Masaya Takino

Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest

The effects of mild hypothermia (MH) were investigated. From 1995 to 1996, 28 adult patients with out-of-hospital cardiopulmonary arrest (CPA) had return of spontaneous circulation and survived for more than two days. Thirteen patients were in the MH group. In the MH group, core temperature was maintained between 33 and 34 degrees C for 48 h, and then re-warmed to a temperature of 37 degrees C, at a rate of no greater than 1 degrees C per day. Fifteen patients, admitted before the MH protocol was instituted, were in the control group. Despite the fact that the number of witnessed arrests in the control group were greater than in the MH group, there were both more survivors (7/13 vs. 5/15) and more fully recovered patients (3/13 vs. 1/15) in the MH vs Control groups. Eleven of 13 MH patients, as compared to 6/15 controls developed pneumonia. Our study, although preliminary, suggests that MH might confer improved outcome, as has been shown in animal models, after CPA. This treatment is associated with an increase in pneumonic complications.

Firm myocardium in cardiopulmonary resuscitation

Firm myocardium in cardiopulmonary resuscitation (CPR) is a rarely described yet potentially important condition. To investigate the clinical nature and implications of firm myocardium in CPR, we retrospectively analyzed 59 adult patients with nontraumatic out-of-hospital cardiac arrest who underwent open-chest CPR in the emergency department and had heart consistency recorded. Consistency of the myocardium varied considerably between patients. Firm myocardium was noticed in 36 cases, mainly in the left ventricle (firm myocardium group). The remaining 23 hearts were not firm (soft myocardium group). Some hearts had an increase in their consistency during CPR. Patient characteristics were similar in the two groups. The firm myocardium group showed greater base deficit on arterial blood gas analysis, suggesting more severe ischemic injury. Very firm heart had a close association with an extremely low end-tidal CO2 tension. Histopathological examination revealed hypertrophy and fibrosis common to the two groups. Both groups received similar treatment except for a shorter duration of direct cardiac massage in the firm myocardium group, although a reasonably prolonged effort was made in most cases. The firm myocardium group responded poorly to treatment. Very firm myocardium never contracted, whereas less firm myocardium usually showed some, albeit insufficient, activity. Most cases in the soft myocardium group regained a pulse. Our results suggest that firm myocardium: (1) is common in patients who receive CPR in the emergency department, (2) indicates ischemic contracture, (3) is not uniform in firmness, reflecting the degree of ischemia and (4) is a grave prognostic factor in cardiac resuscitation.

Septic shock due toPseudomonas aeruginosa in a previously healthy woman

Pseudomonas aeruginosa septicemia rarely occurs in non-immunocompromised adults. We present a case of septic shock followingPseudomonas aeruginosa pneumonia in a previously healthy 48-year-old woman. The onset was sudden, with back pain, pyrexia and shock. Chest radiographs revealed pneumonia, andPseudomonas aeruginosa was identified from blood and sputum cultures. Therapy with dopamine, piperacillin and fluid replacement led to a prompt recovery. Laboratory tests failed to reveal any immunological deficits. Including this case, only five cases ofPseudomonas aeruginosa septicemia in patients though to be non-immunocompromised have been reported. Two remarkable features of this type ofPseudomonas infection are apparent: i) it commonly develops from pneumonia and ii) it has a better prognosis than that in immunocompromised hosts.

Effect of an endothelin-1 antagonist, BQ-485, on cerebral oxygen metabolism after complete global cerebral ischemia in dogs

Endothelin-1 (ET-1) plays an important role in the physiologic or pathophysiologic regulation of cerebral circulation. To evaluate the effects of the newly synthesized ETA receptor-selective antagonist, BQ-485 (N-perhydroazepin-l-ylcarbonyl-Leu-D-Trp-D-Trp-OH), on the cerebral metabolism of oxygen during the delayed cerebral hypoperfusion that follows global cerebral ischemia, we occluded the ascending aorta and caval veins of 10 beagle dogs for 12.5 min. The animals were randomized into two groups. BQ-485 was given directly into the carotid artery at 0.03 mg/kg per min for 30 min, starting 15 min after reperfusion in the treatment group (n = 5). Isotonic saline was infused in the control group (n = 5). A fiberoptic catheter was inserted into the superior sagittal sinus to monitor its oxygen saturation (SssO2) continuously. Arterial O2 content (CaO2), and sagittal sinus O2 content (CssO2) were monitored before and at 0.5, 1, 2, 4, 6 and 8 h after the ischemic insult. BQ-485 significantly prevented the expected decrease in SssO2 and increase in the cerebral O2 utilization coefficient at 4, 6 and 8 h after the ischemic insult (P < 0.05). Thus, BQ-485 ameliorated the mismatch between O2 supply and demand in the delayed hypoperfusion phase. We conclude that ET may be involved in the pathogenesis of delayed cerebral hypoperfusion after cardiac arrest.

The hemolytic uremic syndrome presenting as bilateral leg ischemia

The hemolytic uremic syndrome in adults is an uncommon clinical entity consisting of microangiopathic hemolytic anemia, thrombocytopenia, and renal dysfunction. A previously healthy 42-year-old man, after a 2-day prodromal phase, developed severe pain and coldness in both legs, with purpura in the face and extremities. On admission, hepatorenal dysfunction and disseminated intravascular coagulation were evident. These complicated signs and symptoms led to nonspecific supportive therapy because of delayed diagnosis. The patients condition gradually improved except for ischemia of the legs, which progressed into symmetrical necrosis; eventually, bilateral below-knee amputation was required. This is the first reported case of the hemolytic uremic syndrome complicated by bilateral leg ischemia. A presumed cause of the ischemia was disseminated intravascular coagulation, a rare complication of the hemolytic uremic syndrome.