonists reversed these neuroprotective impacts. The in vitro results mostly matched the findings in vivo. OGD/R increased the expression of tumor necrosis factor-alpha(TNF-α), TLR4 and NF-κB p65. When nicotine was added to the OGD/R model, the expression of TLR4, NF-κB p65, and TNF-α decreased, while the phosphorylation of JAK2 increased, which was prevented by preconditioning with α7nAChR or JAK2 antagonists.CONCLUSION: The neuroprotective effect of VNS correlated with the activation of α7nAChR. VNS may alleviate cerebral IR injury by inhibiting TLR4/NF-κB and activating the α7nAChR/JAK2 signaling pathway.

Establishment of a Rat Model of Capillary Leakage Syndrome Induced by Cardiopulmonary Resuscitation After Cardiac Arrest

Objective:Cardiopulmonary resuscitation(CPR)after cardiac arrest(CA)is one of the main causes of capillary leakage syndrome(CLS).This study aimed to establish a stable CLS model following the CA and cardiopulmonary resuscitation(CA-CPR)model in Sprague-Dawley(SD)rats.Methods:We conducted a prospective,randomized,animal model study.All adult male SD rats were randomly divided into a normal group(group N),a sham operation group(group S),and a cardiopulmonary resuscitation group(group T).The SD rats of the three groups were all inserted with 24-G needles through their left femoral arteries and right femoral veins.In group S and group T,the endotracheal tube was intubated.In group T,CA induced by asphyxia(AACA)was caused by vecuronium bromide with the endotracheal tube obstructed for 8 min,and the rats were resuscitated with manual chest compression and mechanical ventilation.Preresuscitation and postresuscitation measurements,including basic vital signs(BVS),blood gas analysis(BG),routine complete blood count(CBC),wet-to-dry ratio of tissues(W/D),and the HE staining results after 6 h were evaluated.Results:In group T,the success rate of the CA-CPR model was 60%(18/30),and CLS occurred in 26.6%(8/30)of the rats.There were no significant differences in the baseline characteristics,including BVS,BG,and CBC,among the three groups(P>0.05).Compared with pre-asphyxia,there were significant differences in BVS,CBC,and BG,including temperature,oxygen saturation(SpO_(2)),mean arterial pressure(MAP),central venous pressure(CVP),white blood cell count(WBC),hemoglobin,hematocrit,pH,pCO_(2),pO_(2),SO_(2),lactate(Lac),base excess(BE),and Na+(P<0.05)after the return of spontaneous circulation(ROSC)in group T.At 6 h after ROSC in group T and at 6 h after surgery in groups N and S,there were significant differences in temperature,heart rate(HR),respiratory rate(RR),SpO_(2),MAP,CVP,WBC,pH,pCO_(2),Na+,and K+among the three groups(P<0.05).Compared with the other two groups,the rats in group T showed a significantly increased W/D weight ratio(P<0.05).The HE-stained sections showed consistent severe lesions in the lung,small intestine,and brain tissues of the rats at 6 h after ROSC following AACA.Conclusion:The CA-CPR model in SD rats induced by asphyxia could reproduce CLS with good stability and reproducibility.

The effects of hyperbaric oxygen therapy on paroxysmal sympathetic hyperactivity after cardiopulmonary resuscitation: a case series

The onset of cardiac arrest (CA) is sudden and critical.Due to cerebral ischaemia and hypoxia, the prognosis for post-cardiopulmonary resuscitation (CPR) patients is poor. Paroxysmal sympathetic hyperexcitability (PSH) is a potentially life-threatening condition, which is characterized by episodes of increased heart rate and blood pressure,sweating, hypothermia, and forced posture.[1] Hypoxicischaemic encephalopathy post-CPR can lead to PSH,which often indicates a worse prognosis.

Synchronized ventilation during resuscitation in pigs does not necessitate high inspiratory pressures to provide adequate oxygenation

The optimal ventilation method for patients suffering from cardiac arrest and receiving cardiopulmonary resuscitation(CPR)remains unclear,and the recent guidelines do not provide detailed information.[1-3]During CPR,changing thoracic pressures due to chest compressions and ventilation pressure infl uence venous return and cardiac output,respectively.[4-6]Novel mechanical ventilation modes that are synchronized to chest compressions may improve blood flow and oxygenation.[4]In this porcine trial,we investigated the feasibility of a specially designed chest compression synchronized ventilation(CCSV)mode with peak pressures limited to 40 mbar(1 mbar=0.1 kPa)and an experimental synchronized ventilation(SV)limited to 20 mbar,respectively,intended to achieve a more lung-protective ventilation pattern during resuscitation.We evaluated whether the diff erent synchronized pressure levels ameliorate hemodynamics,gas exchange and pulmonary function and compared it to intermittent positive pressure ventilation(IPPV).

Cardiac arrest secondary to pulmonary embolism treated with extracorporeal cardiopulmonary resuscitation:Six case reports

BACKGROUND Massive pulmonary embolism(PE)results in extremely high mortality rates.Veno-arterial extracorporeal membrane oxygenation(VA-ECMO)can provide circulatory and oxygenation support and rescue patients with massive PE.However,there are relatively few studies of extracorporeal cardiopulmonary resuscitation(ECPR)in patients with cardiac arrest(CA)secondary to PE.The aim of the present study is to investigate the clinical use of ECPR in conjunction with heparin anticoagulation in patients with CA secondary to PE.CASE SUMMARY We report the cases of six patients with CA secondary to PE treated with ECPR in the intensive care unit of our hospital between June 2020 and June 2022.All six patients experienced witnessed CA whilst in hospital.They had acute onset of severe respiratory distress,hypoxia,and shock rapidly followed by CA and were immediately given cardiopulmonary resuscitation and adjunctive VA-ECMO therapy.During hospitalization,pulmonary artery computed tomography angiography was performed to confirm the diagnosis of PE.Through anticoagulation management,mechanical ventilation,fluid management,and antibiotic treatment,five patients were successfully weaned from ECMO(83.33%),four patients survived for 30 d after discharge(66.67%),and two patients had good neurological outcomes(33.33%).CONCLUSION For patients with CA secondary to massive PE,ECPR in conjunction with heparin anticoagulation may improve outcomes.

Cerebral Malaria: Epidemiological, Clinical and Prognosis Aspects in the Anesthesia-Resuscitation Department CHU Ignace Deen

Objective: To describe the epidemiological, clinical, paraclinical and prognostic aspects of cerebral malaria received in the anesthesia-resuscitation department. Methodology: This was a prospective descriptive type study carried out in the anesthesia-resuscitation department over a period of three (03) months (June 01 to August 31, 2022). All patients admitted for cerebral malaria were included. Sociodemographic, clinical and prognostic parameters were studied. Results: We collected 25 cases out of 105 admitted patients (23.8%). The average age was 27.6 ± 9.5 years with extremes of 11 and 50 years. The sex ratio was 0.7 (M/F). Students and housewives were in the majority, i.e. 52% and 24%. Neurological disorders were found on admission in all patients, dominated by impaired consciousness at 100% followed by convulsion (60%), prostration (44%), confusion (36%) associated with deep coma in (68%). Gross hemoglobinuria was present in (84%) of cases. On the blood count, anemia was present in (70%) of the patients followed by thrombocytopenia in more than half of the cases (60%) and transfusion was necessary in 19 cases. P Falciparum malaria was found in all patients (100%), the average parasite density was 60342.8 ± 30425.6 trophozoites/μl with extremes of 9000 to 100000 trophozoites/μl. All our patients were treated with intravenous injectable artesunate. Transfusion was performed in 76% of our patients. Eighty percent of the patients had benefited from dialysis. High oxygen therapy was performed in (92%) of cases. The average duration of hospitalization was 5.74 ± days with extremes of 1 to 17 days. Mortality was 48%. Conclusion: Cerebral malaria can take different clinical forms, the most important of which is cerebral involvement. Prompt initiation of appropriate resuscitation can reduce mortality.

Complete Neurological Recovery after Prolonged Resuscitation in a Young Patient with Non-Shockable Rhythm

Background: Out-of-hospital cardiac arrest (OHCA) with ongoing CPR on arrival to emergency department still a challenge to decide how long the resuscitation should continue or when to terminate it. Case Summary: A patient with a 1-week history of difficulty in breathing suffered from an OHCA. The electrocardiogram upon arrival to the hospital showed pulseless electrical activity. Cardiopulmonary resuscitation was initiated and continued for a total of 90 minutes without any interruption until return of spontaneous circulation (ROSC) was achieved. Post-cardiac care was offered, and the patient was discharged with complete neurological recovery. Discussion: In non-shockable rhythms, the powerful defibrillator machine is not used during resuscitation. In such cases, identifying the offending cause, performing high quality CPR and administering epinephrine are the only effective tools in resuscitating a patient.

Is aggressive intravenous fluid resuscitation beneficial in acute pancreatitis? A meta-analysis of randomized control trials and cohort studies

BACKGROUND There is conflincting evidence on the intravenous fluid(IVF)strategy for acute pancreatitis(AP).We perform a metaanalysis of the available evidence.AIM To investigate if aggressive IVF therapy in AP patients is beneficial to decrease mortality and improve outcomes.METHODS Metaanalysis of available randomized controlled trials and cohort studies comparing aggressive IVF vs non-aggressive IVF resuscitation.RESULTS There was no significant difference in mortality between the aggressive(n=1229)and non-aggressive IVF(n=1397)patients.Patients receiving aggressive IVF therapy had higher risk for acute kidney injury and acute respiratory distress syndrome.There also was no significant difference in the overall incidence of systemic inflammatory response syndrome,persistent organ failure,pancreatic necrosis when comparing both study groups.CONCLUSION Early aggressive IVF therapy did not improve mortality.Moreover,aggressive IVF therapy could potentially increase the risk for acute kidney injury and pulmonary edema leading to respiratory failure and mechanical ventilation.Studies are needed to investigate which subset of AP patients could benefit from aggressive IVF therapy.

Effect of metronome rates on the quality of bag-mask ventilation during metronome-guided 30:2 cardiopulmonary resuscitation:A randomized simulation study

BACKGROUND: Metronome guidance is a feasible and effective feedback technique to improve the quality of cardiopulmonary resuscitation(CPR). The rate of the metronome should be set between 100 to 120 ticks/minute and the speed of ventilation may have crucial effect on the quality of ventilation. We compared three different metronome rates(100, 110, 120 ticks/minute) to investigate its effect on the quality of ventilation during metronome-guided 30:2 CPR.METHODS: This is a prospective, randomized, crossover observational study using a Respi Trainer r. To simulate 30 chest compressions, one investigator counted from 1 to 30 in cadence with the metronome rate(1 count for every 1 tick), and the participant performed 2 consecutive ventilations immediately following the counting of 30. Thirty physicians performed 5 sets of 2 consecutive(total 10) bag-mask ventilations for each metronome rate. Participants were instructed to squeeze the bag over 2 ticks(1.0 to 1.2 seconds depending on the rate of metronome) and defl ate the bag over 2 ticks. The sequence of three different metronome rates was randomized.RESULTS: Mean tidal volume significantly decreased as the metronome rate was increased from 110 ticks/minute to 120 ticks/minute(343±84 m L vs. 294±90 m L, P=0.004). Peak airway pressure significantly increased as metronome rate increased from 100 ticks/minute to 110 ticks/minute(18.7 vs. 21.6 mm Hg, P=0.006).CONCLUSION: In metronome-guided 30:2 CPR, a higher metronome rate may adversely affect the quality of bag-mask ventilations. In cases of cardiac arrest where adequate ventilation support is necessary, 100 ticks/minute may be better than 110 or 120 ticks/minute to deliver adequate tidal volume during audio tone guided 30:2 CPR.

Upper gastrointestinal bleeding from a Mallory-Weiss tear associated with transesophageal echocardiography during successful cardiopulmonary resuscitation:A case report

BACKGROUND In recent years,it has been recognized that transesophageal echocardiography(TEE)is of great value in resuscitation of cardiac arrest.However,its safety has rarely been reported.CASE SUMMARY We present a 59-year-old male patient scheduled to undergo cardiac surgery for rheumatic heart disease.Upper gastrointestinal bleeding from a Mallory-Weiss tear appeared following cardiopulmonary resuscitation,TEE,and percutaneous cardiopulmonary bypass resuscitation when he suffered from aesthesia-related cardiac arrest.Gastrointestinal injury was diagnosed promptly and treated effectively.However,the exact etiology of gastrointestinal injury was unclear;the interaction of closed-chest cardiac massage and the application of TEE may be involved as a most possible mechanism of injury.CONCLUSION Serious complications should be considered when TEE is used in patients with special pathophysiological conditions.

COVID-19 and resuscitation:La tournée of traditional Chinese medicine?

BACKGROUND As it has been established in previous publications of the author,the current extra-hospital statistics referring to cardiopulmonary resuscitation(CPR)are far from being minimally satisfactory(14%-17% success).Since the appearance of acquired immune deficiency syndrome,its application has been increasingly undermined as other subsequent pandemics(H1N1,Ebola,coronavirus disease 2019)seriously infringing lay rescuers intervention during classical CPR steps(mouth-to-mouth ventilation),forcing to modify vital support protocols.Both KI-1 Yong quan and PC-9 Zhong chong alternative rescue maneuvers could come to aid those victims of impending death situation due to both cardiac arrest or stroke,upgrading current survival rates of said unfortunate patients.AIM To validate a complementary resuscitation maneuver originated in Chinese Medicine knowledge,carefully integrated into international CPR protocols[World Journal of Critical Care Medicine(WJCCM),August 2013].METHODS The model to verify its statistical validity of quoted research was the Retrospective Cohort Study,which redeems the“semiotic paradigm”that gave rise to medical semiotics.Its value strives in the differential detail if the deceased patients are considered the control group instead of the patients that may be deceased.Thus,combining the semiotic paradigm with the Retrospective Cohort Study allows us to manage the collateral potential lethal effects of the random process in cases of extreme emergencies.RESULTS The statistic results provided by the methodological analysis of this work were previously published in WJCCM August 2013,ISSN 2220-3141.In a total of 89 patients in which the Yong quan maneuver was tested,75 survived and 14 died.In order to compare this data with the percentages of survivors in the other maneuvers,we stipulate the assumption that if 89 patients are the 100%of the sample,how many patients would survive if the survival rate is 6.4%in CPR,30%in defibrillation and 48%in CPR+defibrillation.By this way we obtained the approximate values of patients that would survive when applying these classical resuscitation maneuvers.Then we obtained the format of the tables to perform the exact Fisher test with the help of a statistical processor;the consequent result in a valuation of P<0.0001 was considered"extremely statistically significant".CONCLUSION The author herein provides a methodological-statistical analysis of such contribution which does not imply any cost at all and could even help prevent the withdrawal of classical CPR practices.

Combined early fluid resuscitation and hydrogen inhalation attenuates lung and intestine injury

AIM:To study the effects of combined early fluid resuscitation and hydrogen inhalation on septic shockinduced lung and intestine injuries.METHODS:Wistar male rats were randomly divided into four groups:control group(Group A,n = 15);septic shock group(Group B,n = 15);early fluid resuscitation-treated septic shock group(Group C,n = 15);and early fluid resuscitation and inhalation of 2% hydrogentreated septic shock group(Group D,n = 15).The activity of hydroxyl radicals,myeloperoxidase(MPO),superoxide dismutase(SOD),diamine oxidase(DAO),and the concentration of malonaldehyde(MDA) in the lung and intestinal tissue were assessed according to the corresponding kits.Hematoxylin and eosin staining was carried out to detect the pathology of the lung and intestine.The expression levels of interleukin(IL)-6,IL-8,and tumor necrosis factor(TNF)-α in lung and intestine tissue were detected by enzyme-linked immunosorbent assay method.The expression levels of Fas and Bcl2 in lung tissues were determined by immunohistochemistry and Western blotting.RESULTS:Septic shock elicited a significant increase in the levels of MDA(10.17 ± 1.12 nmol/mg protein vs 2.98 ± 0.64 nmol/mg protein) and MPO(6.79 ± 1.02 U/g wet tissue vs 1.69 ± 0.14 U/g wet tissue) in lung tissues.These effects were not significantly decreased by Group C pretreatment,but were significantly reduced by Group D pretreatment(MDA:4.45 ± 1.13 nmol/mg protein vs 9.56 ± 1.37 nmol/mg protein;MPO:2.58 ± 0.21 U/g wet tissue vs 6.02 ± 1.16 U/g wet tissue).The activity of SOD(250.32 ± 8.56 U/mg protein vs 365.78 ± 10.26 U/mg protein) in lung tissues was decreased after septic shock,and was not significantly increased by Group C pretreatment,but was significantly enhanced by Group D pretreatment(331.15 ± 9.64 U/mg protein vs 262.98 ± 5.47 U/mg protein).Histological evidence of lung hemorrhage,neutrophil infiltration and overexpression of IL-6,IL-8,and TNF-α was observed in lung tissues,all of which were attenuated by Group C and further alleviated by Group D pretreatment.Septic shock also elicited a significant increase in the levels of MDA,MPO and DAO(6.54 ± 0.68 kU/L vs 4.32 ± 0.33 kU/L) in intestinal tissues,all of which were further increased by Group C,but significantly reduced by Group D pretreatment.Increased Chiu scoring and overexpression of IL-6,IL-8 and TNF-α were observed in intestinal tissues,all of which were attenuated by Group C and further attenuated by Group D pretreatment.CONCLUSION:Combined early fluid resuscitation and hydrogen inhalation may protect the lung and intestine of the septic shock rats from the damage induced by oxidative stress and the inflammatory reaction.

Fluid resuscitation in acute pancreatitis

Acute pancreatitis remains a clinical challenge,despite an exponential increase in our knowledge of its complex pathophysiological changes.Early fluid therapy is the cornerstone of treatment and is universally recommended;however,there is a lack of consensus regarding the type,rate,amount and end points of fluid replacement.Further confusion is added with the newer studies reporting better results with controlled fluid therapy.This review focuses on the pathophysiology of fluid depletion in acute pancreatitis,as well as the rationale for fluid replacement,the type,optimal amount,rate of infusion and monitoring of such patients.The basic goal of fluid epletion should be to prevent or minimize the systemic response to inflammatory markers.For this review,various studies and reviews were critically evaluated,along with authors’recommendations,for predicted severe or severe pancreatitis based on the available evidence.

Changes of Tumor Necrosis Factor-α and the Effects of Ulinastatin Injection during Cardiopulmonary Cerebral Resuscitation

Summary: The changes of tumor necrosis factor-α (TNF-α) and brain ultrastructure during cardiopulmonary resuscitation and the effects of ulinastation injection were observed, and the mechanism was investigated. Twenty-four adult healthy Sprague-Dawley rats were randomly divided into control group (8 rats), resuscitation group (8 rats) and ulinastatin (UTI) group (8 rats). Rats in control group underwent tracheotomy without clipping the trachea to induce circulatory and respiratory standstill. Rats in resuscitation and ulinastatin group were subjected to the procedure of establishing the model of cardiopulmonary cerebral resuscitation (CPCR). Rats in ulinastatin group were given with UTI 104 U/kg once after CPCR. In the control group, the plasma was collected immediate, 30 min, 2 h, 4 h, and 6 h after tracheotomy. In resuscitation group and UTI group, plasma was collected immediate after tracheotomy, 30 min, 2 h, 4 h and 6 h after successful resuscitation. The plasma levels of TNF-α were determined by radioimmunoassay (RIA). At the end of the experiment, 2 rats were randomly selected from each group and were decapitated. The cortex of the brain was taken out immediately to observe the ultrastructure changes. In control group, there were no significant differences in the level of TNF-α among different time points (P>0.05). In resuscitation group, the level of TNF-α was increased obviously after resuscitation (P<0.01) and reached its peak 2 h later after resuscitation. An increasing trend of TNF-α showed in UTI group. There were no differences in TNF-α among each sample taken after successful resuscitation and that after tracheotomy. The utrastructure of brains showed the injury in UTI group was ameliorated as compared with that in resuscitation group. In early period of CPCR, TNF-α was expressed rapidly and kept increasing. It indicated that TNF-α might take part in the tissue injury after CPCR. The administration of UTI during CACR could depress TNF-α and ameliorate brain injury. By regulating the expression of damaging mediator, UTI might provide a protective effect on the tissue injury after CPCR.