Category Archives: Resus

Life-saving medicine

All Updates, PHARM, Resus

Naloxone in cardiac arrest

Previous case reports and animal studies have suggested a possible role for naloxone in cardiac arrest even in the absence of opioid overdose.
Possible mechanisms include reducing the myocardial depressant effect of endogenous opioids, stimulating catecholamine release, and providing antiarryhthmic effects through an effect on cardiomyocyte ion channels.
A retrospective review of 32,544 out of hospital cardiac arrests over 5 years revealed 36 to have received pre-hospital naloxone. Of these, only one survived to hospital discharge, who tested positive for opiates in a urine toxicology screen in the emergency department.
No need to change the guidelines yet then.
Naloxone in cardiac arrest with suspected opioid overdoses
Resuscitation. 2010 Jan;81(1):42-6

All Updates, Resus

Ionised hypocalcaemia after ROSC

Ionised hypocalcaemia has been observed post-cardiac arrest in previous studies. Investigators in Utah induced VF in a swine model and resuscitated them back to spontaneous circulation1. Ionised hypocalcaemia was associated with hypotension and impaired LV function, and its treatment with a calcium infusion resulted in improved mean arterial pressure and left ventricular stroke work.
Although iv calcium is not recommended as a blind treatment in cardiac arrest, in part due to concerns about exacerbating cellular injury, this study reminds us that the treatment of ionised hypocalcaemia is important, and may be necessary after ROSC.
1. Hypocalcemia following resuscitation from cardiac arrest revisited
Resuscitation 2010 Jan;81:117–122

All Updates, ICU, Resus

Therapeutic hypothermia with simple measures

Thirty-eight post-cardiac arrest patients were effectively cooled to the target temperature range of 32-34 celsius using intravenous cold saline and ice packs to groin, axillae, and neck. The ice packs were frozen 250 ml saline bags wrapped in pillow cases. If shivering occurred muscle relaxation with rocuronium was used until the target temperature was reached. Interestingly, rebound hyperthermia occurred in 8/34 patients.
Although a small study, these data reassure those of us who induce therapeutic hypothermia without the use of dedicated cooling equipment.
Cold saline infusion and ice packs alone are effective in inducing and
maintaining therapeutic hypothermia after cardiac arrest
Resuscitation 2010;81:15–19

All Updates, ICU, Resus, Ultrasound

Differentiating arteries from veins

In a letter to Critical Care Medicine, ultrasound legend Michael Blaivas reminds readers that during ultrasound-guided central venous catheterisation, an additional technique for differentiating the common carotid artery from the internal jugular vein: pulse-wave doppler.

Image reproduced with kind permission of Dr Blaivas

Blaivas states: “The left panel shows a classic arterial tracing from the common carotid artery with a normal velocity. The right panel shows the vessel of choice on the same patient: the right internal jugular vein. The image shows a slightly chaotic venous tracing from the jugular. This a common appearance and is markedly different from the waveform of the carotid.”
Posterior vessel wall penetration by needles during internal jugular vein central catheter placement using ultrasound guidance: is that a real danger? Author’s Reply.
Crit Care Med. 2010 Feb;38(2):736-7

All Updates, Guidelines, ICU, Resus

Surviving Sepsis Campaign guideline adherence and mortality

Data from 15,022 subjects at 165 sites at which the Surviving Sepsis Campaign (SSC)  6 hour and 24 hour care guideline bundles were introduced were submitted from 2005 to early 2008. As adherence to the guidelines increased (18.4 to 26.1%), hospital mortality decreased (37 to 30.8%). The study was partly funded by manufacturers of some of the monitoring and therapeutic components of the SSC guidelines.
The Surviving Sepsis Campaign: Results of an international guideline- based performance improvement program targeting severe sepsis
Crit Care Med. 2010 Feb;38(2):367-74
An insightful editorial points out several methodological weaknesses in this study, as well as the interesting point that the guidelines published in 2004 drew on evidence published predominantly between 2000 and 2003, and subsequent research has called a number of components into question. Examples are:

  • The Corticosteroid Therapy of Septic Shock (CORTICUS) study did not confirm that low-dose corticosteroids were beneficial
  • the Normoglycaemia in Intensive Care Evaluation and Survival Using Glucose Algorithm Regulation (NICE- SUGAR) study reported that targeting tight glycemic control may be harmful
  • Early goal-directed therapy is the subject of no less than three ongoing clinical trials supported by national research funding agencies
  • and the effect of drotrecogin alfa (activated) is being re-examined in both industry-sponsored and investigator-initiated trials.

While scientific skepticism is healthy, there is no doubt at least that in part due to the efforts of the SSC more clinicians than ever are aware of the importance of timely aggressive management of severe sepsis / septic shock.
The Surviving Sepsis Campaign: robust evaluation and high-quality primary research is still neede
Crit Care Med. 2010 Feb;38(2):683-4

Acute Med, All Updates, ICU, Resus

Heliox in COPD exacerbation

A 65:35 helium-oxygen mix was compared with 35% oxygen in air in patients with COPD exacerbations requiring non-invasive ventilation. In this RCT there was no difference in intubation rates between the heliox or air/oxygen groups.
A multicenter, randomized trial of noninvasive ventilation with helium-oxygen mixture in exacerbations of chronic obstructive lung disease
Crit Care Med. 2010 Jan;38(1):145-51