Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of "limited" resuscitations.

BACKGROUND: The results of in-hospital resuscitations may depend on a variety of factors related to the patient, the environment, and the extent of resuscitation efforts. We studied these factors in a large tertiary referral hospital with a dedicated certified resuscitation team responding to all cardiac arrests. METHODS: Statistical analysis of 445 prospectively recorded resuscitation records of patients who experienced cardiac arrest and received advanced cardiac life support resuscitation. We also report the outcomes of an additional 37 patients who received limited resuscitation efforts because of advance directives prohibiting tracheal intubation, chest compressions, or both. MAIN OUTCOME MEASURES: Survival immediately after resuscitation, at 24 hours, at 48 hours, and until hospital discharge. RESULTS: Overall, 104 (23%) of 445 patients who received full advanced cardiac life support survived to hospital discharge. Survival was highest for patients with primary cardiac disease (30%), followed by those with infectious diseases (15%), with only 8% of patients with end-stage diseases surviving to hospital discharge. Neither sex nor age affected survival. Longer resuscitations, increased epinephrine and atropine administration, multiple defibrillations, and multiple arrhythmias were all associated with poor survival. Patients who experienced arrests on a nursing unit or intensive care unit had better survival rates than those in other hospital locations. Survival for witnessed arrests (25%) was significantly better than for nonwitnessed arrests (7%) (P =.005). There was a disproportionately high incidence of nonwitnessed arrests during the night (12 AM to 6 AM) in unmonitored beds, resulting in uniformly poor survival to hospital discharge (0%). None of the patients whose advance directives limited resuscitation survived. CONCLUSIONS: Very ill patients in unmonitored beds are at increased risk for a nonwitnessed cardiac arrest and poor resuscitation outcome during the night. Closer vigilance of these patients at night is warranted. The outcome of limited resuscitation efforts is very poor.

Ultrasonography in the evaluation of hemoperitoneum in war casualties.

The aim of this study was to evaluate the sensitivity, specificity, accuracy, and positive and negative predictive values of emergent ultrasound examination in the detection of hemoperitoneum among war casualties, and to compare the results of this method in a specific war situation and civil conditions. Ninety-four wounded individuals with suspected blunt or penetrating abdominal trauma were treated at a level I war hospital (group W), and 242 civilians with multiple injuries with suspected blunt abdominal trauma were evaluated at the emergency center of a university hospital (group C). All examinations were performed in less than 5 minutes with a portable ultrasonographic scanner, and typical points were scanned (Morison's pouch, Douglas and perisplenic spaces, paracolic gutter). In group W, hemoperitoneum was identified correctly in 19 patients, with three false-negative and no false-positive findings, whereas group C presented 98 true-positive results, 13 false-negative results, and again no false-positive results. We observed that ultrasonography in specific war conditions showed sensitivity of 86%, specificity of 100%, accuracy as high as 97%, positive predictive value of 100%, and negative predictive value of 96%, whereas in civil conditions the corresponding values were 88%, 100%, 95%, 100%, and 91%, respectively. The sensitivity, specificity, accuracy, and positive and negative predictive values of emergent ultrasound examination in the diagnosis of hemoperitoneum are approximately equal in war and civil conditions.

Intraperitoneal bupivacaine for analgesia after laparoscopic cholecystectomy.

BACKGROUND: The effects of intraperitoneal administration of bupivacaine on pain after laparoscopic cholecystectomy were studied in a prospective, double-blind, randomised trial. METHODS: Eighty ASA 1 and 2 patients were randomly assigned to one of two groups. Immediately after pneumoperitoneum was obtained patients in group 1 were given 15 ml of 0.5% bupivacaine injected under direct vision into the hepato-diaphragmatic space, near and above the hepato-duodenal ligament and above the gallbladder. At the end of operation another 15 ml of bupivacaine was injected. Patients in group 2 were given 15 ml of 0.9% saline solution in a similar fashion. Postoperative pain was assessed using a visual analogue scale (VAS 100 mm) at 0.5, 4, 8, 12 and 24 h after surgery. Analgesic consumption was also recorded. RESULTS: Patients' data were similar in the two groups. Pain was more intense in the saline group at each time point. Significant differences between the groups were present for up to 8 h. Analgesic consumption was significantly lower in the bupivacaine group. No side-effects occurred. CONCLUSION: We conclude that reducing pain with intraperitoneal bupivacaine is effective, easy to administer, and without side-effects.