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August 1999
Volume 63 |
Number 8
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RESIDENTS' REVIEW
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| Anesthesiology
and Resuscitation |
Carlos A. Archilla, M.D.
Anesthesiologists have contributed significantly to the dramatic
changes in the field of resuscitation over the past 30 years and
continue to play an important role in modern resuscitation. In
France and other countries, it is the anesthesiologist who first
responds to an out-of-hospital arrest. In the United States, anesthesiologists
have a critical role in the management of in-hospital cardiac
arrests. The initial survival rate from an in-hospital cardiac
arrest in the United States is approximately 40-50 percent, and
about 13-18 percent will survive to be discharged from the hospital.1
Most residency programs have anesthesiology residents responding
to all in-hospital arrests. Although the residents' primary role
is airway management, it is my belief that this role can be expanded
to include more leadership in arrest management. We, as anesthesiology
residents, are well-trained in the areas of physiology, pharmacology
and critical care medicine. This knowledge, in conjunction with
our unparalleled skills in airway management, make us masters
in the management of the "ABCs" of cardiopulmonary resuscitation
(CPR). Anesthesiologists also have a vital role in the exciting
field of disaster medicine, providing not only resuscitation and
airway management but also sedation and pain control to facilitate
extrication of victims.
The prompt initiation of resuscitation is critical. The
famous "Golden Hour" has been reduced to a few minutes. It takes
approximately 6-8 minutes before permanent ischemic damage and
worsening neurological outcomes occur in the brain.2
Data vary, but some studies show ischemic damage to the epicardium
as early as four minutes into the arrest. This definitely puts
primary responders in a very valuable position. Both CPR teaching
at all levels in the community and the recent introduction of
automatic external defibrillators provide more tools for primary
responders.
Recent changes in CPR include new techniques tested in
both animal and human populations in order to improve forward
blood flow and rapid return of spontaneous circulation. These
new techniques include active compression-decompression CPR and
interposed abdominal compression CPR. Interposed abdominal compression
and phased chest abdominal compression-decompression CPR in animal
models show increased survival rates and increased coronary artery
blood flow compared to standard CPR.3
Preliminary human trials have shown dissimilar results from animal
studies and more human trials are in progress.
Not only is CPR changing but advanced cardiac life support
(ACLS) guidelines are being reviewed. The routine use of calcium,
glucose and bicarbonate is no longer in the ACLS algorithms. New
studies in the area of post-resuscitation injury are elucidating
the role of oxygen radicals, inflammatory mediators and calcium
in this type of injury. Other exciting changes include the possible
addition of new drugs to the existing ACLS algorithms. Amiodarone
could be a new addition in the treatment of ventricular fibrillation.
Vasopressin, a potent vasoconstrictor, has been shown in animal
studies to improve coronary and cerebral blood flow during an
arrest compared to standard dose epinephrine.4
Another change could be a redefined role for magnesium sulfate
in arrhythmia prophylaxis. In addition to the area of pharmacology,
some changes may be seen in the consideration of using hypothermia
and anesthesia during resuscitation protocols in order to improve
cerebral blood flow, cerebral protection and reduction of oxygen
consumption.
It is imperative that anesthesiology residents learn and
maintain skills in resuscitation. In addition, we should participate
in the education process of hospital staff and have active representation
on the arrest committees of our institutions. Our strong involvement
will help shape the future of this field.
References:
- Ravakhah K, Khalafi K, Bathory T, et al.
Advanced cardiac life support events in a community hospital
and their outcome: Evaluation of actual events. Resuscitation.
1998; 36:95-99.
- Abramson N, Safar P, Detre K, et al. Neurologic
recovery after cardiac arrest: Effect of duration of ischemia.
Crit Care Med. 1985; 13:930-931.
- Tang W, Weil MH, Schock RIB, et al. Phased
chest and abdominal compression-decompression: A new option
for cardiopulmonary resuscitation. Circulation. 1997;
95:1335-1340.
- Morris DC, Dereczyk BE, Grzybowski M,
et al. Vasopressin can increase coronary perfusion pressure
during human cardiopulmonary resuscitation. Acad Emerg Med.
1997; 4:878-883.
Carlos A. Archilla, M.D., recently completed
a residency at The Johns Hopkins Hospital, Baltimore, Maryland,
and is an Attending Anesthesiologist, St. Mary's Anesthesia Associates,
St. Mary's Medical Center, West Palm Beach, Florida.
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