Bulent Kirimli

Augmentation of Artificial Circulation During Cardiopulmonary Resuscitation

Experiments in dogs with ventricular fibrillation were carried out to determine the effects of epinephrine, plasma volume expansion and manual pressure over the abdomen upon carotid flow and arterial pressure during external cardiac compressions. Epincphrine given intravenously produced a significant increase in systolic arterial pressure but no significant change in carotid flow. Epinephrine given subcutaneously over the sternum in 2 mg. increments had no effect on either systolic pressure or carotid flow. Both intravenously and intra-arterially administered dextran 75 improved carotid flow during external cardiac compressions, both routes being equally effective. Volume expansion, therefore, is indicated during external cardiac compressions even in normovolemic subjects, provided there is no pulmonary edema. Constant manual pressure exerted over the upper abdomen during external cardiac compressions produced a significant increase in carotid flow, but is not recommended because it promoted rupture of the liver.

Ventilation—Cardiac Compression Rates and Ratios in Cardiopulmonary Resuscitation

Ventilation-compression frequencies and ratios during cardiopulmonary resuscitation in dogs with ventricular fibrillation and ventilation frequencies in apneic healthy human subjects were studied. Lung inflations interposed between sternal compressions gave better ventilation and about equal carotid blood flows as compared to simultaneous inflations. A ventilation—compression ratio of 3/15 (using air) maintained normal oxygenation and ventilation, whereas 6/30 did not In apneic adults with two inflations (tidal volume 1,000 ml) every 15 seconds, oxygenation and ventilation were adequate with FiO26O compressions per minute, while 120 compressions per minute gave insignificantly greater flows than 72 compressions per minute. The recommendation of a ventilation—compression ratio of 2/15 for one operator and 1/5 interposed for two operators (compressions at one second intervals without interruption) is sound.

Reaction to indigo carmine.

The commonly encountered cardiovascular effects of intravenous indigo carmine administration is transient alpha-receptor stimulation, namely increased total peripheral resistance, diastolic and systolic blood pressure, and central venous pressure with decreased cardiac output, stroke volume and heart rate. These usually cause no problems and frequently go undetected unless the patient is monitored closely during that brief interval. However, significant problems occur occasionally and its use is not totally without risks.

Transurethral prostatectomy complicated by intraperitoneal extravasation of irrigating fluid

A patient underwent transurethral resection of the prostate (TURP), which was complicated at the outset of the procedure by an inadvertent puncture wound of the dome of the bladder and the peritoneum. Shortly after resection was initiated, the patient developed shoulder pain and a tensely distended abdomen, although at this time the serum sodium concentration remained normal. Over the next several hours the patient developed significant hyponatremia. The prolonged and gradual time course of this development suggests that fluid and electrolyte shifts occurred via diffusion across the peritoneal membrane. This case illustrates a rare but potentially dangerous complication of TURP that requires recognition prior to initiation of appropriate therapy.RésuméUn patient a subi une résection transuréthral de sa prostate (TURP) s’étant compliqué par une perforation accidentelle du sommet de la vessie et du péritoine. Peu après le début de la résection le patient a développé une douleur à ľépaule ainsi qu’un abdomen tendu. A ce stade le sodium sérique était normal, Au cours des heures suivantes le patient a développé une hyponatrémie significative. Le temps ďinstallation prolongé et graduel de cette hyponatrémie suggère que le transfert de liquide et électrolytes est survenu par diffusion à travers le péritoine. Ce cas illustre une complication rare et potentiellement dangereuse de la résection transurélhrale de la prostate et dont la détection doit se faire avant le début du traitement adéquat.

Arterial versus venous transfusion in cardiac arrest from exsanguination.

APID REPLACEMENT of circulating blood R volume is fundamental in the treatment of hemorrhage. Blood may be replaced either by the venous or the arterial route. Halstedl in 1883 was first in the United States to use the arterial route for blood replacement in patients suffering from carbon monoxide poisoning. Kohlstaedt and Page2 in 1943 found that in dogs with profound oligemic hypotension, partial reinfusion of blood led to a higher recovery rate with the use of the arterial as compared to the venous route. These investigators recommended arterial transfusion for clinical use in profound shock.

Hazards in use of anode endotracheal tube a case report and review.

While the design and manufacture of plastic tubes have been greatly improved in recent years, spiral-metal-bound latex tubes are still subject to a number of hazards, among them herniation of the intramural cuff-inflating tube into the lumen of the anode tube, preventing entry or exit of gases through the anode tube after cuff inflation. Problems may also occur at the bevel and at junctions. Until better-designed anode tubes are available, extra care is required in their use.

Serum creatine phosphokinase, lactic dehydrogenase, and their isoenzymes in the perioperative period

The purpose of the present investigation was to determine the normal perioperative variations in the serum concentration of creatine phosphokinase (CPK) and its isoenzymes MM, MB, and BB, and of lactic dehydrogenase (LDH) and its isoenzymes LDH1 to LDH5 to distinguish operation-induced changes in these enzymes from those due to acute myocardial infarction or malignant hyperthermia. In 30 patients, 52 to 75 years of age undergoing elective orthopedic operations, 10 serial blood samples were obtained in the perioperative period: two samples before skin incision and eight samples after the incision over a time span of 70 hours. The preinduction mean serum CPK level of 141 U/L increased gradually and significantly and reached a maximum mean concentration of 809 U/L 34 hours after incision (p less than 0.01). The CPK-MM percent increased after incision, whereas that of CPK-MB and CPK-BB decreased, although their absolute values in terms of U/L rose. The preinduction mean serum LDH value of 173 U/L increased gradually after incision and achieved peak levels at 34 hours (203 U/L) and 58 hours (210 U/L) after incision (p less than 0.05). The LDH1:LDH2 ratio did not change. The LDH5 percent increased and peaked 10 hours after incision (p less than 0.05). There was a significant correlation between severity of operation-induced tissue damage and the serum CPK concentration (p less than 0.001). The large increase in total CPK (primarily MM fraction) occurring after surgery may minimize the percentile effects caused by an increase in MB level due to myocardial infarction.

Organization and Education in Acute Medicine

Acute Medicine includes Emergency Care and Intensive Care; resuscitation is part of both. The emphasis in emergency care should be shifted from minor injuries and fractures to “acute life-threatening medical and surgical conditions.” This report will not present data but rather summarize the author’s philosophies and recommendations. These have evolved from the following personal experiences of the past 10 years: (1) about 800 cardiopulmonary resuscitation attempts; (2) about 1,500 cases of prolonged artificial ventilation; (3) establishment of two interdepartmental intensive care units, one at Baltimore City Hospital and one at Presbyterian-University Hospital of Pittsburgh, with 24 hour coverage by anesthesiologists and training programs for physicians, medical students and nurses; (4) cardiopulmonary resuscitation training of 600 medical students, 500 physicians and 2,500 lay and paramedical personnel; (5) studies of emergency care in several countries around the world; ( 6 ) resuscitation research; and ( 7 ) activities on international, national and local symposia and committees. Most of the following recommendations are now being nationally recognized in the United States (1-2, 11, 16, 31).

Changes in serum CPK, LDH, and their isoenzymes in the perioperative period in patients undergoing craniotomy.

Summary The perioperative changes in the serum concentration of creatine phosphokinase (CPK) and its isoenzymes MM, MB, and BB and of lactic dehydrogenase (LDH) and its isoenzymes LDH1 to LDH5 were determined during craniotomy in order to distinguish operation-induced changes in these enzymes from those due to acute myocardial infarction and malignant hyperthermia. Twenty-eight male patients, 29 to 76 years of age (mean ± SD = 58 ± 13.2 years), undergoing craniotomy for tumor reseaction (n = 26) or cerebral artery aneurysm clipping (n = 2) were included in this study. Ten serial blood samples were obtained from each patient: one sample before and another after induction of anesthesia, and eight samples after the incision, over a period of 70 h. The preinduction serum CPK level of 97 ± 32 U/L (mean ± SD) increased gradually and significantly and reached the peak level of 542 ± 116 U/L 34 h after incision (p <0.05). Whereas all of the CPK isoenzymes increased in terms of U/L after incision, only the MM fraction (expressed as percent of total CPK) increased, and the MB and BB fractions (expressed as percent of total CPK) decreased. The preinduction serum LDH level of 150 ± 42 U/L (mean ± SD) increased gradually after incision and reached the peak level of 210 ± 32 U/L 58 h after incision (p <0.05). LDH2 as a percent of total LDH decreased significantly, but the LDH1/LDH2 ratio did not change. LDH4 and LDH5, as percents of total LDH, increased significantly. The large increases in total serum CPK and the concomitant decrease in MB percent after craniotomy may minimize and/or mask the percentage increase in the MB level following acute myocardial infarction. The perioperative serum CPK level as a marker in the diagnosis of malignant hyperthermia should be interpreted in light of the present results and in conjunction with clinical symptomatology.

TREATMENT OF EXSANGUINATING HEMORRHAGE

Principal treatment consists of prompt hemostasis and transfusion of bank blood. Additional therapeutic concepts under investigation by othrs include : Oxygen and controlled hyperventilation (because of increased physiologic dead space and decreased oxygen transport) ; use sf vasodilators (in prolonged shock with splanchnic vasoconstriction) ; use of vasoconstrictors (in threatened cardiac arrest) ; alkalinizing agents (in prolonged shock with low plasma pH) ; warm blood and calcium (in massive transfusion); balanced salt solution (to combat extracellular fluid loss in tissue trauma) ; heparin and fibrinolysin (to prevent and combat intravascular clotting) ; low molecular weight dextran (to promote capillary flow) ; steroids; and hypothermia. Additional therapeutic concepts are under investigation in dogs in our laboratory. Preliminary results are presented below.