Clinical application of cardiopulmonary bypass(CPB) to the resuscitation of DOA patients.
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The science of resuscitation has made remarkable strides and the resuscitation success rate after brief cardiopulmonary arrest under optimum conditions now approaches 75%. However, the success rates for cardiovascular and cerebral resuscitation remain very low. Recently, in animal experiments, it has been reported that CPB (cardiopulmonary bypass) can effect reperfusion and assist reliably in circulation, thereby enhancing survival and cerebral recovery rates after prolonged cardiac arrest. In 1988, we started trials of resuscitation of patients dead on arrival (DOA), using stand-by CPB. Up to this time we have attempted resuscitation of 7 patients in this trial.(1) CPB apparatusWe have placed the CPB apparatus for DOA patients in the emergency room. The reservoir and circuit are primed beforehand with lactated Ringer's solution for emergency use. We call this method the "Stand-By CPB System".(2) Indications for CPB in DOA patientsWhen a DOA patient is admitted to our department, we first attempt resuscitation using standard advanced life support methods. However, if this proves ineffective and the patient fulfils all the criteria for CPB, i.e. witnessed cardiac arrest, endogenous etiology other than brain disease, age under 60 years and patient not resuscitated after more than 20min of SECPR (standard external cardiopulmonary resuscitation), we then consider resuscitation of the patient using CPB.(3) Method of CPB in DOA patientsWe use the femoral vein and artery as cannulation sites. Until restoration of spontanous circulation, CPB flow is regulated at 50-60ml/kg/min. During CPB, efforts are made to control the activated clotting time (ACT), blood temperature and blood pressure. We include a continuous hemofiltration filter in the circuit for dehydration.(4) Clinical casesOver the past 2 years, stand-by CPB has been instituted in 7 patients in our department. Patient age ranged from 21yrs to 60yrs (mean, 37.4yrs). The diseases causing cardiopulmonary arrest were acute myocardial infarction in 4 cases, severe asthma in one case, idiopathic cardiomyopathy in one case, and hyperkalemia due to chronic renal failure in one case. Upon admission, ECG patterns were either ventricular fibrillation or standstill. The time from cardiac arrest to the time of admission ranged from 15min to 30min, and the time from admission to the start of CPB ranged from 19min to 55min.(5) Patient outcomeIn these 5 patients, neurological status was improved including restoration of spontaneous breathing, appearance of auditory brainstem response, and appearance of response to pain. In 5 patients, spontaneous circulation was restored. Only three of these patients, however, were successfully weaned from CPB, and of these, one patient died from LOS (low output syndrome) 11hrs after weaning. In total, two patients were revived by the resuscitation, and one of them recovered without any neurological damage in spite of a 40-min cardiac arrest.Although some problems still remain, we believe there are many advantages of CPB in DOA patients. With the use of CPB, cerebral reperfusion can be optimized, blood temperature and pressure can be controlled promptly, and various agents can be delivered safely and accurately for the prevention or amelioration of reoxygenation injury.
- 一般社団法人 日本救急医学会の論文
一般社団法人 日本救急医学会 | 論文
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