Teaching hospital physicians' skills and knowledge of resuscitation algorithms are deficient.

BACKGROUND: The resuscitation skills of 78 on-call physicians in a tertiary referral center were evaluated in a simulated sudden cardiac arrest (SCA). METHODS: The study subjects consisted of physicians whose on-call duty included handling emergency situations. First they were drawn without warning to a simulated witnessed cardiac arrest (ventricular fibrillation (VF)). They were provided with two nurses and all the equipment and medicine needed to treat SCA. Second, they were asked to write the current treatment protocols for basic life support (BLS) and VF. RESULTS: The median time to defibrillation was 2.38 min, and only 31% of the physicians were able to use the defibrillator correctly. Thirty per cent treated asystole according to the guidelines of the time. Twenty-four per cent were able to return the spontaneous circulation and the median time to ROSC (return of spontaneous circulation) was 5.75 min Only 25% of the physicians wrote the guideline for treatment of VF and basic life support correctly or nearly correctly. CONCLUSION: Regular resuscitation education should be compulsory to all physicians responsible for on-call duties in hospitals. Hospitals should have at least one employee part-time responsible for this duty.

Hyaluronic acid in incision wound fluid: a clinical study with the Cellstick device in children.

When inserted into a human incision wound, the Cellstick device harvests inflammatory cells and collects wound fluid, reflecting time-related changes in cell populations and in wound fluid composition. Hyaluronic acid has been postulated to be an important factor in scar reduction in wound healing and in scarless fetal wound healing. The aim of this work was to determine the concentration and variation of hyaluronic acid and proportions of wound cells in closed surgical wounds in children at two time points. The Cellstick device was inserted subcutaneously into the wound at the end of an elective inguinal hernia operation on 37 healthy boys, and the devices were removed 3+/-1 or 24+/-3 hours after surgery. Haluronic acid concentration was measured from the wound fluid and a differential count of the wound cells was performed. There was a significant decrease in hyaluronic acid concentration from 3+/-1 to 24+/-3 hours after surgery (p<0.001, Kruskal-Wallis anova). The variance of hyaluronic acid concentration in wound fluid differed between the wounds at the two time points (p<0.01, Levene test for homogeneity of variance). A positive correlation between hyaluronic acid concentration and patient age (r=0.91, p<0.05, Spearman) at 3+/-1 hours post surgery and between HA and wound lymphocytes (r=0.38, p<0.05, Spearman) was also found. We conclude that the hyaluronic acid concentration in wound fluid peaks early in children and decreases significantly by 3 to 24 hours after surgery, and the concentrations in the wound fluid of healthy boys are more variable 3 hours than at 24 hours after surgery.

Local and systemic immune response to surgery under balanced anaesthesia in children.

We studied perioperative changes in the immune response and compared changes in the peripheral blood with those in the wound in 20 boys (0.5-3 years) during elective inguinal surgery under balanced anaesthesia. Blood samples were drawn before premedication, immediately, and 4 or 24 h after anaesthesia. Cells from the wound were harvested with the Cellstick device, removed from the wound 4 (n=10) or 24 h (n=10) after anaesthesia. We found decreased lymphocyte counts in the peripheral blood, increased percentages of activated T lymphocytes and B lymphocytes, and decreased percentages of total T lymphocytes, T helper cells and T cytotoxic cells. The percentages of T helper cells and B lymphocytes were lower in the wound than in blood. Mitogen-induced lymphocyte proliferative responses decreased. This study demonstrates perioperative changes in the immune response in children and, as a new finding, that immune effector cells in the blood and in the wound are in a dynamic balance.

Duration of surgery and patient age affect wound healing in children.

The migration of inflammatory cells into a wound and their subsequent changes during wound healing are essential for the complex processes of tissue repair to occur. The aim of this work was to investigate the number of wound leukocytes during early wound healing at different time periods in children. Wound cells of 184 children aged 0-15 years, operated on for a benign disease in the lower abdominal region, were harvested with the Cellstick(R) device. The device was removed from the wound at 3, 6, or 24 hours after surgery and differential cell counts were performed. The cellular patterns were significantly influenced by the age of the patient and by the duration of the surgery. The proportions of neutrophils, lymphocytes, and monocytes changed significantly from 3-24 hours. Our results suggest that there is a distinct time-related change in the pattern of inflammatory cells in the early phase of wound healing in children. This pattern is affected by the age of the child and by the duration of the surgery.

Immune response in infants undergoing application of cast: comparison of halothane and balanced anesthesia.

PURPOSE: To study the immunological effects of two types of anesthesia on the immune response in infants during a minimally stressful surgical procedure. METHODS: The effects of inhalational halothane (halothane + N2O + O2, spontaneous breathing, n = 12) and conventional balanced anesthesia (thiopental + N2O + O2 + fentanyl + vecuronium, mechanical ventilation, n = 12) on immune function were measured in a crossover study in 12 infants undergoing application of casts to the lower extremity or hip joint. Leukocyte and differential counts, lymphocyte subpopulations, spontaneous lymphocyte proliferative responses as well as responses to phytohemagglutinin (PHA), concavalin A (ConA) and pokeweed mitogen (PWM), and serum cortisol concentration were measured before, immediately after and four hours after the end of anesthesia. RESULTS: Halothane anesthesia was associated with a higher percentage of T helper cells than conventional balanced anesthesia [47.1+/-1.8 (SEM)%, 48.1+/-2.3% and 50.7+/-1.9% before, immediately and four hours after anesthesia vs. 45.7+/-1.7%, 44.0+/-2.3% and 45.1+/-1.9%, respectively, by groups, P<0.05]. Leukocyte count and the percentages of activated T cells, natural killer cells and B cells showed similar alterations in both groups, and no alterations were observed in the percentages of T lymphocytes or T cytotoxic cells. Lymphocyte transformation response to PWM was decreased four hours after anesthesia in the halothane but not in the balanced anesthesia group. CONCLUSION: Anesthesia of short duration during minimal surgical stress alters lymphocyte subpopulations and lymphoproliferative responses in infants and, furthermore, halothane anesthesia and balanced anesthesia have different effects.

Correlation between interleukin-6 and matrix metalloproteinase-9 in early wound healing in children.

Interleukin-6 and matrix metalloproteinase-9 concentrations in the wound fluid and their associations to cellular changes were determined in early wound healing. Wound healing of 75 children who underwent elective operations was studied with the Cellstick(R) device, which was inserted into the wound at the end of the operation and removed 3 or 24 hours post-wounding. Differential counts of the wound cells and interleukin-6 and matrix metalloproteinase-9 concentrations in the wound fluid were analyzed. Interleukin-6 and the matrix metalloproteinase-9 concentrations increased in parallel (r = 0.81). The proportion of wound neutrophils increased (p < 0.0001) and lymphocytes decreased (p < 0. 0001) between the observation times. The number of wound neutrophils had a strong correlation with both interleukin-6 (adjusted R2 = 0.41, p < 0.0001) and matrix metalloproteinase-9 concentrations (adjusted R2 = 0.37, p < 0.0001). The extracellular matrix degradation process of the early wound healing seems to be closely linked to the inflammatory response. Both of these measured markers are associated significantly with the neutrophil proportion in the wound.