Predictors of outcome from critical illness. Shock and cardiopulmonary resuscitation

Many of our patients in ICUs suffer from shock, be it due to sepsis, trauma, arrest, or other causes. These patients continue to have a very high mortality rate in spite of very labor intensive and expensive treatment. The ability to identify patients who are likely to succumb to their illness is of utmost importance. Of the multitude of scoring systems published, the APACHE seems to accurately stratify shock patients according to severity of illness. However, these systems tend to be more useful for stratifying risk groups of patients than assessing the risk of death. Hemodynamic data can specifically assess the severity of the shock state in an individual patient. Those who maintain a relatively low cardiac index (< 4.5 L/m/M2) and oxygen delivery (< 15 mL/m/kg or 600 mL/m/M2) have persistent tissue hypoperfusion. Arterial lactate concentrations reflect the severity of this perfusion defect and correlate with outcome. Therefore, by restoring tissue perfusion, we can clearly improve mortality. CPP, although not generally obtainable during cardiac arrest, is the major physiologic determinant of outcome from CPR. ETCO2 monitoring during cardiac arrest in humans correlates with resuscitability, however, provides a rapid noninvasive monitor of cardiac output, and therefore has secured its role as an invaluable tool for assessing the effectiveness of CPR. An ETCO2 over 10 mm Hg is associated with effective CPR. A rapid rise in ETCO2 during CPR heralds recovery of spontaneous circulation. In conclusion, the use of prognostic indicators as predictors of outcome is supported as an important adjunct to the management of critically ill patients. These indicators serve as useful monitors to evaluate treatment and guide clinical management. Understanding the underlying pathophysiologic mechanisms responsible for the wide variety of illnesses associated with circulatory failure is crucial in our concerted effort to reduce mortality in these patients. As knowledge is gained, we hopefully will be able to develop more accurate and specific predictors of outcome to prudently select patients most likely to benefit.     

Early ischaemia after severe head injury. Preliminary results in patients with diffuse brain injuries

Ischaemic brain lesions still have a high prevalence in fatally head injured patients and are the single most important cause of secondary brain damage. The present study was undertaken to explore the acute phase of severely head injured patients in order to detect early ischaemia using Robertson's approach of estimating cerebral blood flow (CBF) from calculated arterio-jugular differences of oxygen (AVDO2), lactates (AVDL), and the lactate-oxygen index (LOI). Twenty-eight cases with severe head injury were included (Glasgow Coma Scale Score below or equal to 8). All patients but one had a non-missile head injury. All the patients had a diffuse brain injury according to the admission CT scan. ICP measured at the time of admission was below 20 mmHg in 17 cases (61%). All patients were evaluated with the ischaemia score (IS) devised in our center to evaluate risk factors for developing ischaemia. Mean time from injury to the first AVDO2/AVDL study was 23.9 +/- 9.9 hours. According to Robertson's criteria, 13 patients (46%) had a calculated LOI (-AVDL/AVDO2) value above or equal to 0.08 and therefore an ischaemia/infarction pattern in the first 24 hours after the accident. Of the 15 patients without the ischaemia/infarction pattern, in three cases the CBF was below the metabolic demands and therefore in a situation of compensated hypoperfusion. No patient in our series had hyperaemia. Comparing different variables in ischaemic and non-ischaemic patients, only arterial haemoglobin and ischaemia score (IS) was significantly different in both groups. The ischaemia score had mean of 4.3 +/- 1.7 in the ischaemic group and 2.7 +/- 1.4 in non-ischaemic patients (p = 0.01). It is concluded that ischaemia is highly prevalent in the early period after severe head injury. Factors potentially responsible of early ischaemia are discussed.     

Effects of intra-aortic balloon occlusion on hemodynamics during, and survival after cardiopulmonary resuscitation in dogs

OBJECTIVE: To evaluate the effect of balloon occlusion of the proximal descending aorta during cardiopulmonary resuscitation (CPR) on hemodynamics, restoration of spontaneous circulation, and 24-hr survival. DESIGN: Prospective, randomized, controlled trial. SETTING: Experimental laboratory in a university hospital. SUBJECTS: Eighteen anesthetized dogs. INTERVENTIONS; Catheters were placed for hemodynamic and blood gas monitoring. An aortic balloon catheter was placed with its tip just distal to the left subclavian artery. After 10 mins of ventricular fibrillation without CPR, 3 mins of Basic Life Support (chest compressions and ventilation with 100% oxygen) was followed by up to 30 mins of Advanced Cardiac Life Support with canine drug dosages. In the treatment group (n = 8), the intra-aortic balloon was inflated when Advanced Cardiac Life Support started and not deflated until shortly after restoration of spontaneous circulation. The control animals (n = 10) were treated with an identical resuscitation but without intra-aortic balloon occlusion. MEASUREMENTS AND MAIN RESULTS: In the treatment group, coronary perfusion pressure was greater during Advanced Cardiac Life Support (p = .026). Restoration of spontaneous circulation was more frequent (7/8 dogs) as compared with the control group (3/10 dogs) (p = .025). There was a trend toward greater 24-hr survival in the treatment group (5/8 dogs) than in the control group (3/10 dogs). CONCLUSIONS: Balloon occlusion of the proximal descending aorta during experimental CPR improves restoration of spontaneous circulation. Further laboratory and human studies are needed to determine the clinical efficacy of this technique.     

Visual motion perception after brain damage: II. Deficits in form-from-motion perception

We investigated form-from-motion perception (FFM perception) in a sample of 39 patients with acquired brain damage. Pronounced FFM deficits were found in two patients (FM1 and FM2) with biparietal lesions. Both patients were able to identify the relevant figure, when it was not embedded in obstructive texture. Moreover, they could localize the figures in the FFM condition, although they could not reliably identify them. The two patients had normal motion coherence thresholds. Their performance in a static figure-ground task did not differ from that of other patients. These findings imply that the FFM deficits are not caused by impairment of basic visual motion or form perception but are the consequence of damage to a parietal brain structure involved in the combined analysis of visual motion and form information. The nature and functional role of this brain structure as well as the implications of our results for models of FFM perception are discussed.     

Alterations of local cerebral blood flow, phorbol 12,13-dibutyrate binding activity, and histological damage during acute focal ischaemia in rat brain. A pathophysiology of acute focal ischaemia: Part 1

The alterations of the local cerebral blood flow (LCBF), 3H-phorbol 12,13-dibutyrate (PDBu) binding activity were measured, and histological findings were also examined during the closed time course (0, 1, 3, 5, 7 hour) after middle cerebral artery occlusion (MCAO) in rat brain to assess the complex pathophysiology of acute focal ischaemia. From 1 to 3 hours after the start of MCAO, significant (p < 0.01) hyperreactivity of the second messenger system involving PDBu binding may be present, despite low perfusion of LCBF, and severe damage in the striatum whereas sparing almost completely the cortex on histological examination. At 5 hours, the PDBu binding activity increased slightly but not significantly but is reduced markedly at 7 hours after MCAO compared with the control group. The measurement of PDBu binding activity, additionally to measuring the LCBF and observation of the histological change might be a useful indicator in determining the threshold and duration of ischaemia which cause functionally irreversible cell damage in the brain.     

Lack of efficacy of 5-HT2A receptor antagonists to reduce brain damage after 3 minutes of transient global cerebral ischaemia in gerbils

Stimulation of the 5-HT2A receptors by serotonin has been reported to exert an excitatory effect on neocortical neurons in rats and mice, to facilitate ischaemia-induced release of excitatory amino acids and to mediate the vasomotor constrictor component of the response of blood vessels to 5-HT. 5-HT2A receptor antagonists have, therefore, been proposed as potential protectants against the effects of cerebral ischaemia. The aim of this study was to evaluate the effects of two relatively selective 5-HT2A receptor antagonists, ketanserin and ritanserin, on delayed hyperactivity and the ensuing neuronal degeneration induced by 3 minutes of bilateral carotid artery ligation in Mongolian gerbils. Effects were compared to that of flunarizine, which blocks calcium overload and served as a positive control in this paradigm. Temporal and/or rectal temperatures were measured and strictly controlled during the ischaemia and the early reperfusion phase. Locomotor activity was measured one day after the ischaemia and neuronal degeneration quantified 7 days later using an image analysis system (Quantimet 570, Leica). Global ischaemia in gerbils elicits hyperactivity associated with a delayed neuronal degeneration predominantly in the CA1 zone of the hippocampus. Ketanserin and ritanserin (3 and 10 mg/kg ip, twice daily for 3 days, pre- and postischaemia) did not protect the CA1 neurons against ischaemic damage. The postischaemic hyperactivity was inhibited only with the higher dose of ketanserin. As previously reported, flunarizine (30 mg/kg po) markedly reduced neuronal degeneration (-44.2%, p < 0.01) and totally abolished the ischaemia-induced hyperactivity. These data demonstrate that ketanserin and ritanserin are not effective protectants of the gerbil hippocampus against ischaemic damage when the body temperature of the animals is controlled, thus suggesting that 5-HT2A receptors are not directly implicated in the pathogenesis of global cerebral ischaemia in this model.     

Sleep EEG alterations in patients suffering from circulatory disturbances. Relation to neurological and psychopathological changes (author''s transl)

In 30 conscious patients (24 men, 6 women) aged 30-74 years suffering from ischemic lesions in the cerebral hemispheres, polygraphic night sleep recordings were performed about 45 days after the beginning of the illness. The alterations in sleep were characterized by a delay in the onset of sleep, prolonged waking periods, and a reduction of deep synchronous sleep. Statistical analysis revealed a relationship between prolonged waking time with higher age as well as with high complex reaction time and euphoric state of mind, which can be considered as a sign of psycho-organic impairment. In contrast thereto, the degree of the neurological symptomatology is of less importance for the kind and extent of the sleep disturbances.     

Diagnosis of death in comatose patients under resuscitation treatment: a critical review of the Harvard report

In this Article, which draws primarily on continental West European views on death and dying, the author contends that the Harvard criteria for irreversible coma (1968) are not reliable for diagnosing death in comatose patients under resuscitation treatment. The Article suggests that use of the Harvard Criteria to diagnose death leaves such patients legally unprotected against surgical assaults such as organ removal and biomedical experiments while they still may be living and capable of perception, possibly including the perception of pain and the spoken word. An alternative to the Harvard Criteria--angiography--is offered, and several additional issues related to the definition and diagnosis of death are discussed. Finally, the author suggests that even prior to death, termination of resuscitation treatment of irreversibly comatose patients, though followed by death, should be lawful.     

Heart surgery, cardiopulmonary bypass, and organic inflammatory response. Part II: changes in leukocytes, arachidonic acid derivatives, and hormones

The use of cardiopulmonary bypass for surgical cardiac procedures is characterized by a whole-body inflammatory reaction due to the contact of blood through nonendothelialized surfaces; this stimulates the organism to recognize the cardiopulmonary bypass system as "nonself" and to activate specific (immune) and nonspecific (inflammatory) responses. These responses are then related with postoperative damage to many body systems of the body, like pulmonary, renal or brain dysfunction, excessive bleeding and postoperative sepsis. In this paper, present knowledge on untoward responses of the patient to cardiopulmonary bypass in cardiac surgery is reviewed and discussed, particularly focusing on the perturbation of the leukocytes, of the hormones and of the products of the arachidonic acid cascade.     

Powder metallurgy T15 tool steel: Part II. Microstructure and properties after heat treatment

The effect of powder particle size and heat treatment on the micro structure and properties of hot isostatically pressed (“hipped”) T15 tool steel has been evaluated. Gas-atomized powder was screened into size fractions covering the range of ≤44 to 1200 /i-m and hipped at 1130 ‡C or 1195 ‡C. The consolidated powders were austenitized at 1175 ‡C or 1225 ‡C and tempered at 538 ‡C, 552 ‡C, or 565 ‡C to control prior austenite grain size, carbide type, carbide volume fraction, and carbide size distribution. Properties measured were bend strength, C-notch impact toughness, and hot hardness. Prior austenite grain size increases with hot isostatic pressing (“hipping”) temperature and austenitizing temperature but is independent of the particle size; similarly, the influence of austenitizing temperature on dissolution of MC and M₆C is independent of the particle size. In each particle size fraction, the volume fraction and size distribution of MC are independent of the tempering temperature. For M₆C, the volume fraction increases and the size distribution is skewed to coarser sizes with increasing tempering temperature. No significant differences in strength and toughness were detected as a function of particle size. Hot hardness is not affected by the particle size. The hot hardness of a powder blend (≤1200 Μm) hipped at 1130 ‡C was superior to that of commercial powder metallurgy (PM) T15 tool steel hipped at 1195 ‡C; this is attributed to a finer carbide size in the noncommercial material. It is established that the subcommercial hipping temperature (1130 ‡C) results in significant microstructural refinement; there is an associated small amount of residual porosity, and this controls the mechanical properties.     

"Save angels perhaps": A critical examination of unconscious thought theory and the deliberation-without-attention effect.

Based on Unconscious Thought Theory (UTT) and a series of experimental and correlational studies, Dijksterhuis and his colleagues conclude that when making complex choices/decisions, conscious thought--deliberation while attention is directed at the problem--leads to poorer choices/decisions than "unconscious thought"--deliberation in the absence of conscious attention directed at the problem. UTT comprises six principles said to apply to decision making, impression formation, attitude formation and change, problem solving, and creativity. Because the implications of UTT for psychological research and theory are considerable, the authors critically examined these six principles (and the studies used to support them) in light of the extant scholarship on unconscious processes, memory, attention, and social cognition. Our examination reveals that UTT is a theory of the unconscious that fails to take into account important work in cognitive psychology, particularly in the judgment and decision making area. Moreover, established literatures in social psychology that contradict fundamental tenets of UTT and its empirical basis are ignored. The authors conclude that theoretical and experimental deficiencies undermine the claims of the superiority of unconscious thinking as portrayed by UTT. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Natural history of sucking patterns in infant goats: A comparative study.

Examined temporal organization of sucking patterns, the phase interaction of sucking and other rhythmical motor patterns, and the effects of feeding on sucking rate in 26 Nubian goats. No changes in sucking rate were noted over the 1st 3 mo. The precise rate concordance between sucking and tail movements suggested that peripheral motor rhythms are regulated by a central sequencing mechanism which in turn is modulated by organismic and peripheral factors. A comparison of sucking patterns in 10 human infants and Ss indicates that qualitative species differences in the prefunctional organization of sucking influence the nature of the interaction between sucking performance and organismic or peripheral factors. (19 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

MRI evaluation of the brain in infantile neuronal ceroid-lipofuscinosis. Part 2: MRI findings in 21 patients

The purpose of this study was to demonstrate the course of infantile neuronal ceroid-lipofuscinosis with brain magnetic resonance imaging (MRI) in children aged 3 months to 11 years. Twenty-one patients and 46 neurologically normal controls of the same age were examined. The images were evaluated visually; then signal intensities were measured and related to those of references. MRI abnormalities were detectable before clinical symptoms. The radiologic picture of the brain varied with the duration of the disease. Pathognomonic MRI findings in the early stage of the disease were generalized cerebral atrophy, strong thalamic hypointensity to the white matter and to the basal ganglia, and thin periventricular high-signal rims from 13 months onward on T2-weighted images. In patients over 4 years old, cerebral atrophy was extreme, and the signal intensity of the entire white matter was higher than that of the gray matter, which is the reverse of normal. This study showed that the abnormalities seen on MRI progress rapidly during the first 4 years of life, then stabilize, in conformity with the clinical and histopathologic pictures of infantile neuronal ceroid-lipofuscinosis.     

Primacy of wholistic processing and global/local paradigm: A critical review.

The question of whether perception is analytic or wholistic is an enduring issue in psychology. The global-precedence hypothesis, considered by many as a modern version of the Gestaltist claim about the perceptual primacy of wholes, has generated a large body of research, but the debate still remains very active. This article reviews the research within the global/local paradigm and critically analyzes the assumptions underlyling this paradigm. The extent to which this line of research contributes to understanding the role of wholistic processing on object perception is discussed. It is concluded that one should be very cautious in making inferences about wholistic processing from the processing advantage of the global level of stimulus structure. A distinction is proposed between global properties, defined by their position in the hierarchical structure of the stimulus, and wholistic properties, defined as a function of interrelations among component parts. It is suggested that a direct comparison between processing of wholistic and component properties is needed to support the hypothesis about the perceptual primacy of wholistic processing. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Changes of respiratory chain activity in mitochondrial and synaptosomal fractions isolated from the gerbil brain after graded ischaemia

In this study we have examined (1) the integrated function of the mitochondrial respiratory chain by polarographic measurements and (2) the activities of the respiratory chain complexes I, II-III, and IV as well as the ATP synthase (complex V) in free mitochondria and synaptosomes isolated from gerbil brain, after a 30-min period of graded cerebral ischaemia. These data have been correlated with cerebral blood flow (CBF) values as measured by the hydrogen clearance technique. Integrated functioning of the mitochondrial respiratory chain, using both NAD-linked and FAD-linked substrates, was initially affected at CBF values of approximately 35 ml 100 g-1 min-1, and declined further as the CBF was reduced. The individual mitochondrial respiratory chain complexes, however, showed differences in sensitivity to graded cerebral ischaemia. Complex I activities decreased sharply at blood flows below approximately 30 ml 100 g-1 min-1 (mitochondria and synaptosomes) and complex II-III activities decreased at blood flows below 20 ml 100 g-1 min-1 (mitochondria) and 35-30 ml 100 g-1 min-1 (synaptosomes). Activities declined further as CBF was reduced below these levels. Complex V activity was significantly affected only when the blood flow was reduced below 15-10 ml 100 g-1 min-1 (mitochondria and synaptosomes). In contrast, complex IV activity was unaffected by graded cerebral ischaemia, even at very low CBF levels.     

Interdendritic Spacing: Part II. A Comparison of Theory and Experiment

The primary spacing data of Part I are compared to the existing theoretical models of Hunt and of Kurz and Fisher, and a significant disagreement is found. A theoretical model based on the Hunt model is developed, and it is found that the theory adequately explains the variation in primary spacing, λ₁, with the growth rate,V. A maximum in λ₁,vs V is predicted and the velocity at which the maximum occurs matches with the result obtained experimentally. It is shown that the maximum in λ₁ corresponds to the dendrite-to-cell transition, and cellular structures are found to grow with much smaller spacings than dendritic structures under identical growth conditions. This paper is based on a presentation made at the symposium “Establishment of Microstructural Spacing during Dendritic and Cooperative Growth” held at the annual meeting of the AIME in Atlanta, Georgia on March 7, 1983 under the joint sponsorship of the ASM-MSD Phase Transformations Committee and the TMS-AIME Solidification Committee.     

The use of color in scientific and medical illustration. Part II: Form

The medical illustrator is confronted with the problem of accurately representing three-dimensional form, more than most other illustrators or graphic artists. Often the illustrator who feels competent when working achromatically finds himself feeling insecure when attempting a full-color illustration. With some illustrators, a sense of color seems to be inborn. However, for those who do not feel secure about their own innate sense of color, it should be very encouraging to learn that the general principles of using color effectively and accurately to depict form have been laid down by generations of artists and can be learned. Moreover, the technique of observing and analyzing the ways that color is modulated by form can also be learned.